EMS SKILL
AIRWAY EMERGENCY: AIRWAY OBSTRUCTION
INFANT
PERFORMANCE OBJECTIVES
Demonstrate competency in recognizing and managing an airway obstruction in an infant who is choking.
CONDITION
Recognize and manage an airway obstruction in an infant who is found choking. Necessary equipment will be adjacent to the manikin
or brought to the field setting.
EQUIPMENT
Infant manikin, infant 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
 Take body substance isolation precautions
 Mandatory (minimal) personal protective equipment – gloves
 Assess scene safety/scene size-up
 If unknown as to possible trauma, manage as trauma (determined
by environment and information obtained from bystanders).
 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 infant and introduce yourself to the infant,
family or caregiver – if circumstance, time and resources
allow
 Use age appropriate techniques to introduce yourself to infant.
 The caregiver should hold the infant during the assessment if the
infant is in distress and responsive.
RESPONSIVE INFANT
PROCEDURE
Skill Component
Key Concepts
 Establish that the infant is choking:
** Call for additional resources – if needed
 Mild Obstruction:
- adequate air exchange
- coughing
- gagging
- stridor/wheezing
 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 make noise (cry)
- cyanosis
- decreasing level of consciousness
 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 infant has a fever and is
congested, hoarse, or drooling.
Airway Emergency: Infant Airway Obstruction
© 2013, 2009, 2008, 2007, 2006, 2001
Page 1 of 6
Skill Component
Key Concepts
 DO NOT interfere if infant has an effective cough.
 Attempt to remove foreign body obstruction:
 Mild obstruction – Do not interfere with infant’s attempt
to relieve the obstruction
 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 infant must be transported
immediately to an Emergency Department Approved for
Pediatrics (EDAP).
 Severe obstruction – Perform up to 5 back slaps
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Place infant prone on forearm
Keep head lower than the body
Support jaw and face
Use heel of hand
Deliver slaps, using the heel of the hand, between
the shoulder blades
 DO NOT perform a blind finger sweep. This may force object
further down the distal airway structures. Only perform finger
sweep if object is visible.
 Place infant on forearm with head lower than the chest while
supporting the head. Hold the jaw and face with fingers
extended. DO NOT cover mouth or compress the soft tissue of
the neck.
 Use the heel of the hand to deliver slaps to the back between the
shoulder blades.
 Each slap should be of sufficient force to dislodge the object.
 Turn the infant by:
 Place infant face up (supine)
 Turn infant onto the opposite arm
 Maintain support of the head and neck
- placing the free hand on the occiput and back, cradling the
infant between both hands and arms
- turning the body as one unit
- maintain control of head and neck at all times
- keep the head slightly lower than the body throughout the
procedure
(keep head lower than the body)
 Perform up to 5 chest thrusts:
 Find lower 1/2 of sternum (1 finger width below nipple
line)
 Use 2 finger pads
 Compress at a depth of at least 1/3 - 1/2 of chest
diameter
 Rate 1 thrust per second
 Technique for chest thrusts is the same as for chest compressions
when performing CPR. DO NOT use upward compressions.
- Lower half of sternum
- 2 finger pads of either index & middle finger or middle & ring
finger of one hand
- Depth 1/3 - 1/2 the anterior/posterior diameter of the infant
- Rate 1 thrust per second to simulate an “artificial cough”
 In children, the most common cause of cardiac arrest is an
inadequate airway. Attempt removal of obstruction for 2 minutes
before leaving the infant to call for other resources.
 Call for ALS - if obstruction is not relieved after 2
minutes or infant becomes unresponsive
** If responsive but still obstructed – continue series of
back slaps and chest trusts until obstruction is
relieved or the infant becomes unresponsive.
 Signs of inadequate breathing include: respiratory distress,
fast/slow respirations, bradycardia, stridor, cyanosis, poor
perfusion, and altered LOC (agitation, irritable cry, nonresponsive to caregivers, etc.).
 Manage ventilations after removal of obstruction:
 If breathing is restored and adequate:
- trauma - initiate spinal immobilization
 If breathing is absent or inadequate:
- perform rescue breathing of 12-20 per minute
(1 breath every 3-5 seconds) with BVM or barrier
device
 Supplemental oxygen should always be used after spontaneous
breathing has resumed.
 When ventilating only use enough force 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.
 When using an infant BVM device, occlude the pop-off-valve if
unable to achieve adequate chest rise since higher pressures may
be necessary.
 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.
Airway Emergency: Infant Airway Obstruction
© 2013, 2009, 2008, 2007, 2006, 2001
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UNRESPONSIVE INFANT
PROCEDURE
(Infants who were previously responsive may have the obstruction relieved when muscles relax)
Key Concepts
Skill Component
 Establish unresponsiveness
 Tap bottom of feet or gently shake and shout.
** Activate the emergency response system or call for
additional EMS personnel - if not called for
previously
 Assess for adequate breathing 5-10 seconds:
 Apnea
 Abnormal breathing
 Gasping
 Look at chest for adequate tidal volume and rate.
 Check breathing for at least 5 seconds and no more than
10 seconds.
 Palpate for brachial/femoral pulse 5-10 seconds unless history of chocking
 Palpate the pulse for at least 5 seconds and no more than
10 seconds.
 Check for other signs of circulation - breathing, coughing or
movement in response to rescue breaths. This is done in
conjunction with palpating for a pulse.
 An agonal gasp is not a breath, but may be present for several
minutes.
 Gasps may sound like a snort, snore, or groan.
 Palpate brachial pulse on same side as the rescuer, inside of the
upper arm and between the elbow and shoulder.
 An alternative to Palpating the brachial pulse is Palpating a
femoral pulse in neonates and infants or at the base of the
umbilical cord in the newborn.
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 Start compressions (C-A-B sequence)
 Complete 30 compressions
 Open airway:
 Medical
- head-tilt/chin-lift
 The tongue is the most common cause of airway obstruction due
to decreased muscle tone.
 Trauma
- jaw-thrust
- neutral position (tragus of ear should be level with
top of shoulder)
 The tongue and epiglottis may obstruct the entrance of the
trachea due to inspiratory efforts creating negative pressure in the
airway.
 Move the infant no more than necessary to maintain an open
airway. A second rescuer is needed to maintain in-line axial
stabilization if spinal immobilization is required.
** Clear/suction airway - if indicated
 If the infant is found in a prone position with suspected trauma,
the infant should be turned using the log-roll method to avoid
flexion or twisting of the neck and back.
 Look in mouth for foreign body:
 Attempt to remove foreign body obstruction - if
visualized
 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.
 The airway is easily obstructed by mucus, blood, pus, edema,
external compression and hyperextension.
 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.
 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
** Clear/suction airway - if indicated
 Continue CPR until foreign body obstruction is relieved
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Five (5) compression cycles should take approximately 2 minutes.
** Call for additional resources - If not called for
previously
Airway Emergency: Infant Airway Obstruction
© 2013, 2009, 2008, 2007, 2006, 2001
Page 3 of 6
Skill Component
Key Concepts
 Reassess infant after obstruction is relieved
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 If a pulse is present and the infant is not breathing adequately,
start BVM ventilations.
Look for:
Responsiveness to stimulus
Breathing
Pulse
Vital signs
 An infant who is not altered should be placed in a position of
comfort.
 An infant who is altered should be placed in a position to protect the
airway, reduce the chances of the airway being occluded by the
tongue, and protected from aspiration of mucus or vomit.
** Start compressions - if heart rate is less than
60/minute with signs of poor perfusion
[begin with compressions]
REASSESSMENT
(Ongoing Assessment)
Skill Component
Key Concepts
 Reassess the infant at least every 60 seconds once
the infant has return of spontaneous respirations
and circulation (ROSC):
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 This is a priority infant and the heart rate must be re-evaluated
every 60 seconds or sooner.
Respirations and circulation continuously
Initial assessment
Relevant portion of the secondary assessment
Vital signs
 Evaluate response to treatment
 Infants 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 the infant’s condition as indicated.
§ Explain the care being delivered and the transport
destination to the child/caregivers
 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.
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 infant’s response to
care provided.
§ Verbalize/Document:
 Reassessment of airway includes:
- chest rise and fall
- skin color
- airway patency
 Event leading up to the obstruction
 Cause of obstruction – type of obstruction/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: 10/01
 Documentation must be on either the Los Angeles County EMS
Report or departmental Patient Care Record form.
Revises: 6/06, 11/07, 1/08, 4/09, 1/13
Airway Emergency: Infant Airway Obstruction
© 2013, 2009, 2008, 2007, 2006, 2001
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AIRWAY EMERGENCY: AIRWAY OBSTRUCTION
INFANT
Supplemental Information
INDICATIONS:

Infants who are choking with signs of mild or severe airway obstruction
CAUSES:
 Intrinsic cause - tongue (most common), infection and swollen air passages
 Extrinsic cause - foreign body, facial injuries, vomitus, etc
CONTRAINDICATIONS:
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None when above conditions apply.
COMPLICATIONS:
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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 Infant
Mild Airway Obstruction
Signs
Severe Airway Obstruction
Signs
• Adequate air exchange
• Responsive and able to cough forcefully
• May wheeze between coughs
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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 make noise(cry)
Decreasing level of consciousness
Rescuer Actions
Mild Airway Obstruction
Severe Airway Obstruction
• Encourage infant to continue coughing and attempt to
breathe as long as there is adequate air exchange.
• Activate ALS response
• If responsive, perform chest thrusts
• DO NOT interfere with the infant’s attempts to expel the
foreign body. Monitor his/her condition.
• If unresponsive, to stimuli start chest compressions
• Activate ALS response if mild obstruction persists.
NOTES:
 Infant is defined as a neonate to 1 year of age (12 months).
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Some signs of inadequate breathing are: respiratory distress, fast/slow respirations, bradycardia, stridor, cyanosis, poor
perfusion, and altered LOC.
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Obstruction may have been relieved prior to EMS arrival. Patient should be transported for medical evaluation.
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DO NOT perform a blind finger sweep. This may force object further down trachea. Perform finger sweep only if object is visible.
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Supplemental oxygen should always be used after spontaneous breathing has resumed.
 An infant who is altered should be placed in a position to protect the airway to reduce the chance of the airway being occluded by
the tongue and protected from aspiration of mucus or vomit.

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.
Airway Emergency: Infant Airway Obstruction
© 2013, 2009, 2008, 2007, 2006, 2001
Page 5 of 6
AIRWAY EMERGENCY: AIRWAY OBSTRUCTION
INFANT
Supplemental Information
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Any infant who received chest 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: Infant Airway Obstruction
© 2013, 2009, 2008, 2007, 2006, 2001
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