Place the fist just above the navel and well below the breastbone, on the midline of the abdomen. Wrap your other hand over it and pull sharply inward and upward. That landmark sits over the soft epigastric region, where a rapid squeeze can push the diaphragm upward and force trapped air out of the lungs.
The anatomy that makes the maneuver work
Abdominal thrusts work by suddenly raising pressure inside the chest. The rescuer’s fist sits below the diaphragm, the dome-shaped muscle separating chest from abdomen. A forceful inward and upward pull compresses the abdominal cavity and shoves the diaphragm up. That compresses the lungs from below, like squeezing a bellows.
The key detail is the upward component. Pressure applied straight back compresses organs against the spine without much effect. Pressure angled up drives the diaphragm into the chest and produces a rapid burst of airflow. The burst is what ejects the object.
The landmark protects two structures. The lower tip of the breastbone, called the xiphoid process, is a small cartilage projection. Direct pressure on it can fracture it or drive it into the liver. The navel marks the level below which the thrust loses mechanical advantage. The safe window is the midline strip between those two points.
The maneuver was described by Henry Heimlich in 1974 and is now called abdominal thrusts or the Heimlich maneuver. Modern guidance folds it into a sequence that begins with back blows. That sequence is taught in lay and professional courses and appears in major first-aid guidance such as the American Red Cross and the American Heart Association.
Plainly: the fist belongs in the middle of the soft belly, not on the ribs and not at the waistband.
Quantified context: why force, angle, and timing matter
Effective thrusts are quick and forceful. Teaching materials describe each thrust as a distinct, sharp compression rather than a slow squeeze. The maneuver depends on speed, because the object needs a sudden pressure spike to dislodge.
Adults receive thrusts in repeated cycles. A common teaching pattern is up to 5 back blows followed by up to 5 abdominal thrusts, alternating until the object comes out or the person becomes unresponsive. Short cycles matter because each thrust partially inflates the lungs and the next cycle builds on that volume.
For adults and children over one year, the thrust is delivered with the person leaning forward if they are standing or sitting. For an unresponsive adult, the rescuer starts CPR after calling emergency services. The compression depth used in CPR is roughly 2 inches in adults, and it is a separate maneuver from abdominal thrusts.
Infants under one year are a different case. Guidelines direct rescuers to 5 back blows and 5 chest thrusts, not abdominal thrusts. The infant’s liver is relatively large and poorly protected by the rib cage, so abdominal pressure risks injury.
For conscious adults, the classic target is the epigastric midline, and the thrust angle is roughly 45 degrees upward. That is not a precision instrument. It is a directional cue: in and up, not straight back and not down.
Edge cases: pregnancy, obesity, size, and infants
Pregnancy changes the landmark. In later pregnancy, the uterus occupies the lower abdomen and the thrust should move to the chest. Chest thrusts are delivered on the lower half of the breastbone, with the same inward-and-upward intent. This avoids compressing the uterus.
Obesity and body shape can make the landmark hard to find. A rescuer may not be able to encircle a large person with both arms. In that case, the rescuer can deliver thrusts with the person lying down or use chest thrusts. The principle holds: generate a sudden rise in chest pressure without crushing the lower rib margin.
Children over one year use the same abdominal landmark as adults, with force scaled to the child’s size. A rescuer kneels behind a standing child and uses a single fist covered by the other hand. The depth of pull is smaller, but the direction stays inward and upward.
Wheelchair users and seated people can receive thrusts from behind while seated, with the rescuer’s arms around the torso. The maneuver is the same; access and positioning differ.
Infants are the clearest exception. Back blows and chest thrusts replace abdominal thrusts under age one. The reason is anatomical: the infant liver sits low and the rib cage is compliant, so abdominal pressure carries a higher risk of organ injury.
Misconceptions and a professional caveat
The most common error is placing the fist too high. Rescuers aiming for the center of the torso often land on the lower breastbone or the xiphoid. That placement risks fracturing the xiphoid and injuring the liver without improving airflow much.
The second error is pushing only inward. A straight backward push compresses the abdomen but does not lift the diaphragm. The upward vector is what creates the pressure spike.
The third error is treating the maneuver as a standalone rescue. Current guidance starts with back blows because they are effective and carry lower injury risk. Abdominal thrusts follow. A rescuer who skips back blows is not following the standard sequence.
Here is the counterintuitive caveat. A person who is coughing forcefully should not receive thrusts at all. A strong cough means air is still moving and the airway is only partially blocked. Thrusts in that situation can convert a partial obstruction into a complete one. The trigger for intervention is a silent, ineffective cough, or the inability to speak or breathe.
Professional rescuers add another layer: abdominal thrusts are not recommended for infants, and they are replaced by chest thrusts in late pregnancy. The common thread is protecting organs the thrust could injure.
Practical actions: steps and thresholds
The sequence below reflects standard first-aid teaching for a conscious adult who cannot speak, breathe, or cough effectively.
Confirm the emergency: ask “Are you choking?” A person who cannot answer needs action. Call emergency services or direct someone else to call, and start the sequence. Deliver up to 5 back blows between the shoulder blades with the heel of your hand while the person leans forward. If the object does not clear, stand behind the person, make a fist, and place the thumb side just above the navel and well below the breastbone. Grasp your fist with your other hand and pull sharply inward and upward, up to 5 times. Alternate 5 back blows and 5 abdominal thrusts until the object clears or the person becomes unresponsive.
If the person becomes unresponsive, lower them to the ground, call emergency services if not already done, and begin CPR. Do not continue abdominal thrusts on an unresponsive person.
Red flags that change the plan:
Infant under one year: use back blows and chest thrusts, never abdominal thrusts. Visible pregnancy or known late pregnancy: use chest thrusts instead. The person is coughing forcefully: do not intervene; encourage coughing. You cannot reach around the person’s abdomen: switch to chest thrusts. The person becomes unresponsive: stop thrusts and start CPR.
For an unresponsive adult, chest compressions in CPR generate similar pressure changes and are the recommended action once consciousness is lost. That switch is a threshold, not a preference.
Comparing rescue techniques by situation
| Technique | Who it fits | Hand placement | Key limitation |
|---|---|---|---|
| Back blows | Conscious adults, children, and infants | Heel of hand between shoulder blades | Often paired with another technique, not used alone |
| Abdominal thrusts | Conscious adults and children over one year | Fist just above navel, below breastbone, midline | Higher injury risk; avoided in pregnancy and infancy |
| Chest thrusts | Late pregnancy, obesity, infants | Lower half of breastbone | Less familiar to lay rescuers |
| CPR compressions | Unresponsive adults and children | Center of chest, lower half of breastbone | Replaces thrusts once the person is unresponsive |
| Self-administered thrusts | Alone, conscious adult | Own fist above navel, or firm object edge | Hard to generate enough force; call for help first |
The table shows a pattern. Placement shifts with body shape and life stage, but the goal never changes: a sudden rise in chest pressure.
Timeline: what happens during and after a choking event
| Time point | What happens | Action threshold |
|---|---|---|
| 0 seconds | Airway blocked; speech and cough stop | Recognize the emergency |
| First seconds to a minute | Oxygen in the blood begins to fall | Start back blows and thrusts |
| 1 to 3 minutes | Consciousness can fade without air exchange | Call emergency services if not already done |
| 3 to 4 minutes | Risk of brain injury rises with prolonged hypoxia | Continue the sequence without pause |
| 4 to 6 minutes | Serious neurological risk grows | CPR if unresponsive |
| After the object clears | Airway reopens; coughing may continue | Seek medical evaluation |
| Hours to days after | Rare complications such as rib fracture or internal injury can appear | Report pain, blood, or breathing trouble |
The timeline explains why the sequence is fast and repetitive. Each cycle buys seconds, and the object often clears within the first few cycles.
Limitations: what the technique cannot promise and when to stop
Abdominal thrusts are effective but not guaranteed. Success depends on the object’s size and position, the rescuer’s force, and the person’s anatomy. A large object wedged low in the airway may not move with any external pressure.
Injury is a real cost. Rib fractures, xiphoid fracture, and injury to internal organs have been reported after abdominal thrusts. That risk is why the technique is avoided in infants and modified in pregnancy. It is also why thrusts are reserved for people with ineffective coughs, not for mild choking.
Training matters. Lay rescuers who have practiced the landmark and the angle perform better than untrained rescuers. A first-aid course with a manikin is the most reliable way to learn the force and direction.
The technique also has a hard stop. Once the person is unresponsive, thrusts end and CPR begins. Continuing thrusts on an unresponsive person delays compressions and wastes time.
This article is general educational information, not a diagnosis, treatment plan, or substitute for certified first-aid training. For a choking emergency, call your local emergency number immediately and follow dispatcher instructions. Consult a qualified local professional or certified instructor to learn and practice the technique.