Back blows should be delivered between the shoulder blades, using the heel of your hand. This applies to adults, children, and infants alike. The target is the area on the upper back directly between the two shoulder blades, struck firmly with five rapid blows while the person is leaning forward or positioned head-down.
Exact Placement and Hand Position
The strike zone is the flat area of the upper back between the shoulder blades, roughly in the center. You use the heel of your hand, which is the firm, fleshy base of your palm near the wrist. This part of the hand delivers concentrated force without risking injury from a fist or fingertips.
Each blow should be firm and deliberate, not a gentle pat. The goal is to create enough pressure behind the obstruction to pop it loose from the airway. You deliver five quick strikes in succession, then switch to five abdominal thrusts if the object hasn’t come out. Keep alternating between the two until the blockage clears or the person becomes unresponsive.
Why Body Position Matters
Where you strike only works properly if the person is positioned correctly. Gravity plays a major role in helping dislodge a stuck object, so the choking person needs to be leaning forward. The Merck Manual recommends bending the person forward at the waist to about 90 degrees if possible. You wrap one arm around their waist or chest for support while delivering blows with your free hand.
Research published in AIMS Public Health found that a prone or head-down position significantly increases the effectiveness of back blows. When the head is lower than the chest, gravity pulls the foreign object toward the mouth rather than deeper into the airway. This principle is already standard practice for infants but applies to older children and adults as well. Several documented cases of failed Heimlich maneuvers were resolved once the person was repositioned head-down and given back blows.
Back Blows on Infants Under One Year
The location is the same (between the shoulder blades), but the technique and positioning are different. Lay the infant face down along your forearm, using your thigh or lap for support. Hold the baby’s chest in your hand and support the jaw with your fingers. The infant’s head should point downward, lower than the body. Give up to five quick, forceful blows between the shoulder blades using the palm of your free hand.
For infants, you use your palm rather than just the heel of your hand, since the striking surface needs to match a much smaller back. The force should be firm relative to the baby’s size but obviously far less than what you’d use on an adult. After five back blows, flip the infant face-up on your forearm and deliver five chest thrusts using two fingers on the breastbone, just below the nipple line. Alternate until the object comes out.
Back Blows on Children and Adults
For children over one year old and adults, the American Heart Association’s current guidelines recommend the same alternating cycle: five back blows followed by five abdominal thrusts. Small children can be laid across your legs to achieve the head-down position more easily. For older children and adults, stand slightly to the side and behind the person, lean them forward, and deliver the blows between the shoulder blades with the heel of your hand.
For pregnant individuals or people with obesity, back blows don’t change. The modification applies only to the thrust portion: instead of abdominal thrusts, you place chest thrusts against the breastbone (sternum), since abdominal compression could be harmful or ineffective in these situations.
When to Start Back Blows
Not every choking episode calls for intervention. If someone is coughing forcefully, their body is doing the work on its own, and you should let them keep coughing. Back blows are for severe airway obstruction, where the person cannot talk, cry, laugh, or cough with any force.
The universal sign of choking is both hands clutching the throat. Other signs of a severe blockage include skin turning bluish (especially around the lips and fingertips), wheezing or high-pitched breathing noises, panicked gasping, and loss of consciousness. If you see these signs, start the cycle of five back blows and five abdominal thrusts immediately. If the person becomes unresponsive at any point, lower them to the ground and begin CPR.