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TheWilliams
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Vol7.No.
Primed;" U.S.A.
Printed
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VoL 7. No. 10
10
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special article
special article

The choking controversy:

controversy: critique of evidence
evidence
the Heimlich maneuver
on the maneuver
JOSEPH S.
JOSEPH S. REDDING,
REDDING, MD,
MD, FACP
FACP

Sed quis
Sed quis custodiet
custodier ipsos
ipsos custodes?
custodes? were mentioned,
were mentioned, and and twotwo cases
cases of of fractured
fractured ribsribs were
were
Juvenal, Satire
Juvenal, Satire VI
VI c.
c. 120
120 AD
AD noted to have occurred "when
noted to have occurred "when the maneuver was the maneuver was
improperly performed. 3
improperly performed." ,,3

In 1963,
In 1963, Haugen'
Haugen t reported
reported aa series series of of middle-aged
middle-aged Additional physiological
Additional physiological observations
observations were were ad- ad-
or elderly people who died suddenly
or elderly people who died suddenly in restaurants in restaurants vanced in support of the maneuver.
vanced in support of the maneuver. In 10 normal In 10 normal
while displaying poor table manners,
while displaying poor table manners, overimbibing, overimbibing, conscious volunteers,
conscious volunteers, the the abdominal
abdominal thrust thrust applied
applied in in
and
and conversing
conversing with with companions.
companions. At At autopsy,
autopsy, chunkschunks the early
the early expiratory
expiratory phase phase expelled
expelled an an average
average of of 0.94
0.94
of
ofsteak,
steak, ham,
ham, herring,
herring, or or lobster
lobster were
were found obstruct-
obstruct- liter air,
liter air, and
and when when applied
applied in in the
the late
late expiratory
expiratory phase
phase
ing
ing the the airway
airway at at points
points from from the the hypopharynx
hypopharynx to to 0.35 liter
0.3S liter were
were expelled.
expelled. When When pressure
pressure was was measured
measured
both
both mainstem
mainstem bronchi.bronchi. If If autopsies
autopsies had had not not revealed
revealed at the
at the mouth
mouth using using aa pressure
pressure gauge gauge visible
visible toto both
both
the
the true cause,
cause, these
these deaths
deaths would would probably
probably have have been
been the
the subject
subject and and thethe experimenter,
experimenter, the the average
average pressure
pressure
attributed
attributed to to coronary
coronary occlusion.
occlusion. Consequently,
Consequently, he he developed
developed by by thethe maneuver
maneuver was was 31 31 mmmm Hg. Hg.4 4
used
used thethe designation
designation "Cafe "Cafe Coronary"
Coronary" and and concluded
concluded Other investigators
Other investigators noted noted higher
higher peak peak expiratory
expiratory
that
that thethe only
only practical
practical treatment
treatment was was immediate
immediate tra- tra- flows and
flows and expiratory
expiratory volumesvolumes when when pressure
pressure was was ap-
ap-
1
cheotomy on the
cheotomy on the scene. t scene. plied low
plied low on on thethe anterior
anterior chestchest wallwall than
than when
when itit was
was
Someyears
Some years later,
later, "Four
"Four beaglesbeagles weighing
weighing 17 17kg kg (38
(38 applied to
applied to thethe abdomen
abdomen of of 66 anesthetized
anesthetized human human
lb)each,
lb) each. were
were anesthetized";
anesthetized"; they they were
were intubated
intubated withwith volunteers. When
volunteers. When the the airway
airway was was totally
totally occluded,
occluded,
aa No.
No. 32 32 cuffed
cuffed endotracheal
endotracheal tube, tube, the
the lumen
lumen of which which chest thrust
chest thrust developed
developed higher higher airwayairway pressures
pressures thanthan
wasplugged
was plugged with with aa rubber
rubber stopper.
stopper. Total
Total obstruction
obstruction did
did abdominal
abdominal thrust. thrust.5s
ofofthethe airway
airway was was produced
produced by by adding
adding 3-4 3-4 mlml of of air
air Observations on
Observations on 66 other other conscious
conscious volunteers
volunteers
totothe
the cuff
cuff "simulating
"simulating aa bolus bolus of of food
food caught
caught in in the
the showed that they developed average
showed that they developed average airway pressures airway pressures r
human
human larynx."
larynx." Not Not unexpectedly,
unexpectedly, the the animals
animals devel-
devel- of 72
12 mm
mm Hg Hg when
when coughing
coughing from from the the resting
resting lung
lung i
of
oped
opedrespiratory
respiratory distress.
distress. When When pressure
pressure was was applied
applied level and
level and 115 115mm mm Hg Hg whenwhen coughing
coughing from from thethe end
end
upward
upward toward toward the the diaphragm
diaphragm from from belowbelow the the rib rib inspiratory level
inspiratory levelagainst
against complete
complete airway airway obstruction.
obstruction.
cage
cage"the"the endotracheal
endotracheal tube tube (bolus)
(bolus) popped
popped out out of of the
the After they
After they had had beenbeen anesthetized,
anesthetized. and and with
with their
their
trachea."
trachea." On On this
this basis,
basis, Henry Heimlich"2 described
Henry J.J.Heimlich described airways completely
airways completely obstructed,
obstructed, their their airway
airway pressures
pressures
his
hismethod
method of of applying
applying pressure
pressure to to the
the abdomen
abdomen of of averaged 35
averaged 3S mmmm Hg Hgwithwith backback blows,
blows, 15 15nun
mm Hg Hg with
with
victims
victimsof of the
the cafe
cafe coronary
coronary syndrome,syndrome. intended
intended to to abdominal thrust,
abdominal thrust, andand 19 19mm mm Hg Hg with
with chest
chest thrust.
thrust.
clear
cleartheir
their airways
airways of ofobstructing
obstructing foreign foreign material
material by by With their
With their airways
airways partially
partially obstructed,
obstructed, back back blows
blows
forceful
forcefulupward
upward displacement
displacement of of the
the diaphragm.
diaphragm. In In produced negligible expiratory
produced negligible expiratory volumes andflowrates volumes and flow rates
2
this
thisinitial
initial report,
report," he he requested
requested wide wide public
public dissemi-
dissemi- whereas
whereas chest chest thrusts
thrusts produced
produced slightly slightly higher
higher expir-
expir-
nation
nation of of information
information regardingregarding the the technique
technique and and atory volumes
atory volumes (97 (97 versus
versus 91 91 ml)
ml) and and flow
flow rates
rates (2.2
(2.2
primary
primaryor or hearsay
hearsay reports
reports of of use
use ofof the
the method.
method. versus2.0
versus 2.0liter/sec)
liter/sec) thanthan did didabdominal
abdominal thrusts. thrusts. Meat
Meat
HeHegotgotboth.
both. TheThe popular
popular press pressgave
gave the themaneuver
maneuver placed below
placed below the the epiglottis
epiglottis of of anesthetized
anesthetized animals animals
widespreadcoverage,
widespread coverage, and and 99monthsmonths later,
later, he hereported
reported could
couldnot
notbe bedislodged
dislodged by byanyanyof ofthethe maneuvers.
maneuvers. Meat Meat
162162victims
victims of of food-choking
food-choking or or drowning
drowning who who sur-sur- placed
placed at at thethe epiglottis
epiglottis or or inin the
the vallecula
vallecula was was most
most
Vivedafter
vived after application
application of of the
the method.
method. No No failures
failures often
often dislodged
dislodged by by back
back blows.blows. Abdominal
Abdominal or or chest
chest
thrusts
thrusts were
were not not asaseffective
effective in in dislodging
dislodging the the meat;
meat;
From(he
From theDivision
Division ofofRespiratory/Critical
Respiratory/Critical Care.
Care. Department
Depanmenl ofof
AnCSlhesiology.Medical
Medical University
University ofofSouth
South Carolina.
Carolina. 171
171Ashley
Ashley
however,
however, the thecombination
combination ofofback back blowsblowsfollowed
followedby by
Anesthesiology.
Avenue.Charleston.
Avenue, Charleston. SC
SC29403.
29403. abdominal
abdominal or or chest
chest thrusts
thrusts was was more more effective
effective than
than
475
475
 ~
-~-----
--..;,._--------------l
476
476 CRITICAL CARE
CRITICAL CARE MEDICINE
MEDICINE October, 1979
October, 1979

back blows
back blows or or manual
manual thruststhrusts alone.
alone. When
When meat meat waswas sures used
sures used in in the
the treatment
treatment of of food choking,"7 Addi-
food choking. Addi-
placed in
placed in thethe hypopharynx,
hypopharynx, finger finger extrication
extrication was was tional
tional reports
reports of of persons
persons whowho survived
survived after
after applica-
applica-
successful in
successful in 75%
75% of of trials
trials in in animals
animals and and human
human tion
tion of
of his
his maneuver
maneuver were were accompanied
accompanied by by aa number
number
volunteers."6
volunteers. of interesting claims.
of interesting claims.
AA National
National Research
Research Council Council (NRC) (NRC) Conference
Conference (1) In
(1) In reference
reference to to his
his 1975 Journal of
1975 Journal of American
American
onon Emergency
Emergency Airway Airway Management
Management was was held
held June
June Medical
Medical Association article,'5 he
Association article," he stated
stated "at
"at the
the same
same
21-22, 1976
21-22, 1976 at at the
the National
National AcademyAcademy of of Sciences
Sciences in in time
time the
the AMA
AMA issuedissued aa news
news release
release reporting
reporting that
that
Washington,
Washington, D.C., D.C., to to review
review the the current
current statestate ofof the
the Heimlich
Heimlich maneuver
maneuver had had received
received the
the official
official en-
en-
knowledge.
knowledge. A A paper
paper 'The "The Heimlich
Heimlich maneuver—an
maneuver-an dorsement
dorsement of of its
its Commission
Commission on on Emergency
Emergency Medical
Medical
analysis
analysis of of the
the first
first 500
500 lives
lives saved"
saved" was was distributed
distributed Services."
Services." Actually,
Actually. an an editorial
editorial statement
statement on on the
the
and
and presented
presented at at the
the initial
initial plenary
plenary session.
session. TheThe work-
work- maneuver" had concluded "the Commission
maneuver' had concluded "the Commission recom- recom-
shop
shop on on Manual
Manual MethodsMethods for for Airway
Airway Control
Control was was in
in mends
mends thatthat the
the National
National Academy
Academy of of Sciences—Na-
Sciences-Na-
session
session withwith brief
brief interruptions
interruptions from from 22 PM PM on on June
June tional
tional Research Council, the American Heart
Research Council, the American Heart Asso-
Asso-
21
21 until
until the
the early
early hours
hours of of the
the next
next morning.
morning. Most Most ofof. ciation,
ciation. and other comparable organizations inter-
and other comparable organizations inter-
this
this time
time waswas devoted
devoted to to discussion
discussion of of manual
manual meth- meth- ested
ested inin emergency
emergency care care procedures
procedures collect
collect and
and eval-
eval-
ods
ods ofof relieving
relieving foreign
foreign body body airway
airway obstruction.
obstruction. This This uate
uate data
data to to determine
determine the the place
place ofof the
the Heimlich
Heimlich
discussion was characterized by requests
discussion was characterized by requests for data sup- for data sup- maneuver
maneuver in in the
the instruction
instruction of of the
the public
public inin proper
proper
porting
porting Dr.Dr. Heimlich's
Heimlich's proposalproposal that that his
his maneuver
maneuver be be emergency
emergency care care practices."
practices. ,.
used
used in the management of victims of foreign body
in the management of victims of foreign body It was
(2) It
(2) was stated
stated that
that "it
"it remained
remained for for independent
independent
airway
airway obstruction
obstruction and and replies
replies indicating
indicating thatthat data
data do
do studies
studies by by Dr.
Dr. Edward
Edward Patrick
Patrick of of Purdue
Purdue University
University
exist that Dr. Heimlich had not
exist that Dr. Heimlich had not had time to summa- had time to summa- and
and Dr.
Dr. G.G. (sic)
(sic) Raymond
Raymond Fink Fink ofof the
the University
University of of
rize,
rize, that
that hehe invited
invited critics
critics to to come
come and and examine,
examine, and and Washington
Washington to to elucidate
elucidate the the scientific
scientific basis
basis for
for yet
yet
that
that his status as a scientist qualified him to
his status as a scientist qualified him to evaluate.
evaluate. another
another observation
observation in in reports
reports ofof successful
successful useuse of
of the
the
AA copy
copy of of his
his questionnaire
questionnaire for for the
the reporting
reporting of of cases
cases maneuver
maneuver .... . . these
these investigators
investigators also also proved
proved that
that
in which the maneuver had been
in which the maneuver had been used was presented. used was presented. objects
objects partially
partially oror completely
completely obstructing
obstructing the the airway
airway
As the hours passed, it became evident that complete
As the hours passed, it became evident that complete are
are expelled by the flow of air from the airway rather
expelled by the flow of air from the airway rather
agreement
agreement on on thethe sequence
sequence of of actions
actions toto bebe taken
taken inin than
than the
the build-up
build-up of of pressure.
pressure. Their
Their workwork demon-
demon-
the management of foreign body
the management of foreign body airway obstruction airway obstruction strated
strated that
that even
even ifif aa pressure
pressure spike
spike might
might occur
occur with
with
could not be achieved and that the best way of re-
could not be achieved and that the best way of re- back
back pounding. as another investigator suggested, itit
pounding, as another investigator suggested,
moving a foreign body from the airway was not
moving a foreign body from the airway was not could
could notnot expel
expel an an obstructing
obstructing bolus."
bolus." Dr. Dr. B.
B. Ray-
Ray-
known. At the plenary session on the morning of June mond
known. At the plenary session on the morning of June mond Fink disclaims participating in any studies in-
Fink disclaims participating in any studies in-
22, some of the members of the panel changed their volving
22, some of the members of the panel changed their volving thethe Heimlich
Heimlich maneuver
maneuver since
since thethe NRC
NRC meet-
meet-
previous positions, and some disagreed with the pre- ing
previous positions, and some disagreed with the pre- ing in
in June
June 19761976 (personal
(personal communication,
communication, 1979). 1979).
sentation of the proceedings.
sentation of the proceedings. (3) 'Dr.
(3) 'Dr. Trevor
Trevor Hughes,
Hughes. Associate
Associate Professor
Professor of of
Subsequently, the
Subsequently, the Report
Report onon Emergency
Emergency AirwayAirway Anesthesiology
Anesthesiology at at the
the University
University of of North
North Carolina,
Carolina,
Management of
Management of the
the National
National Research
Research Council
Council made
made has
has conducted
conducted an independent (italics
an independent (italicsmine)
mine)study
studynownow
the following
the following guarded
guarded recommendations
recommendations for for foreign in
in press
press entitled
entitled 'Computerized
'Computerized analysis
analysis of of data
data on on
body obstruction:
body obstruction: (I)
(1) back
back blows
blows (four
(four inin rapid
rapid succes-
succes- 536
536 case reports
reports of the application
application of the Heimlich
Heimlich
manual thrusts
sion); (2) manual thrusts (four in succession);
succession); (3)(3) maneuver.'
maneuver.' Trevor
Trevor Hughes presented
presented a paperpaper at the the
repeat
repeat the sequence
sequence until the measures
measures are effective 1978 annual
annual meeting
meeting of the AmericanAmerican Society of of
or until the victim becomes unconscious.
unconscious. When When thethe Anesthesiologists,
Anesthesiologists. an abstract
abstract of which is contained
contained in
victim was unconscious,
unconscious, the sequence
sequence above was to to the Abstracts
Abstracts of Scientific Papers
Papers of that
that Society,
Society,
be followed by: (1) (I) finger
finger probing
probing of the the pharynx,
pharynx, (2) entitled
entitled "Choking on food or foreign body-an anal-
"Choking on food or foreign body—an anal-
attempted
attempted positive pressure
pressure ventilation,
ventilation, (3) if ventila-
ventila- ysis
ysis ofof 428
428 reports
reports claiming
claiming successful
successful treatment
treatment by by
tion was unsuccessful,
unsuccessful, repeat
repeat the entire
entire sequence.
sequence. A A the
the Heimlich
Heimlich maneuver."
maneuver." None None of of the
the cases
cases were
were
caveat
caveat was added
added that the NRC/EMS
that the NRC/EMS Committee
Committee was was collected
collected by by Hughes
Hughes and and 392
392 were
were supplied
supplied by by Heim-
Heim-
concerned
concerned about
about the lack of relevant
relevant evidence
evidence on lich.
lich. Failures
Failures were
were reported
reported with
with back
back blows
blows (60),
(60),
which
which to determine
determine the effectiveness and and adverse
adverse con-
con- finger
finger probes
probes (25),
(25). and
and other
other therapies
therapies (34),
(34). but
but none
none
sequences
sequences associated
associated with the the techniques
techniques and and urged
urged with
with the
the Heimlich
Heimlich maneuver.
maneuver. AfterAfter stating
stating that
that it
it was
was
that
that experimental
experimental and and survey research
research techniques
techniques be impossible
impossible to to determine
determine how how many
many of of the
the victims
victims
applied
applied to obtain
obtain information
information on the risk-to-benefit
risk-to-benefit would
would have have died,
died, thethe author
author concluded
concluded that that "the
"the
ratio
ratio of the manual
manual maneuvers.
maneuvers. Little
Little action
action appears
appears results
results demonstrate
demonstrate that that the
the Heimlich
Heimlich maneuver
maneuver is an
is an
to have
have resulted
resulted from
from this urging.
urging. extremely
extremely successful
successful therapy
therapy forfor upper
upper airway
airway ob- ob-
In July
In July 1978,
1978, Dr.
Dr. Heimlich
Heimlich reviewed
reviewed the the evidence
evidence struction
struction by by food
food or or foreign
foreign body."
body."
supporting his maneuver
supporting maneuver and and opposing
opposing otherother mea- Although no failures
(4) Although failures with
with the
the Heimlich
Heimlich maneu-
maneu-
 -------_
,_, ~-------- ---.- ..

Vol. 7,
Vol. 7, No.
No. 10
10 Redding-HEIMLICH MANEUVER
Redding—HEIMLICH MANEUVER 477
477

ver have
ver have been
been reported,
reported, Dr. Dr. Heimlich
Heimlich states
states "it "it has
has given.
given. Reported
Reported success
success oror failure
failure was
was tabulated
tabulated with with
been determined
been determined that that failure
failure was
was generally
generally due due to to one
one back
back blows
blows (BB),(B8), abdominal
abdominal thrusts
thrusts (AT),(AT), chestchest
of
of three
three reasons:
reasons: the the technique
technique was was improperly
improperly per- per- thrusts
thrusts (CT), finger probes
(CT), finger probes (FP), use of
(FP). use of instrumenta-
instrumenta-
formed ...
formed . . . the obstructing substance was something
the obstructing substance was something tion
tion (IN)
(IN) such
such as as suction
suction equipment,
equipment, endoscopy,
endoscopy. or or
that
that could
could not not be
be dislodged...
dislodged ... or or there
there waswas excessive
excessive others
others unspecified,
unspecified, and and cardiopulmonary
cardiopulmonary resuscitation
resuscitation
delay
delay inin applying
applying the the maneuver,
maneuver, usually
usually thethe result
result of of (CPR).
(CPR). In In 116
116 cases,
cases, only
only one
one method
method was was used,
used, andand
trying
trying other
other methods
methods ....•• " success
success waswas attributed
attributed to to that
that maneuver.
maneuver. In In 29 cases,
29 cases,
In study,9 pieces
recent study,"
In a recent pieces of ofraw
raw beef.
beef, boiled
boiled mutton,
mutton, more
more than
than one one maneuver
maneuver was was credited
credited with with being
being
and orange
and orange segments
segments were were placed
placed in in aa silicone
silicone rubber
rubber successful.
successful. One One or or more
more maneuvers
maneuvers were were usedused in 7S
in 75
cast
cast of
of aa human
human larynx.
larynx. The The lowest
lowest pressures
pressures needed
needed cases
cases with
with only
only oneone measure
measure classified
classified asas successful.
to
to dislodge these
these items when when they were not not completely
completely A
A few
few reports
reports were
were more
more explicit.
explicit. For
For example,
example, in one
wedged
wedged in in the
the laryngeal
laryngeal cast cast were
were 70,70, 20,
20, and
and IS IS cmcm case
case BBBB were
were marked
marked unsuccessful
unsuccessful with with AT AT marked
marked
H2O,
H20, respectively,
respectively. for for the
the beef,
beef. mutton,
mutton. and and orange
orange successful.
successful. An An explanatory
explanatory note note stated
stated "back
"back blows blows
segments.
segments. When When they they were
were lodged
lodged so so that
that there
there was was gave
gave spraying
spraying of of small
small particles.
particles. Abdominal
Abdominal thrust thrust
no
no air
air leak,
leak, the
the pressures
pressures required
required were
were > 100 em
>100 cm H H2200 dislodged
dislodged the the entire
entire matter."
matter." In In most
most cases
cases the the se-
se-
for
for the beef and and mutton
mutton and and 353S cm
em H220 0 for the orange
orange quence
quence of of maneuvers
maneuvers was was not
not indicated
indicated andand it it was
was notnot
segments.
segments. The The laryngeal
laryngeal cast cast was
was then
then attached
attached to to the
the possible
possible to to judge
judge whether
whether a maneuver
maneuver marked
marked unsuc-unsuc-
endotracheal
endotracheal tubes tubes of of 12
12 patients
patients whowho were
were anesthe-
anesthe- cessful
cessful might
might havehave contributed
contributed to to the
the successful
successful resultresult
tized
tized and
and relaxed
relaxed with with curare.
curare. TheTbe "medium"
"medium" pres- pres- attributed
attributed to to another.
another.
sures
sures developed at the resting lung level with the
developed at the resting lung level with the One patient
One patient recovered
recovered spontaneously
spontaneously before before assist-
assist-
Heimlich
Heimlich maneuver,
maneuver, sternalsternal thrust,
thrust, and
and back
back blowsblows ance could be given.given, In another
another case BB, BB, AT, FP, FP, IN,
IN,
were
were 10, 20, and
10,20, and 25 2S cmcm H 0, respectively.
H220. respectively. The The meat meat and CPR were recordedrecorded as unsuccessful to be followed followed
could not be expelled. In I patient, the
could not be expelled. In Ipatient. the orange segment orange segment by successful tracheotomy.
tracheotomy. Three Three patients
patients dieddied after
after
was
was expelled
expelled by by the
the Heimlich
Heimlich maneuver
maneuver and and sternal
sternal unsuccessful BB, AT, FP. Two of them also received
thrusts,
thrusts. but only when aided by gravity. The investi-
but only when aided by gravity. The investi- unsuccessful IN and and the other
other received unsuccessful
unsuccessful
gators
gators noted
noted that
that as as the
the mass
mass ofof the
the obstructing
obstructing object object CT.
increased
increased so did the effect of shaking and
so did the effect of shaking and gravity.
gravity. Adverse
Adverse consequences
consequences were reported reported in 24 cases. cases.
They
They concluded
concluded that that thethe most
most effective
effective method
method was was AT were followed by abdominal abdominal tenderness
tenderness in 12 12
the use of back blows combined with the patient one of which
which discomfort
discomfort was was noted
the use of back blows combined with the patient cases, in one noted for for several
several
hanging head-downward, but believed that if the food Vomiting occurred
occurred in four cases, cases. pharyngeal
pharyngeal
hanging head-downward, but believed that if the food weeks. Vomiting
has passed through the larynx, it is unlikely that any abrasion in one, retinal
retinal detachment
detachment in one, and and esoph-
esoph-
has passed through the larynx, it is unlikely that any abrasion
first-aid measure can help, and relief depends on the
first-aid measure can help, and relief depends on the ageal laceration
laceration in one. CT CT were followed by chest
patient's ability to cough.
patient's ability to cough. tenderness in one. FP
tenderness FP were credited
credited with three three cases
During the fall of 1978,
During 1978, packets
packets of material
material were
were of pharyngeal
pharyngeal abrasion,
abrasion, one of whom also had had teeth
mailed to some individuals
individuals (personal
(personal communication,
communication, loosened. IN led to vomiting
loosened. vomiting in one case.
1979) and
1979) and organizations
organizations (personal
(personal communication,
communication, In all, there
there were 386 trials trials of various
various maneuvers
maneuvers
1979) accompanying
1979) accompanying a letter warning
letter warning them them of thethe (Table
(Table 1),I), with 2S6
256 classified successes, and 130 clas-
and clas-
dangers
dangers of using
using any method
method other
other than
than the Heimlich
Heimlich failures. There
sified failures. There were successes and and failures
failures at- at-
maneuver
maneuver and and implying
implying legal liability for using or tributed to each
tributed each of thethe maneuvers.
maneuvers. When When the reported
reponed
advocating
advocating any any other
other method
method for resuscitation
resuscitation of vic- failures were
failures were examined
examined (Table
(Table 2), it was apparent
apparent that that
food-choking."10 The
tims of food-choking. The enclosed
enclosed materials
materials criti- each of the maneuvers
each maneuvers was sometimes
sometimes given credit credit for
cized the methods
methods of other other investigators
investigators who had had after another
success after another method
method had had been
been classified
classified as a
worked
worked on the problem,
problem, and and the
the recommendations
recommendations of failure.
failure.
organizations
organizations that that endorsed
endorsed otherother methods.
methods. In re-
sponse to this campaign, the
this campaign, the Emergency
Emergency Cardiac
Cardiac Care
Care
TABLE I.
TABLE 1_ Effectiveness of food choking
choking maneuvers
maneuvers
Committee
Committee of the American Heart Association re-
of the American Heart Association re-
quested Maneuver
Maneuver Trials
Trials Succcsscs"
Successes" Failures
Failui
quested that
that I provide
provide an evaluation
evaluation of case reports
reports of
management
management of of foreign
foreign body
body airway
airway obstruction
obstruction col-
col- BB 109 53 (22)
S3 (22) 56
lected AT 168 132 (74)
U2{14) 36
lected by them (personal communication, 1979).
by them (personal communication, 1979).
CT 25 16(9)
16 (9) 9
Three different
Three different forms
forms hadhad been
been used
used in collecting
collecting FP
FP 52 30 (9)
30(9) 22
22
AHA data. Some
the AHA Some were illegible,
illegible. some
some answers
answers IN 18 13 (2)
13(2) 5
ambiguous, and
were ambiguous, and some
some questions
questions were unan-unan- CPR
CPR 14 12 (0)
12(0) 2
Data could
swered. Data could be compiled
compiled from from 225 cases. °" Reponed
Reported as
as "successful"
"successful" when
when used
used as
as one
one or
or more
more maneuvers,
maneuvers.
Thirty-four of 208 victims
Thirty-four victims were
were described
described as uncon-
uncon- Figures in parentheses
Figures parentheses indicate
indicate "successful"
-successrul- application
application with
witb no
scious or
or partly
partly unconscious at the time treatment was
unconscious at the time treatment was other maneuver
other maneuver used.
 -_- -~-------.. --- ..-----~.-
478 CRITICAL CARE MEDICINE
CRITICAL CARE MEDICINE October,
October, 1979
478

TABLE 12. Effectiveness

TABU Effectiveness of subsequent
subsequent maneuvers after initial
maneuvers after initial fail- emergency surgical
emergency intervention will be needed.
surgical intervention needed. Mea- Mea-
ures
ures sures for
sures for relief foreign body
relief of foreign body obstruction
obstruction shouldshould not not
Initial
Initial failures
failures Successful subsequent
Successful maneuvers"
subsequent maneuvers" be taught
be taught out out of of the
the context
context of other other CPRCPR measures.
measures.
BB 56 AT 38, CT
AT CT 4, FP
FP 5.
5, IN 4, AT
AT ++ FP Legal liability
Legal liability for for failure
failure to to use the the Heimlich
Heimlich maneu- maneu-
AT 36 BB 14, CT 2. FP
14, CT S, IN
FP S. 6, BB
IN 6. + CPR
DB + 2, IN
CPR 2. ver exclusively
ver exclusively should should not not be inferred
inferred fromfrom the the case
+
+ CPR
CPR of Gary Daniels v. The
Gary L. Daniels The Harrisburg
Harrisburg School School District,
District,
CT
CT 9 2, FP
BB 2. FP 2, IN 3, CPR
CPR because this
because this case
case waswas concluded
concluded by by settlement
settlement ratherrather
FP
FP 22 BB4, AT 7, CTCT 2.
2, IN 4.
4, BB ++ CPR
CPR
than verdict
than verdict of the the court.
court. There
There isisinsufficient
insufficient evidence
evidence
IN 5 FP. BB +
FP, + CPR
CPR
BB
on which
on which to to strongly
strongly recommend
recommend any any of these
these maneu-
maneu-
CPR
CPR 2
vers, and certainly none
and certainly none sufficient sufficient to condemn any
condemn any
Maneuvers or
° Maneuvers or combinations
combinations of maneuvers
maneuvers reported
reported as
as "SUC:-
"suc- other measures.
Q

other measures.
cessful" after
cessful" after reported
reported "failure"
"failure" with
with the
the initial
initial measure
measure applied.
applied.
Those organizations
Those organizations that that originally advocated
originally advocated
adoption of the
adoption the measure
measure on on such
such shaky
shaky grounds,
grounds, albeitalbeit
To subject
To subject these
these datadata to to the
the usual
usual forms of analysis
analysis with reservations,
with reservations, cannot cannot be be held
held entirely
entirely blameless
blameless
would be
would be to falsely attribute
attribute aa validity
validity which
which it does what followed.
for what followed. The The wavewave of publicity
publicity given the the
not possess. Computer
not Computer analysisanalysis of thesethese figures would would measure by well intentioned,
measure intentioned. but but uncritical,
uncritical, persons
persons
not be
not be helpful.
helpful. The The reports
reports were were voluntarily
voluntarily submit-
submit- has been remarkable.
has been remarkable. In In one
one community, information
community. information
ted, unverified, probably
ted, unverified, probably were were heavily
heavily weighted
weighted by on the
on the Heimlich
Heimlich maneuver,
maneuver, without without reference
reference to to other
other
the reporters in favor of successful
the reporters in favor of successful results. and. results, and, in in measures, was
measures, was distributed
distributed to schools, schools, grocery
grocery stores,
stores.
most 13
most cases. were not received from clinically trained
cases, were not received from clinically trained restaurants, and
restaurants, and even
even printed
printed on on dairy
dairy milk
milk cartons.
cartons,"
observers.
observers. The The true
true condition
condition of of the
the victim
victim at at the
the timetime The maneuver
The maneuver is so well fixed fixed in the the public
public mindmind as
of treatment can be determined
of treatment can be determined in only five cases;in only five cases; 33 the only
the only solution
solution for foreignforeign body body airway
airway obstruction
obstruction
patients
patients died
died in in spite
spite of of treatment,
treatment, II survived
survived only only that to
that to correct
correct the the situation
situation would would be like trying trying to
after tracheotomy.
after tracheotomy, and and 1 recoveredwithout
1 recovered withouttreatment.
treatment. recover the
recover the contents
contents of aa feather
feather pillow
pillow released
released from from
In the
In the remainder.
remainder, to to assume
assume that that the
the application
application of of aa a church
church steeple.
steeple.
particular form of treatment resulted
particular form of treatment resulted in a "life saved" in a "life saved" To borrow
To liberally from,
borrow liberally from, and and to to paraphrase,
paraphrase. Mur- Mur-
is to be
is to be guilty
guilty of of post
post hochoc reasoning.
reasoning. phy,"14 no
phy, no manman may may be judge
judge in in his
his own
own cause.
cause. ItIt maymay
For example,
For example. on on the
the first
first day
day of thethe 19th century,
century. be argued
argued that,that. in the the long
long run, run. the
the collective
collective experi-
experi-
David Ramsay"
David Ramsay" reportedreported to the the Medical
Medical Society
Society of ence of those
ence those who who try try anan ideaidea will discard
discard what what is
South Carolina
South Carolina that that "upwards
"upwards of 2000 persons persons (sup-(sup- but there
false, but there is reason
reason for for concern
concern aboutabout the the inef-
posedly restored
posedly restored to life after after drowning)
drowning) walked walked in ficiency
ficiency of ofthethemethod.
method.The Thespecialist
specialistshould
shouldbe bespar-
spar-
procession, on
procession. on a day day set apart apart a few years years ago,
ago, to ing in references
ing references to to promising
promising ideas. Because discredit
ideas. Because discredit
solicit public
solicit public charity
charity in behalf behalf of...
of ... (the
(the Royal
Royal Hu- the fate
is the fate of mostmost new ideas, ideas. the the time
time lag alone
alone must must
mane
mane Society)."
Society)." Among Among the the resuscitation
resuscitation measures
measures be responsible
responsible for much much mischief.
mischief. At least at at this time,
this time.
recommended for drowning
recommended for drowning victims at victims at the
the time
time were were the weight
the weight of anecdotal
anecdotal data data advanced
advanced in supportsupport of of
restoration
restoration of of body
body heatheat by by being
being placed
placed in in bed
bed withwith the Heimlich
the Heimlich maneuver
maneuver still falls short short of the the "up-
"up-
another
another person,
person. application
application of of sal
sal ammonica
ammonica to to the
the wards of 2000
wards 2000 persons"
persons" reported
reported to have have been
been resus-
resus-
wrists
wrists and
and ankles
ankles only,
only. and fumigation
and fumigation of of the
the rectum
rectum citated from
citated from drowning.
drowning. 11 On
11
On tbe the other
other hand,
hand, "the "the
12
with
with tobacco
tobacco smoke.
smoke.':'! zealot oflarge
zealot of large samples
samples seldom
seldom stickssticks at at obscuring
obscuring bias bias
Has this
Has this analysis
analysis of case C3Se reports,
reports. then,
then. been
been an an with mere
with massiveness.?"14
mere massiveness."
futility? Not
exercise in futility? Not entirely.
entirely. Application
Application of fun- fun-
damental logic makes
damentallogic makes it possible
possible to drawdraw somesome impor-
impor- REFERENCES
REFERENCES
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tant conclusions. The case reports provided by the
conclusions. The case reports provided the 1.
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Haugen RK:
RK: The
The cafe
cafe coronary;
coronary; sudden
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deaths in restaurants.
restaurants.
AHA
AHA are are as valid
valid as the the anecdotal
anecdotal data data on on which
which JAMA
JAMA 186:142, 19631963
2. Heimlich
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method exclu- 1974
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food-c:hoking.
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The Heimlich maneuver
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reported to to be JAMA
JAMA 234:398, 19751975
4. Heimlich HJ. Hoffman
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Caneslri FR:
FR: Food-choking
Food-choking andand
successful in less than half of its trials
than half trials and
and 36 failures
failures drowning deaths
drowning prevented by external
deaths prevented external subdiaphragmalic
subdiaphragmatiC:
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reported. In In those
those failures,
failures. all of the tbe other
other ma- compression. Ann
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Cordon AS, Belton
Belton MK, Ridolpho PF:
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Emergency manage-
manage-
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sometimes when when thethe Heimlich
Heimlich ma- ment foreign body
ment of foreign body airway
airway obstruction.
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chap 6. Advances
Advances in
neuver had
neuver had failed.
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They can can hardly
hardly be be termed
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Edited by P Safar.
Safar. New York,
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Springer-Verlag, 1977
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blows." is evident
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some cases
cases nonenone of the the Heimlich HJ:
7. Heimlich HJ: The
The Heimlich
Heimlich maneuver;
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where it stands
stands today.
today.
manual methods
manual methods are are successful
successful and and instrumental
instrumental or or Med 10:89.
Emerg Med
£mf!rg 1978
10:89, 1978
 f..f:.~
J ~'!..:-~

:-;~::~ol.
% Vol. 7.7,No.
No. 10
10 Redding-HEIMLICH
Redding—HEIMLICH MANEUVER
MANEUVER 479
479

8. AMA
AMA Commission
Commission on on Emergency
Emergency Medical
Medical Services: (Editorial)
Services: (Editorial) Medicine in the
Medicine the XVIIIth
XVlIltb Century.
Century. Charleston,
Charleston, W.P.
W.P. Young,
Young.
Statement
Statement on the
the "Heimlich
"Heimlich Maneuver." JAMA 234:416,
Maneuver." JAMA 234:416, 1975 1801
9. Ruben
Ruben H, Macnaughton
Macnaughton FI:Fl: The
The treatment
treatment of food-c:boking.
food-choking. W: AA letter
Cullen W:
12. CuUen to Lord
letter to Lord Catbc:an
Cathcart c:oncerning the recovery
concerning the recovery oC
of
The Practitioner
77ie Practitioner221:715,
221:725,1978
1978 persons drowned
persons drowned and and seemingly
seemingly dead.
dead. Edinburgh,
Edinburgh. William
William
10.
10. Gary
Gary L. Daniels
Daniels v. The
The Harrisburg
Harrisburg School District 547-S and
District, 547-S and Creech,
Creech. 1791
1791
924-S 1977.
1917, Proceedings
Proceedings of the
the Dauphine
Dauphine County
County Court
Coun of Brown NC:
13. Brown NC: The
The HeimUch
Heimlich maneuver.
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Common
Common Pleas,
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Nov. 20, 1978 (Harrisburg,
(Harrisburg, Pa.).
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