For decades, the standard response for an adult choking victim in the United States was a single-minded focus on abdominal thrusts, commonly known as the Heimlich Maneuver. However, resuscitation science is constantly evolving. Based on the latest international consensus and updated guidelines, there has been a significant shift in how Healthcare Providers (HCPs) are taught to manage Foreign Body Airway Obstruction (FBAO).
The “New 5+5 Choking Sequence” marks a return to a multi-modal approach, combining back blows with abdominal thrusts to increase the success rate of dislodging an object. For HCPs, this isn’t just a minor change—it’s a fundamental update to the Basic Life Support (BLS) workflow. This guide provides a comprehensive look at the 5+5 sequence, the science behind it, and how to implement it in a clinical or pre-hospital setting.
The Evolution of Choking Rescue: Why the Change?
The transition to the 5+5 sequence (5 back blows followed by 5 abdominal thrusts) is driven by data from the International Liaison Committee on Resuscitation (ILCOR). Research indicated that while abdominal thrusts are effective, they are not always successful as a standalone measure.
By incorporating back blows, rescuers utilize two different physical mechanisms to clear an airway:
- Back Blows: These create a vibratory force and a sudden pressure wave that can loosen an object from the larynx or trachea.
- Abdominal Thrusts: These use the residual air in the lungs to create an “artificial cough,” pushing the object out from below.
Evidence suggests that using these techniques in combination is more effective than using either one alone. For healthcare providers, this “balanced” approach ensures that if one method fails to move the object, the other may succeed before the patient loses consciousness.
The 5+5 Sequence Step-by-Step
As an HCP, your response to choking should be systematic. The 5+5 sequence is intended for victims with a severe airway obstruction (unable to breathe, silent cough, or cyanosis).
1. Assessment and Consent
First, determine if the obstruction is mild or severe. If the victim can cough forcefully or speak, do not interfere; encourage them to keep coughing. If they cannot breathe or are clutching their throat (the universal choking sign), identify yourself as a trained provider and ask, “Are you choking? I can help you.”
2. Five Back Blows
- Position yourself slightly behind and to the side of the victim.
- Support the victim’s chest with one hand and lean them forward so that if the object is dislodged, it exits the mouth rather than sliding further down the airway.
- Use the heel of your other hand to deliver five distinct, powerful blows between the victim’s shoulder blades.
- Each blow should be a separate attempt to clear the obstruction.
3. Five Abdominal Thrusts
If the object is not cleared after five back blows, immediately transition to thrusts:
- Stand behind the victim and wrap your arms around their waist.
- Make a fist with one hand.
- Place the thumb side of your fist just above the victim’s navel, well below the breastbone.
- Grasp your fist with your other hand and deliver five quick, upward, and inward thrusts.
4. The Cycle
Continue the cycle of 5 back blows and 5 abdominal thrusts until the object is forced out or the victim becomes unresponsive.
Special Considerations: Pregnancy and Obesity
The 5+5 sequence must be adapted for patients where abdominal thrusts are impossible or dangerous, such as those in late-stage pregnancy or victims with extreme obesity.
In these cases, HCPs should perform Chest Thrusts instead of abdominal thrusts. After delivering the 5 back blows, place your fist on the center of the victim’s breastbone (the same location used for CPR compressions) and deliver five quick, backward thrusts. This increases intrathoracic pressure without risking injury to the abdomen or fetus.
Transitioning to Unconscious Choking Protocols
If the 5+5 sequence fails and the victim becomes unresponsive, the protocol shifts immediately from FBAO rescue to Standard BLS/CPR.
- Lower the victim to the ground carefully.
- Activate EMS/Code Team and retrieve the AED.
- Start Chest Compressions: Do not check for a pulse. The pressure from compressions may be enough to dislodge the object.
- Check the Airway: Every time you open the airway to give breaths, look into the mouth. If you see an object that can be easily removed, perform a finger sweep. Never perform a blind finger sweep, as this can push the object deeper.
- Attempt Breaths: If the chest does not rise, reposition the head and try again. Then return to compressions.
Conclusion
The implementation of the 5+5 choking sequence represents a more versatile and evidence-based approach to emergency airway management. For healthcare providers, mastering this sequence is essential for providing the highest level of care during a Foreign Body Airway Obstruction. By combining the mechanical advantages of back blows and abdominal thrusts, you significantly improve the chances of a positive outcome before a patient reaches the point of respiratory or cardiac arrest. Precision, composure, and a thorough understanding of this updated algorithm are the hallmarks of a prepared HCP.
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Frequently Asked Questions (FAQs)
Is the Heimlich Maneuver no longer used?
The technique of abdominal thrusts (the Heimlich Maneuver) is still a core component of the rescue. The update simply integrates it into a sequence with back blows rather than using it as the sole intervention.
Why was the 5+5 sequence added to the HCP guidelines?
Resuscitation councils worldwide (including ILCOR) reviewed clinical data showing that combining techniques is more effective at dislodging difficult obstructions than using abdominal thrusts alone.
What if I am alone with the victim?
If you are the sole rescuer, the priority is to begin the 5+5 sequence immediately. If you have a mobile phone, activate your speakerphone to call 911/dispatch while you perform the maneuvers.
Can back blows cause internal injury?
While any forceful maneuver carries a small risk of injury, the risk of death from a complete airway obstruction is absolute. The force of back blows is necessary to create the pressure wave needed to move the object. Always recommend that a victim be evaluated by a physician after any successful choking rescue to check for potential internal damage.
Does the 5+5 sequence apply to infants?
The infant choking protocol has always used a variation of this (5 back slaps and 5 chest thrusts). The recent update brings the adult and child protocols into closer alignment with the infant model, creating a more consistent approach across all age groups.
Should I use the 5+5 sequence if the person is coughing?
No. If the victim is coughing forcefully, their airway is only partially obstructed. Stay with them and encourage them to cough. Only intervene with the 5+5 sequence if the cough becomes silent, they cannot breathe, or they turn blue.
