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The US National Institute of Health recommend (in some, limited circumstances) the use of the Heimlich maneuver as first aid for choking victims:

How to perform the Heimlich maneuver:

  • First ask, "Are you choking? Can you speak?" DO NOT perform first aid if the person is coughing forcefully and able to speak -- a strong cough can dislodge the object.
  • Stand behind the person and wrap your arms around the person's waist.
  • Make a fist with one hand. Place the thumb side of your fist just above the person's navel, well below the breastbone.
  • Grasp the fist with your other hand.
  • Make quick, upward and inward thrusts with your fist.
  • Continue these thrusts until the object is dislodged or the victim loses consciousness.

I used to be a First Aid volunteer in Australia, and was explicitly admonished not to ever use the Heimlich maneuver, as it was considered dangerous and not evidence-based. Other techniques were taught.

Is the Heimlich maneuver evidence-based for use as an appropriate first-aid technique for choking victims?

  • 2cts: After combing through 40 years of research, William Terry Ray, director of the University of Cincinnati College of Nursing's Nurse Anesthesia program, told the Enquirer that "there is no one definitive treatment to relieve an obstructed airway on a conscious person." businessinsider.com/… – Spork Aug 22 '14 at 8:38
  • @Spork: Sounds like an answer. Please post it so we can vote on it. – Oddthinking Aug 22 '14 at 9:49
  • YouTube (Science Insider): Why The Heimlich Is Not The Best Way To Save A Choking Victim – user22865 Dec 28 '18 at 12:41
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Absence of evidence:

Dr. Richard M. Bradley, a member of the Red Cross' Preparedness, Health and Safety Services advisory council and an associate professor of emergency medicine at the University of Texas Medical School at Houston said:

To the best of my knowledge, after doing a pretty thorough literature search, no controlled studies exist comparing back blows to abdominal thrusts or anything else.

The inventor of the Heimlich maneuver, Henry Judah Heimlich, a thoracic surgeon, believes some of those lives could have been saved by his maneuver versus slapping someone on the back, he insisted:

I don't want to fight the Red Cross. But I don't want people dying needlessly.

However, it seems that Heimlich lacks evidence:

QuackWatch, closely affiliated with the National Council Against Health Fraud, said:

Heimlich and his spokespeople have regularly stated that "thousands of lives" have been saved by use of abdominal thrusting. However, they have produced no objectively collected, widely accepted data to support the claim. During the past year, the National Council Against Health Fraud has asked Heimlich several times for details on his allegedly successful cases, but he has produced nothing.

In addition, AUSTRALIAN RESUSCITATION COUNCIL published a paper in 2010 saying that there is not enough scientific evidence to support the use of abdominal thrusts and their use is not recommended in first aid. (2)

Moreover, Dr. Robert S. Baratz, a Certified Medical Review Officer and a Clinical Assistant Professor of Medicine, emergency medicine has published a paper saying:

For years Henry Heimlich and his associates have promoted abdominal thrusts, the so-called Heimlich maneuver, as a first measure in the treatment of near-drowning. Despite a lack of data, studies, and physiological or medical sense ,abdominal thrusts have been advocated by Dr. Henry Heimlich, regularly, in multiple venues. Heimlich’s advocacy is based on his opinion, using arguments, described by reporter Pamela Mills-Senn, who wrote an extensive review on the matter, and quoted recently, as “circular, using his own pronouncements to validate his theories.”

William Terry Ray, director of the University of Cincinnati College of Nursing's Nurse Anesthesia program, looked at 40 years of research. The reviews concluded that a person may have to use the back blows as well as abdominal thrusts to relieve the obstruction, depending on what caused the person to choke.

Ray noted:

No definitive study exists to support Heimlich's theory that slapping someone on the back can push an obstruction further down the throat. The literature on this is not conclusive either.

He added:

Studies cited in a review of research projects "used animals, cadavers and anecdotal evidence." But not living human subjects.

While the Absence of Evidence is not Evidence of Absence, I found that the Heimlich maneuver (see below):

  • caused life-threatening complications reported in 32 cases reports.
  • may cause injury, vomiting and aspiration and delay CPR for drowning victims.
  • highly likely to cause bruising to the abdomen.
  • may cause serious injuries, including fracture of the xiphoid or ribs.

Heimlich has also been at odds with the Red Cross over his claims that the maneuver could help drowning victims and someone suffering an asthma attack, surprisingly, later AHA warned against the use of the Heimlich maneuver for drowning rescue, and they said (4) :

Attempts to remove water from the breathing passages by any means other than suction (e.g. abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially dangerous. The routine use of abdominal thrusts or the Heimlich maneuver for drowning victims is not recommended.

There is no evidence that water acts as an obstructive foreign body. Maneuvers to relieve FBAO [Foreign Body Airway Obstructions] are not recommended for drowning victims because such maneuvers are not necessary and they can cause injury, vomiting and aspiration and delay CPR.

The AHA Guidelines were based on a series of referenced scientific articles.

In 2006, The Red Cross changed their recommendation, ending their promotion of Heimlich maneuver as the primary treatment for choking. They said:

Highlights of the skills changes, as a result of the new data, include: for CPR, students will now be instructed to perform cycles of 30 chest compressions and two breaths; and to aid a conscious choking victim, utilize a series of five back blows and five abdominal thrusts.

Moreover, life-threatening complications associated with use of abdominal thrusts have been reported in 32 case reports. (1)

For example: even when done correctly, Heimlich maneuver can injure the person on whom it is performed. Bruising to the abdomen is highly likely and more serious injuries can occur, including fracture of the xiphoid process or ribs. (3)

To keep this answer objective, I will not give a conclusion.


(1) Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, Hatanaka T, Hazinski MF, Jacobs I, Monsieurs K, Morley PT, Nola JP, Travers AH. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81:e48–e70. http://www.resuscitationjournal.com

(2) "Australian(and New Zealand) Resuscitation Council Guideline 4 AIRWAY". Australian Resuscitation Council (2010). Retrieved 2014-02-09.

(3) Broomfield, James (2007-01-01). "Heimlich maneuver on self". Discovery Channel. Retrieved 2007-06-15.

(4) "Part 10.3: Drowning". Circulation (American Heart Association) 112 (24): 133–135. 2005-11-25. doi:10.1161/CIRCULATIONAHA.105.166565. Retrieved 2008-04-04.

  • You quote only people saying no definitive answers exist, while none of your sources actually advice against it (for lack of evidence). There are many national health agencies that still advocate the Heimlich, do you think your research would convince them? Your boldfaced 'no' is not supported by your own references. It should be 'no idea'. – Spork Aug 22 '14 at 8:59
  • You say that it is not the most appropriate response. Based on absence of evidence. That's like saying no to 'Did man land on the moon?' because you personally have not sought out positive evidence. Based on your current sources: You don't know yet. – Spork Aug 22 '14 at 9:08
  • He's providing evidence of absence by quoting subject experts. While it's probably weak evidence, it's by no means no evidence. – Sklivvz Aug 22 '14 at 9:13
  • My point is that absence of evidence does not warrant the answer of No in bold-face at the start of this answer. It's clear that the conclusion was the start of this answer, not the result of research. – Spork Aug 22 '14 at 9:14
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    To clarify the question wording: the Heimlich may be both harmful (e.g. cause bruising and broken bones - or even death) and the most appropriate (because the lives saved outweigh the bruising), so I deliberately didn't ask the one-sided "Does it cause harm?". Of course, if there is evidence of harm and no evidence of benefit despite searching and despite the fact that the model predicts there should be evidence, the recommendation should default to "First, do no harm". – Oddthinking Aug 22 '14 at 10:01
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Scope: My answer comprises sources that support efficacy for the Heimlich Maneuver to alleviate choking, and sources that show a lack of evidence for a comparison with other methods. I consider only the risks and benefits in healthy individuals between the ages of 1 and 65 of the maneuver for Foreign Body Airway Obstruction (FBAO). I interpret 'most appropriate' as 'the method with highest patient survival rate'.

Out of scope: Drowning (which is not choking, and even Heimlich has retracted support there), infants, the elderly, the sick, Heimlich's son hating him, Heimlich's personal flaws and support of controversial AIDS cures.


Henry Heimlich named the maneuver (seen below) after himself, and has been a strong proponent of this invention, as well as of many other of his inventions, through his (again eponymous) Heimlich Institute. In a study performed by Heimlich and others investigating its efficacy he describes the intuitive reason it should work as follows:

Sudden elevation of the diaphragm compresses the lungs, which explosively forces air out through the trachea, ejecting the obstructing object

source: Heimlich HJ, Hoffmann KA, Canestri FR. (1975).

enter image description here

The Benefits

Informally, many people have been reported to have survived after having been administered the Heimlich maneuver. Some people reportedly still breathing after the technique include Ronald Reagan, Elizabeth Taylor and Goldie Hawn. Usually, these reports describe people choking on solid food items. Apart from the study below, I have found no non other scientific sources that showed statistics (other than Heimlich's own reports).

Foreign body airway obstruction represents a true emergency in adults, with a 3.3% mortality rate in the current study. The Heimlich maneuver was used frequently and with good success.

source: Soroudi A. et al., 2011

The US National Library of Medicine advocates using the technique after less dangerous methods have been exhausted. Their source for claiming so is Rosen's Emergency Medicine: Concepts and Clinical Practice. The maneuver is still taught in many classes.

Reported Detractors

The Red Cross has published guidelines in 2006 that do still show the Heimlich maneuver. The change is that first slaps on the back are recommended, and only then abdominal thrusts (Heimlich). This has been reported to be downgrading or detracting from the Heimlich maneuver. However:

The Red Cross certainly isn’t discounting the use of abdominal thrusts. But we include back blows, abdominal thrusts and chest compressions in our training because there is no clear scientific evidence to say that one technique is more effective than the others when treating a choking victim.

source: Red Cross' Blog

There are many complications associated with the Heimlich maneuver, some severe, which has led to many people detracting from the method. All sorts of things in the abdomen can rupture when under high pressure. Realize that it should be used as a final solution, with care, much like CPR (which can break ribs or kill victims, too), in the event that it is administered. Care should be taken, too, when forcibly slapping someone on the back when choking (which can also even lead to death).

Concluding

There is no doubt within the scientific community that the Heimlich maneuver can lead to complications, neither is there doubt that it has been administrated to people choking whom thereafter were not choking anymore. There is not enough evidence to support the alternative presented by the Red Cross, but neither is there enough evidence to detract from it.

After combing through 40 years of research, William Terry Ray, director of the University of Cincinnati College of Nursing's Nurse Anesthesia program, told the Enquirer that "there is no one definitive treatment to relieve an obstructed airway on a conscious person."

source: "Business Insider: Health Medical Dr. Heimlich Is Horrified By The Red Cross' Protocol For Saving Choking Victims"

Heimlich himself at 96 did administer his eponymous technique to a woman in his retirement home with effective results, so he obviously still stands by his original claims.

  • While researching this answer, I also found that I would want to choke on something as solid as possible. Especially when I'm old. sciencedirect.com/science/article/pii/S0749379704000777 – Spork Aug 22 '14 at 15:39
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    I'm getting my head around the San Diego Hospital report you quote. 3.3% died overall. So, 96.7% survived. Of those who had the Heimlich maneuver, there was an 86.5% rate of patient improvement. That's confusing. I can't draw hard conclusions because the intervention was likely not applied randomly to choking victims, and I'm not clear how "patient improvement" and survival differ, but it sounds like a negative outcome, in contradiction with the positive tone in the conclusions. (To be clear: I know I am confused by this.) – Oddthinking Aug 22 '14 at 15:56
  • Of the people that got a Heimlich an 86.5% improvement was reported becasue of it. The patients need not necessarily have died in the remaining 13.5% (coma being the worst of such imaginable outcomes, [forceps or surgery] and surviving being another). Also, one would assume Heimlich would've been done only after other attempts did not succeed, a good portion of that 513 survived never getting the Heimlich. – Spork Aug 22 '14 at 16:11

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