When performing abdominal thrusts on a choking victim, you stand behind the person, wrap your arms around their waist, and deliver sharp inward and upward thrusts just below the ribcage. This compresses the diaphragm, creating a sudden spike in pressure inside the chest that forces air upward through the airway, pushing the lodged object out. Current American Heart Association guidelines recommend alternating five back blows with five abdominal thrusts, repeating the cycle until the object comes out or the person becomes unresponsive.
When Abdominal Thrusts Are Needed
Abdominal thrusts are for severe airway obstruction, meaning the person cannot cough, speak, or breathe effectively. Someone with a partial blockage who is coughing forcefully is still moving air, and you should encourage them to keep coughing rather than intervene physically. The moment to act is when coughing stops working or never starts at all.
The classic signal is the “universal choking sign,” where a person clutches their throat with one or both hands. Other signs of severe obstruction include an inability to speak or make sound, weak or silent coughing, and skin color changes. On lighter skin, you may notice a bluish tint around the lips and fingernails. On darker skin, the lips and gums may turn gray or white. These color changes indicate oxygen levels are dropping and intervention is urgent.
The Updated Rescue Sequence
The AHA’s most recent guidelines changed the recommended approach for adults and children. Instead of jumping straight to abdominal thrusts, you now alternate between two techniques:
- Five back blows: Stand to the side and slightly behind the person. Support their chest with one hand and lean them forward. Deliver five firm blows between the shoulder blades with the heel of your other hand.
- Five abdominal thrusts: Move behind the person, wrap your arms around their waist, and deliver five quick thrusts (detailed below).
Continue alternating between back blows and abdominal thrusts until the object is expelled or the person loses consciousness. If the person becomes unresponsive, lower them to the ground and begin CPR.
Hand Placement and Technique
Proper hand placement makes the difference between an effective thrust and a wasted one. The target zone is the epigastric region, the soft area of the upper abdomen between the navel and the bottom of the ribcage. Foreign objects that cause choking typically lodge above the vocal cords, and the burst of pressure from a correctly placed thrust is what pushes them free.
Here’s the technique step by step: Stand directly behind the person and wrap both arms around their waist. Make a fist with one hand and place the thumb side against the abdomen, roughly at navel level or slightly above. Grab that fist with your other hand. Pull sharply inward and upward in one quick motion, as if you’re trying to lift the person off the ground. Each thrust should be a distinct, forceful movement, not a squeeze.
A well-executed thrust generates roughly 50 to 60 cm H₂O of pressure inside the chest. That’s meaningful force, though still less than a strong voluntary cough (which can reach nearly 180 cm H₂O). The reason abdominal thrusts work is that a choking person can’t generate a cough on their own, so you’re creating that expulsive pressure artificially.
How Effective Are Abdominal Thrusts?
A recent meta-analysis of six studies covering 789 cases found that the Heimlich maneuver successfully cleared the airway about 71% of the time. That’s a strong success rate for an emergency technique anyone can perform without equipment. The alternating approach with back blows improves overall odds because each method generates pressure in a slightly different way, and what fails on one attempt may succeed on the next.
Modifications for Special Situations
Pregnant or Large-Bodied Individuals
If you cannot reach around the person’s abdomen, or if they are visibly pregnant, switch to chest thrusts. Place your hands at the base of the breastbone, just above where the lowest ribs meet. Press hard into the chest with a quick thrust, using the same sharp inward motion you would for abdominal thrusts. The pressure still transmits to the airway, just through a different path.
Infants Under One Year
Never perform abdominal thrusts on an infant. Their small, fragile organs are too vulnerable to the force involved. Instead, alternate five back blows (with the infant face-down on your forearm, head lower than the body) with five chest compressions using the heel of one hand on the breastbone. For children older than one year, use the same adult sequence of back blows and abdominal thrusts, adjusting your force to the child’s size.
Choking While Alone
You can perform abdominal thrusts on yourself. Make a fist and place it against your upper abdomen in the same position another person would use. Grab your fist with your other hand and thrust sharply inward and upward. Alternatively, lean your upper abdomen over the back of a sturdy chair, the edge of a table, or a railing, and use your body weight to drive the edge into your abdomen. Research from a study published in Thorax found that self-administered thrusts generate pressure comparable to thrusts delivered by another person. The chair method actually produced the highest pressures measured in that study, roughly double those from a standard standing Heimlich maneuver.
Potential Injuries From the Maneuver
Abdominal thrusts involve real force applied to a vulnerable area of the body, and injuries can happen. A literature review identified 37 reported cases of complications. Abdominal injuries were the most common (17 cases), with stomach rupture accounting for most of those. Injuries to the aorta were the second most frequent category (10 cases). Pancreatic injuries, though rare, tended to occur in younger patients. The elderly are at highest risk for complications overall.
These injuries are uncommon relative to how often the maneuver is performed, and they don’t change the calculus: a choking victim who cannot breathe will die without intervention. But they do explain why anyone who receives abdominal thrusts should be medically evaluated afterward, even if the object came out and they feel fine. Internal damage from the compressions, including bruising to organs, cracked ribs, or in rare cases inflammation of the pancreas, may not produce immediate symptoms. One documented case involved a healthy three-year-old who developed pancreatic complications days after a successful Heimlich maneuver.
If the Person Becomes Unresponsive
When a choking victim loses consciousness, the situation shifts from choking rescue to cardiac arrest protocol. Lower the person carefully to the ground and begin CPR immediately. Each time you open the airway to deliver a breath, look in the mouth for a visible object. If you can see one, remove it. Do not blindly sweep the mouth with your fingers, as this can push the object deeper. Continue CPR until the person revives, the object is expelled, or emergency medical services arrive.