Tag Archives: foreign body airway obstruction

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”.

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.

Shawn Chillag’s  paper in 2010 (entitled The Heimlich Maneuver: Breaking Down The Complications) summarized the then current literature of case reports on complications of the Heimlich Maneuver.

There were 41 cases of significant injury with 27 cases of injury in the abdomen or diaphragm and 14 cases of injury in the thorax.

Among the 14 thorax injuries, 3 involved the esophagus, 4 the mediastinum, 5 the rib cage, and 2 the aortic valve.

Of the 27 abdominal injuries, 13 were severe lacerations or ruptures of the stomach, all on the lesser curvature ranging from 2 cm to 10 cm long.All were in adults from age 39 to 93 with 9 older than 60 years; one report gave no age. All but one, who died rapidly, underwent emergency surgery with 4 expiring and 8 doing well.

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?

The Australia  and New Zealand Committe on Rescucitation (ANZOR) guidelines for choking (PDF accessed 10/13/2019 anzcor-guideline-4-airway-jan16) specifically advise against using abdominal thrusts stating:

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.

the ANZOR guidelines recommend starting with back blows

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].

After the five back blows ANZOR advises moving on to try five chest thrusts.

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.

Skeptically Yours,

-ACP

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

 

Reference 1. Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, Hatanaka T, Hazinski MF, Jacobs I, Monsieurs K, Morley PT, Nola JP, Travers AH. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81:e48–e70. http://www.resuscitationjournal.com

 

 

A Call To Reconsider The Heimlich Experiment: Let’s Scientifically Determine The Best Approach To Choking Victims

What should you do if you encounter someone choking on food?

If you ask someone on an American street  the likely answer will be to “perform a Heimlich maneuver.”

This is understandable because we frequently hear of celebrities performing or having performed on them a Heimlich maneuver and saving or being saved from choking to death. In addition, we have  descriptions of individuals relating their own stories of lives saved.

For example, in May of 2016, 96-year-old Dr. Henry Heimlich, widely credited as the inventor of the eponymous abdominal thrust procedure, made headlines around the world when he reportedly performed it on a fellow retirement home resident in Cincinnati.

Surprisingly, despite the widespread belief that the Heimlich maneuver is the scientifically-affirmed treatment of choice for choking victims, there is only anecdotal evidence for its effectiveness as well as its dangers and there is no scientific consensus on the best approach to a person who is choking or has foreign body airway obstruction (FBAO).

The Origins of The Heimlich maneuver

In 1972,  Heimlich writes in his autobiography “Heimlich’s Maneuvers“,  he came across a NY Times article  which revealed that the sixth leading cause of accidental deaths in the
US  was  choking on a foreign body, usually food ,and that 3900 individuals were dying from foreign body airway obstruction (FBAO) a year.

 

The typical scenario for these deaths was first described  in a 1963 JAMA report on 9 patients who suddenly collapsed at a dinner table and were subsequently pronounced dead on arrival to the emergency room. Death had been attributed to coronary artery disease but  at autopsy these victims were found  to have food obstructing their airways  (4 by steak, 2 by beef, one by ham and one by kippered herring). The author termed these sudden deaths in resturants “The Cafe’ Coronary.”

In 1972 there was no consensus on how to treat victims of the Cafe’ Coronary and Heimlich noted that the three options were

  1. Inserting a large-caliber hypodermic needle into the trachea or performing a tracheotomy
  2. Utilizing an instrument designed to remove the object from the throat
  3. Slapping choking victims on the back.

Noting the risks of option one, the impracticality of option two and the lack of scientific evidence to support option 3,  Heimlich pondered a better approach, one that would utilize the residual air in the victim’s lungs to forcefully expel the lethal food bolus “like the cork from a Champagne bottle.”

Pop Goes The Cafe’ Coronary

Heimlich first described his  namesake maneuver in an article in Emergency Medicine in June of1974 entitled “Pop Goes The Cafe Coronary.”

Standing behind the victim the rescuer puts both arms around him just above the belt line, allowing head, arms and upper torso to hang forward. Then, grasping his own right wrist with his left hand, the rescuer rapidly and strongly presses into the victim’ abdomen, forcing the diaphragm upward, compressing the lungs and expelling the obstructing bolus

Heimlich states in the 1974 article that the procedure was adapted from “experimental work “with four 38-pound beagles.

Although admitting that these results might not be duplicated in humans, he indicates that “there is certainly no risk in recommending that the procedure be tried in actual cafe’ coronary emergencies.”

“then, as experiences are reported, the method can be evaluated.”

Shockingly, Heimlich, in this article (subsequently picked up and promoted by the lay press) proposed to  all Americans that they begin an experiment on helpless choking victims to see if his newly developed idea was of any benefit.

He requests in the last lines of this monumental communication that Americans help him gather information from the experiment.

“Should you use, or learn of anyone else using, the Heimlich method by the way, please report the results either to EM or me.”

Flimsy Experimental Basis For Heimlich

Four 38 pound beagles-The experimental work supporting an unsupervised, unregulated national experiment on choking victims!

Below is the sum total of the description Heimlich provides for his experiments:

After being given an intravenous anesthetic, each dog was “strangled” with a size 32 cuffed endotracheal tube inserted into the larynx. After the cuff was distended to create total obstruction of the trachea, the animal went into immediate respiratory distress as evidenced by spasmodic, paradoxical respiratory movements of the chest and diaphragm. At this point, with a sudden thrust. I pressed the palm of my hand deeply and firmly into the abdomen of the animal a short distance below the rib cage, thereby pushing upward on the diaphragm. The endotracheal tube popped out of the trachea and, after several labored respirations, the animal began to breathe normally. This procedure was even more effective when the other hand maintained constant pressure on the lower abdomen directing almost all the pressure toward the diaphragm.

We repeated the experiment more than 20 times on each animal with the same excellent results When a bolus of raw hamburger was substituted for the endotracheal tube, it, too, was ejected by the same procedure, always after one or two compressions.

This “experimental work” seems to have been sloppily done and would not have passed muster through a legitimate current day peer-reviewed scientific journal. It seems more like the observations of an 18th century  scientist than a 20th century one.

Here are a few of the red flags I see that suggest either these experiments weren’t really done or that they need to be repeated with better documentation or by an investigator who is unbiased as to the outcome.

  • The beagles are all exactly the same size
  • There are no measurements recorded. Of any kind.
  • Important data was not recorded: What anesthetic was utilized? What was the position of the animals? How long between experiments?. How many “more than 20 times” were the animals choked.? How big was the hamburger bolus?

Flimsy Experimental Work Embellished And Republished

A year later Heimlich was  apparently emboldened by reports of the successful application of his now namesake maneuver and his “special communication” ,published in JAMA, in October of 1975 reiterated his previous publication with a near identical description of the experiments on the four 38 pound beagles.

He added some more details to these experiments. For example, we learn the beagles were anesthetized, with thiamyial sodium given intravenously.

And he embellishes the method for choking the dogs

A cuffed, No. 32 endotracheal tube, the lumen plugged by a rubber stopper, was inserted under direct vision through the mouth into the larynx. The cuff was distended with 3 to 4 ml of air, causing total obstruction of the trachea, simulating a bolus of food caught in the human larynx. The animal immediately went into respiratory distress, as evidenced by spasmodic paradoxical respiratory move- ments of the chest and diaphragm.

At first, the rib cage was manually compressed in an attempt to increase the intrapulmonary pressure and expel the bolus. This procedure was unsuccessful. It was later realized that the compressibility of the lungs by this technique was inadequate due to the rigidity of the chest wall. Furthermore, any increase in intrapleural pressure would be dissipated by depressing the diaphragm.

Apparently realizing that he needed to provide some evidence that his abdominal thrusts were superior to chest compression He added to  his experimental description the following:

At first, the rib cage was manually compressed in an attempt to increase the intrapulmonary pressure and expel the bolus. This procedure was unsuccessful.

And adds a gratuitous explanation for the failure of the chest compression:

It was later realized that the compressibility of the lungs by this technique was inadequate due to the rigidity of the chest wall. Furthermore, any increase in intrapleural pressure would be dissipated by depressing the diaphragm.

Subsequently, I pressed the palm of my hand deeply and firmly upward into the abdomen of the animal a short dis- tance below the rib cage, thereby pushing against the dia- phragm. The endotracheal tube (bolus) popped out of the trachea.

Interestingly, there is no published, peer-reviewed paper verifying the research that Heimlich claims to have done in developing this procedure. And according to his son, Peter M. Heimlich, his father’s archives at a University of Cincinnati medical library include no documentation of the research on the beagles.

 

The Chest Thrust (Guildner Maneuver): A Superior Approach?

Two years later, Charles W. Guildner, an Everett, Washington anesthesiologist and American Heart Association (AHA) consultant, published the results of experiments he performed on six human volunteers which concluded that chest thrusts were  superior to abdominal thrusts in generating air flow out of the trachea and presumably more effective at clearing foreign bodies obstructing the airway of choking victims. Guildner’s results are supported by  a study by Audun Langhelle of Oslo, Norway, published in 2000 by the journal Resuscitation.

Langhelle compared peak airway pressure with standard chest compressions versus Heimlich maneuvers done by emergency physicians in cadavers with simulated complete airway obstruction in a randomized crossover design.  Mean peak airway pressure was significantly lower with the Heimlich maneuver than with the chest compressions.

Heimlich Markets and Bullies To Gain Prominence For His Maneuver 

Prior to 1976, the guidelines of the AHA and the American Red Cross (ARC)  recommended back blows as the best treatment for responding to a conscious choking victim. After a 1976 National Academy of Science conference on emergency airway management (at which Heimlich was an invited participant), both organizations adopted the following recommendations:

  1. Back blows (4)
  2. Manual thrust (4)
  3. If ineffective repeat back blows and manual thrusts until they are effective or until the victim becomes unresponsive.
Host Johnny Carson demonstrates the Heimlich maneuver on actress Angie Dickenson while Dr. Henry Heimlich watches on April 4, 1979..

For Heimlich, having his maneuver incorporated in US first aid guideliness only two years after he introduced it wasn’t enough. He then embarked on a ten-year media campaign he called “back blows are death blows” in which he accused the AHA and ARC of putting lives at risk because they continued to recommend that treatment.

In 1986, with support from Dr. C. Everett Koop, U.S. Surgeon General under President Ronald Reagan, Heimlich got his way. The AHA removed backblows from its guidelines and endorsed the Heimlich maneuver as the sole approach to the choking victim. The ARC followed suit.

Heimlich’s typical rhetoric on this issue can be found in a July, 1988 NY Times editorial where he extensively quotes Koop’s condemnation of back blows and states:

“The organizations and journals responsible for disseminating this medical error should advise Americans that the back slap, taught for more than a decade as a treatment for choking, causes death.”

Review Of The Literature Finds Abdominal Thrusts and Chest Compressions Equivalent

In 2005, the American Red Cross, after reviewing the scientific literature concluded that back blows, abdominal thrusts, and chest thrusts were equally effective for FBAO.

As a result, the ARC’s 2005 Guidelines for Emergency Care and Education essentially returned to their 1976-1985 recommndation to treat conscious, choking children and adults, now called “the five and five”: first perform 5 back blows; if that fails to remove the obstruction, proceed with 5 abdominal thrusts. If necessary, repeat the cycle.”

Heimlich, ever vigilant of the primacy of his maneuver, condemned this to the Cincinnati Enquirer in a 2013 interview.

Those recommendations “horrify” Heimlich. “There has never been any research saying the back slap saves lives,” he said. “We know the Heimlich maneuver works. So it comes down to a matter of life or death.”

Richard Bradley, MD writing in defense of this change on the Red Cross blog  in 2013 wrote:

A review of the scientific literature suggested that back blows, abdominal thrusts and chest compressions are equally effective. Additionally, the use of more than one method can be more effective to dislodge an object. These findings are consistent with those of international resuscitation societies.

The Red Cross certainly isn’t discounting the use of abdominal thrusts. But we include back blows, abdominal thrusts and chest compressions in our training because there is no clear scientific evidence to say that one technique is more effective than the others when treating a choking victim.

. “Additionally, the use of more than one method can be more effective to dislodge an object. These findings are consistent with those of international resuscitation societies.”

The AHA ‘s 2005  Adult Basic Life Support guidelines were published in Circulation recognizing that there was insufficient evidence to promote the Heimlich maneuver (like the ARC, now referring to it by the generic abdominal thrust) over back slaps or chest thrust

Chest thrusts, back blows/slaps, or abdominal thrusts are effective for relieving FBAO (Foreign Body Airway Obstruction) in conscious adults and children >1 year of age, although injuries have been reported with the abdominal thrust. There is insufficient evidence to determine which should be used first. These techniques should be applied in rapid sequence until the obstruction is relieved; more than one technique may be needed. Unconscious victims should receive CPR. The finger sweep should be used in the unconscious patient with an obstructed airway only if solid material is visible in the airway. There is insufficient evidence for a treatment recommendation for an obese or pregnant patient with FBAO.

Interestingly, the switch in recommendations and the change in terminology were likely influenced by Dr. Heimlich’s son investigative blogger Peter M. Heimlich. 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.info

The AHA Goes Back To The Heimlich

In 2010, the AHA guidelines revisited foreign body airway obstruction (FBAO) and gave the abdominal thrust priority again “for simplicity in training.”:

Although chest thrusts, back slaps, and abdominal thrusts are feasible and effective for relieving severe FBAO in conscious (responsive) adults and children ≥1 year of age, for simplicity in training it is recommended that abdominal thrusts be applied in rapid sequence until the obstruction is relieved. If abdominal thrusts are not effective, the rescuer may consider chest thrusts. It is important to note that abdominal thrusts are not recommended for infants <1 year of age because thrusts may cause injuries.

The 2015 AHA guidelines did not update  the 2010 FBAO recommendations

Scientific Support For The Heimlich

An abstract presented at the 2012 AHA meetings reviewed the scientific literature to answer the question:

For adults, either conscious or unconscious, with obstructed airway, does any specific resuscitation techniques compared to currently recommended techniques, lead to different outcomes?”

This review found only two studies provided significant evidence to support recommendations

  1. one fair quality LOE 3b study suggests that peak airway pressures developed by chest compressions are significantly higher than the pressure from abdominal thrusts
  2. 2. one poor quality LOE 4 study suggests that for conscious adults with an obstructed airway, abdominal thrusts generate higher peak airway pressures when delivered when the victim is supine as compared to seated and that back blows do not generate any significant change in airway pressure.

The final conclusion of this review:

Clearly, there is a dearth of evidence to support basic life support treatment guidelines for this important problem.

 

Choking Treatment Recommendation in Australia/New Zealand/UK

In the resuscitation guidelines of medical organizations in Australia and New Zealand, the Heimlich maneuver is warned against as unproven and  to be avoided due to “life-threatening complications” associated with its use. Instead, first aid authorities in those countries recommend first performing a series of backblows followed by, if necessary, a series of chest thrusts, the treatment studied by Guildner (1976) and Langhelle (2000).

The Resucitation Council of the United Kingdom recommends the following for choking victims:

  1. Encourage to cough
  2. Give back blows (up to 5). Support the chest with one hand and lean the victim well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the airway.Give five sharp blows between the shoulder blades with the heel of your other hand
  3. Give abdominal 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.

Skeptically Yours,

-ACP

N.B. In Part Two of this analysis of the Heimlich maneuver we will review the evidence of the harm the Heimlich maneuvers have done over the years.