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”.
Complications Of The Maneuver
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.
The Elderly: High Risk For Both Choking And HM Complications
According to Injury Facts 2017, choking is the fourth leading cause of unintentional injury death. Of the 5,051 people who died from choking in 2015, 2,848 were older than 74.
Chillag, et al speculated that altered skeletal anatomy in the elderly might contribute to difficulty in properly applying the HM:
The significant loss of height that occurs with aging is axial; the lower rib to pelvis distance may decrease significantly with aging, perhaps making the xiphoid to umbilicus target for the usual HM not always achievable.
Chillag, et al advised caution in using the HM on the elderly:
Particular care seems indicated in the frail elderly with altered anatomy, vascular disease, fragile bones, and frequent esophageal swallowing problems.
The authors of the 2018 case report described above concluded:
Though HM is a life-saving procedure, we believe it would be wise to not only exercise caution when performing abdominal thrusts on the elderly and ensuring that it is indeed indicated, but also closely monitoring the individuals for dysphagia, odynophagia, respiratory distress, or shock after the maneuver.
What Do Countries Who Have Not Been Influenced By Henry Heimlich Recommend?
Life-threatening complications associated with use of abdominal thrusts have been reported in 32 case reports. (see reference1 below )[Class A not recommended; LOE IV] Therefore, the use of abdominal thrusts in the management of FBAO is not recommended and, instead back blows and chest thrusts should be used.
If the person is conscious send for an ambulance and perform up to five sharp, back blows with the heel of one hand in the middle of the back between the shoulder blades. Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than to give all five blows. An infant may be placed in a head downwards position prior to delivering back blows, i.e. across the rescuer’s lap [Class B; LOE IV].
If back blows are unsuccessful the rescuer should perform up to five chest thrusts.
Heimlich Maneuver: Time For A Reconsideration
Thus, it is clear the Heimlich maneuver was recommended by Henry Heimlich for general usage without any human clinical studies to support its safety and efficacy. With Heimlich’s aggressive promoting of the technique it became the recommended way to treat choking conscious individuals despite experimental evidence showing it inferior to chest thrusts and no controlled human trials to support its safety and effectiveness.
Australia and New Zealand, countries free of Heimlich’s influence, do not recommend the Heimlich maneuver for choking victims.
It is entirely possible that chest thrusts are a safer and more effective maneuver for removing foreign bodies from choking victims. Since Dr. Heimlich died in December, 2016 perhaps the organizations that teach CPR can reevaluate their recommendations in this area without fear of public shaming or retribution.
Given the uncertainty in the treatment of choking victims and the number of deaths a national trial comparing chest thrusts versus abdominal thrusts as the initial procedure should be initiated as soon as possible.
Special thanks to investigative blogger Peter M. Heimlich for providing his unique archive of information on Henry Heimlich to assist me in this post and putting me in touch with Charles Guildner MD, the retired anesthesiologist (turned fine arts photographer) who published research showing chest thrusts produce greater airflow than abdominal thrusts. Dr. Guildner’s photos of the landscape and the lives of the people of the rural heartland are wonderful and can be found here. Research by Peter and his wife Karen M. Shulman has resulted in scores of exposes in the lay press about what they term Dr. Heimlich’s “wide-ranging unseen history of fraud,” and is documented on their website: http://medfraud.in