A Call To Reconsider The Heimlich Experiment: Part II, The Complications of The Maneuver

The Heimlich Maneuver (HM) has entered the American public’s consciousness as the method of choice for saving the life of a conscious choking victim.
In my first post on the Heimlich Experiment (A Call To Reconsider The Heimlich Experiment: Let’s Scientifically Determine The Best Approach To Choking Victims) I showed:
-that the the maneuver was accepted as the optimal treatment of chokers due to a promotional campaign by its developer, Henry Heimlich.
-that the experimental evidence actually supports chest thrusts as the optimal treatment.
-that unbiased reviews of the clinical literature do not provide evidence that the Heimlich Maneuver should be the first treatment for chokers.
Despite these facts, it is clear to me that thousands of people have utilized what they consider to be the Heimlich Maneuver on what they believed to be  a conscious choking victim with what they thought was a positive outcome as a result.
Unfortunately without proper documentation it  is impossible to know in these anecdotal cases:
-that a true Heimlich was applied
-that he victim would have died from foreign body airway obstruction if the maneuver had not been applied
-that the outcome was positive.
In addition, given that individuals are much more motivated to report positive outcomes we do not know how many cases there are where the Heimlich maneuver failed or resulted in adverse outcomes.

Heimlich and Koop: “Back Blows Are Lethal”

Heimlich promoted his maneuver while simultaneously doing his best to characterize alternative treatments as dangerous, frequently quoting C. Everett Koop, then Surgeon General of the United States.
Despite a total lack of scientific evidence,  Koop wrote an opinion piece in the journal of the Public Health Service in 1985 advocating the “Heimlich Maneuver” as the “best rescue techniqe in any choking situation.”

“Millions of Americans have been taught to treat persons whose airways are obstructed by a foreign body by administering back blows, chest thrusts and abdominal thrusts. Now they must be advised that these methods are hazardous, even lethal. A back slap can drive a foreign object even deeper into the throat. Chest and abdominal thrusts, because they refer to blows to unspecified locations on the body, have resulted in cracked ribs and damaged spleens and liver, among other injuries.”

Koop was prodded to make these totally unsubstantiated proclamations in a government funded journal by none other than Heimlich and his protege Ed Patrick (who has claimed co-creation credit for the HM). Koop’s comments are quite ironic given that we now know that the Heimlich maneuver has caused dozens of injuries with some resulting in death .
What’s even more striking about Koop’s statement is how confusing and sloppy it is. It appears that he doesn’t even understand what the Heimlich is,  grouping abdominal thrusts (the generic name for the HM) along with back blows and chest thrusts as methods which are “hazardous, even lethal.” In one sentence he says that abdominal thrusts have resulted in cracked ribs and damaged spleens and liver, among other injuries”.

Given that the public has been told to perform the HM on conscious, choking victims with little or no precise guidance on how much force to apply it is not surprising that significant complications have routinely been reported after HM application.
A 2018  case report describes one of the many possible complications that can ensue when one pushes forcefully on the abdomen of a choking person. The setting is a familiar one-an elderly individual begins choking on her food:

An 85-year old woman was in the hospital recovering from knee arthroplasty. While eating, she began to choke on her food. The event was noticed by a nurse who immediately performed HM. The episode resolved.

The next day  the woman became short of breath and had difficulty swallowing and the chest x-ray below was obtained showing a large incarcerated hiatal hernia.

(a) Large hiatal hernia occupying most of the lower right chest cavity. (b) Baseline chest film, where the diaphragmatic hernia cannot be appreciated. (c) Postoperative chest film, with resolution of the diaphragmatic hernia.
Following surgery to repair the hernia the patient developed septic shock and severe malnutrition and spent 50 days in the hospital before being discharged to a rehab facility.

An 11 year old boy suffered a pancreatic transection and survived surgery
A 3 year old boy developed pancreatitis and a pseudocyst
An 88 year old man suffered a laceration of the liver
A 51 year old man died from asphyxiation post HM with autopsy showing laceration of the mesentery.

Severe Injuries To The Aorta

Patients who have aneurysms of the thoracic or abdominal aorta are at risk for complications when extreme pressure is applied to the abdomen. The 2010 review noted:

There were 8 major aorta injuries with 6 deaths. One survivor had displacement of a prior stent endograft and was doing well heimlichwith surgery. The other survivor had surgery for thrombosis of a 4.5 cm aneurysm with a leg amputation and permanent hemodialysis. One man had an incorrect applica- tion of the HM resulting in thrombosis in an abdominal aneu- rysm; he expired. One thrombosis of the aorta without aneurysm was treated with tissue plasminogen activator with a poor out- come. Another died from ruptured aortic dissection without an aneurysm. The HM definitely seemed needed in 6 of the 8. Aneurysms were present in 5, and an atherosclerotic aorta was present in all. The age range was from 62 to 84 years; 6 of the 7 were men.

The most recent HM case report was in February of this year and described a 67 year old man who developed left sided weakness immediately following application of the HM. The cause-dissection of the proximal thoracic aorta, a life-threatening condition.
Since that 2010 review I am also aware of case reports describing a fatal splenic rupture, a gastric perforation and another incarcerated hernia following HM.
These case reports likely represent only the tip of the iceberg-we basically have no idea what the complication rate of HM performance is.

Heimlich Maneuver Often Credited For Saving Life When It Is Really  A Guildner Maneuver (Chest Thrust)

Chillag, et al in their 2010 paper pointed out that:

In many of these reports it was difficult to ascertain if the HM was definitely indicated or performed correctly.
In 8, the HM was definitely needed; in 5 it was unknown. It is not clear if the HM was performed properly in any of the 13. Seven of these had repeated efforts which may be appropriate, but some descriptions seemed excessively zealous.

Just as it is difficult to know whether it was a Heimlich or a chest thrust that resulted in success it is difficult to say  which caused complications.
The recent report that Senator Joe Manchin of West Virginia “saved the life” of Missouri Senator Claire McCaskill illustrate sthis problem. McCaskill is reported to have suffered a fractured rib as a result of Manchin’s actions.
A true Heimlich Maneuver would not have fractured her rib. On the other hand, a chest thrust would have. Was McCaskill saved (and injured) by a chest thrust or a Heimlich maneuver? Given that these events occurs in a chaotic, confused and hectic way it is typically impossible to know with certainty.