SKILL
AIRWAY EMERGENCY: AIRWAY OBSTRUCTION
CHILD
PERFORMANCE OBJECTIVES
Demonstrate competency in recognizing and managing an airway obstruction in a child (1-year-old to puberty) who is choking.
CONDITION
Recognize and manage an airway obstruction in a child who is found choking. Necessary equipment will be adjacent to the manikin or
brought to the field setting.
EQUIPMENT
Child manikin, child bag-valve-mask device, O2 connecting tubing, oxygen source with flow regulator, pediatric resuscitation tape,
goggles, various masks, gown, gloves, timing device.
PERFORMANCE CRITERIA
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Items designated by a diamond () must be performed successfully to demonstrate skill competency.
Items identified by double asterisks (**) indicate actions required, if indicated.
Items identified by the symbol (§) should be practiced.
Ventilations and compressions must be performed at the minimum rate required.
PREPARATION
Skill Component
Key Concepts
 Mandatory (minimal) personal protective equipment – gloves
 Take body substance isolation precautions
 Assess scene safety/scene size-up
 If unknown as to possible trauma, manage as trauma
(determined by environment and information obtained from
bystanders).
 Depending on the size of the child and if spinal immobilization is
required, an additional rescuer is needed to maintain in-line axial
stabilization.
** Consider spinal immobilization - if indicated
 Evaluate need for additional BSI precautions
 Situational - goggles, mask, gown
 Approach the child and introduce yourself to the child and
caregiver
 Use age appropriate techniques to introduce yourself to the child
 The caregiver should hold the young child during the
assessment if the child is in distress and responsive.
RESPONSIVE CHILD
PROCEDURE
Skill Component
Key Concepts
 Establish that the child is choking:
 Mild Obstruction:
- adequate air exchange
- coughing
- gagging
- stridor/wheezing
** Call for additional resources – if needed
 Severe Obstruction:
- poor or no air exchange
- increased respiratory distress
- weak, ineffective cough or no cough
- stridor (high-pitched noise while inhaling) or no noise
- unable to speak
- clutching the neck (universal sign of choking)
- cyanosis
- decreasing level of consciousness
Continued
Airway Emergency: Child Airway Obstruction ©
2013, 2009, 2008, 2007, 2006, 2003
Page 1 of 5
Skill Component
Key Concepts
 Signs and symptoms of airway obstruction may be caused by a
foreign body or infection of the upper airway such as epiglottitis
and croup.
 Infection should be suspected if the child has a fever and is
congested, hoarse, drooling, lethargic, or is limp.
 DO NOT interfere if child has an effective cough.
 Attempt to remove foreign body obstruction:
 Mild obstruction - Encourage child to cough
 Severe obstruction - Perform abdominal thrusts
(Heimlich maneuver)
- Stand or kneel behind the victim and place thumb
side of fist above child’s umbilicus
- Grab fist with other hand and give quick inward and
upward thrusts - as many times as needed
 Continue abdominal thrusts until obstruction is relieved or
the child becomes unresponsive.
 ONLY attempt to remove an obstruction caused by a foreign body.
An obstruction caused by an infection will not clear with obstruction
maneuvers and the child must be transported immediately to the
closest emergency department approved for pediatrics (EDAP).
 Straddle responsive child and perform Heimlich maneuver if found
lying down.
 Deliver as many abdominal thrusts as needed until the object is
expelled, the child starts to breathe, or becomes unresponsive.
 Give each new thrust as a separate and distinct movement..
** If unresponsive – start sequence for airway
obstruction for unresponsive child.
 Manage ventilations after removal of obstruction:
 If breathing is restored and adequate:
- medical - place in position to protect airway – if child
is altered or unresponsive
- trauma - initiate spinal immobilization – if indicated
 If breathing is absent or inadequate:
 There is no universal recovery position for children. A child who is
altered should be placed in a position to protect the airway and
reduce the chances of the airway being occluded by the tongue
and from aspiration of mucus or vomit.
 Signs of inadequate breathing are respiratory distress, fast/slow
respirations, bradycardia, stridor, cyanosis, poor perfusion, and
altered LOC.
 Supplemental oxygen should always be used after spontaneous
breathing has resumed.
- perform rescue breathing of 12-20 per minute
(1 breath every 3-5 seconds) with BVM or barrier
device
 Use only enough force when providing positive pressure ventilation
to allow for adequate chest rise. Over-inflation causes gastric
distention that will affect tidal volume by elevating the diaphragm.
 Use of a BVM by a single rescuer can result in an inadequate seal
on the face and may not be as effective as a barrier device.
 If the airway is open and it is difficult to compress the bag and air
leaks around the seal, an airway obstruction may still be present.
UNRESPONSIVE CHILD
PROCEDURE
(Children who were previously responsive may have obstruction relieved when muscles relax)
Skill Component
Key Concepts
 Establish unresponsiveness
** Call for additional resources – if needed
 Assess breathing for at least 5 seconds and no more than 10
seconds.
 Assess breathing 5-10 seconds for:
 Apnea
 Abnormal breathing
 Gasping
 Agonal gasps are not breathing but may be present in the 1
several minutes after sudden cardiac arrest.
st
 Gasps may sound like a snort, snore, or groan.
rd
 If more than 2 rescuers, the 3 rescuer should open the airway
and start ventilations.
Airway Emergency: Child Airway Obstruction ©
2013, 2009, 2008, 2007, 2006, 2003
Page 2 of 5
Skill Component
Key Concepts
 Palpate for carotid pulse 5-10 seconds - unless history of
chocking
 Palpate the pulse for at least 5 seconds and no more than
10 sec.
 Palpate carotid pulse on same side as the rescuer. DO NOT
reach across the neck. An alternative to Palpating a carotid
pulse is to palpate a femoral pulse.
** NO need to check for pulse if chocking has been
established.
 Start compressions if unsure if child has a pulse. Unnecessary
CPR is less harmful than if CPR is not performed when
indicated.
 Start compressions (C-A-B sequence)
 Ratio cycle: 30 compressions to 2 ventilations
 Complete 5 sequences (2 minutes) of CPR
 Open airway:
 Medical
- head-tilt/chin-lift
 Trauma
- jaw-thrust
- neutral position (tragus of ear should be level with
top of shoulder)
 Use the jaw thrust maneuver when a head, neck, or spine injury is
suspected.
 If the jaw thrust maneuver does not open the airway to allow for
adequate ventilation, use the head tilt-chin lift technique.
 Use shoulder padding to maintain airway and spinal alignment.
 The tongue and epiglottis may obstruct the entrance of the trachea
due to inspiratory efforts creating negative pressure in the airway.
 The child’s airway is more compliant and may collapse during their
respiratory effort. The airway is easily obstructed by mucus, blood,
pus, edema, external compression, and hyperextension.
 Look in mouth for foreign body:
 Attempt to remove foreign body obstruction - if
visualized
 Attempt 2 breaths with BVM or mouth-to-barrier-device
(1 second/breath)
Repositions head and attempt 2
ventilation is unsuccessful
nd
ventilation – if 1
st
**- If object is not visible – continue CPR, starting with
compressions
 Always look in mouth for foreign body prior to giving breaths
 In children, the most common cause of cardiac arrest is an
inadequate airway.
 DO NOT perform a blind finger sweep, this may force object further
down the trachea. Perform finger sweep only if object is visible.
 To remove foreign body:
- insert the index finger inside the cheek and into the throat to the
base of the tongue.
- use a hook like motion to grasp the foreign body and maneuver
it into the mouth so it can be removed.
** Clear/suction airway - if indicated
 Continue CPR until foreign body obstruction is relieved
** Call for additional resources - If not called for
previously
 Reassess child after obstruction is relieved

-
 If a pulse is present and the child is not breathing adequately,
start BVM ventilations.
Check for:
Responsiveness to stimuli
Breathing
Pulse
 If the child is not altered he/she should be placed in a position of
comfort.

** Provide rescue breathing – 12-20/minute
(every 3-5- seconds) - if indicated
A child who is altered should be placed in the recovery position
to reduce the chance of the airway being occluded by the
tongue, and aspiration of mucus or vomit.
 There is no universal recovery position for children. A child who
is altered should be placed in a position to protect the airway
and reduce the chances of the airway being occluded by the
tongue and from aspiration of mucus or vomit.
 A child who is awake and alert should be placed in a position of
comfort.
Airway Emergency: Child Airway Obstruction ©
2013, 2009, 2008, 2007, 2006, 2003
Page 3 of 5
REASSESSMENT
(Ongoing Assessment)
Skill Component
Key Concepts
 Reassess the child at least every 5 minutes once the
child has return of spontaneous respirations and
circulation (ROSC):
 This is a priority patient and must be re-evaluated at least every
5 minutes or sooner, if any treatment is initiated, medication
administered, or condition changes.
 Primary assessment
 Relevant portion of the secondary assessment
 Vital signs
 Evaluate response to treatment
 The child must be re-evaluated at least every 5 minutes if any
treatment was initiated or medication administered.
 Evaluate results of reassessment and compare to
baseline condition and vital signs
 Evaluating and comparing results assists in recognizing if the
child is improving, responding to treatment or condition is
deteriorating.
**Manage child’s condition as indicated.
 Communication is important when dealing with the child, family,
or caregiver. This is a very critical and frightening time for all
involved and providing information helps in decreasing the
stress they are experiencing.
§ Explain the care being delivered and the transport
destination to the child/caregivers
PATIENT REPORT AND DOCUMENTATION
Skill Component
Key Concepts
§ Give patient report to equal or higher level of care
personnel
 Report should consist of all pertinent information regarding the
assessment finding, treatment rendered and child’s response to
care provided.
§ Verbalize/Document:
 Reassessment of airway includes:
- chest rise and fall
- skin color
- airway patency
 Cause of obstruction - identify foreign body
 Observed or reported signs of obstruction:
- skin signs
- absent or inadequate respirations
 Response to obstruction maneuver
 Reassessment of airway
 Additional treatment provided
Developed: 10/03
 Documentation must be on either the Los Angeles County EMS
Report or departmental Patient Care Record form.
Revised 6/06, 10//07, 11/08, 4/09,, 1/13
Airway Emergency: Child Airway Obstruction ©
2013, 2009, 2008, 2007, 2006, 2003
Page 4 of 5
AIRWAY EMERGENCY: AIRWAY OBSTRUCTION
CHILD
Supplemental Information
INDICATIONS:
 Children who are choking with signs of mild or severe airway obstruction (1 year of age to puberty)
CAUSES:
 Intrinsic cause - tongue (most common), infection, and swollen air passages
 Extrinsic cause - foreign body, facial injuries, vomitus, etc
CONTRAINDICATIONS:
 None when above condition applies.
COMPLICATIONS:
 Gastric distention
 Rib fractures
 Sternal fractures
 Separation of ribs from sternum
 Laceration of liver or spleen
 Pneumothorax
 Hemothorax
 Lung and heart contusion
 Fat emboli
 Other internal injuries
Recognizing Choking in the Responsive Child
Mild Airway Obstruction Signs
Severe Airway Obstruction Signs
• Adequate air exchange
• Responsive and able to cough forcefully
• May wheeze between coughs
•
•
•
•
•
•
•
•
Poor or no air exchange
Weak, ineffective cough or no cough
Stridor (high-pitched noise while inhaling) or no noise
Increased respiratory difficulty
Possible cyanosis
Unable to speak
Clutching the neck (universal choking sign)
Decreasing level of consciousness
Rescuer Actions
Mild Airway Obstruction
Severe Airway Obstruction
• Encourage victim to continue coughing and attempt to
• Activate ALS response
breathe as long as there is adequate air exchange.
• If responsive, perform abdominal thrusts
• DO NOT interfere with the child’s attempts to expel the
• If unresponsive, start chest compressions
foreign body. Monitor his/her condition.
• Activate ALS
• Activate ALS response if mild obstruction persists.
NOTES:
 Child Obstructed Airway technique is indicated for children 1 year of age to puberty. A child reaches puberty when the child
displays secondary sexual characteristics.

Some signs of inadequate breathing are respiratory distress, fast/slow respirations, bradycardia, stridor, cyanosis, poor
perfusion, and altered LOC.

Obstruction may have been relieved prior to EMS arrival. The child should be transported for medical evaluation.

An additional rescuer is needed to maintain in-line axial stabilization if spinal immobilization is required.

If the child is in a prone position with suspected trauma, the child should be turned using log-roll method to avoid flexion or twisting
of the neck or back.
 There is no universal recovery position for children. A child who is altered should be placed in a position to protect the airway and
reduce the chances of the airway being occluded by the tongue and from aspiration of mucus or vomit.

DO NOT perform a blind finger sweep. This may force object further down trachea. Perform finger sweep only if object is visible.

Supplemental oxygen should always be used after spontaneous breathing has resumed.

The tongue is the most common cause of airway obstruction due to decreased muscle tone. Intrinsic causes of an obstruction
include infection and swollen air passages. Extrinsic causes include foreign body, facial injuries, vomitus, etc.

The tongue and epiglottis may obstruct the entrance of the trachea due to inspiratory efforts creating negative pressure in t he
airway

Any child who received abdominal thrusts must be evaluated medically to ensure there are no complications, injuries or retained
foreign body fragments.
 DO NOT hyperventilate. Hyperventilation reduces the success of survival due to cerebral vasoconstriction resulting in
decreased cerebral perfusion. In addition, hyperventilation increases intrathoracic pressure and decreases venous return to
the heart resulting in diminished cardiac output. Rescuers have a tendency to ventilate too rapidly.
 Priority patients are patients who have abnormal vital signs, signs/symptoms of poor perfusion, or if there is a suspicion that the
patient’s condition may deteriorate.
Airway Emergency: Child Airway Obstruction ©
2013, 2009, 2008, 2007, 2006, 2003
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