Give back blows between the shoulder blades, on the flat mid-back, with the heel of one hand — that's the spot, and the name to attach to it is "interscapular," the area between the shoulder blades over the spine. The target is the upper-middle back, not the neck, not the lower back, and not the fleshy part over the kidneys. Placement is only half the skill, though: five firm blows, delivered with the victim leaning forward, follow a sequence that most bystanders get wrong. This guide covers the exact landing zone, the aiming technique for adults, children, and infants, and the placement errors that make the maneuver less effective than it should be.
The Interscapular Target: Where the Heel of Your Hand Lands
The correct landing zone is the midline of the upper back, directly between the shoulder blades, roughly at the level of the T3 to T7 vertebrae. Lay two fingers on either side of the spine and you'll feel the bony ridges of the scapulae; the gap between them is the target. The heel of your hand — the firm, fleshy base of the palm near the wrist — sits flat over that gap.
That anatomical precision matters because the goal isn't to hit the person hard. It's to transmit a sudden pressure wave through the chest that mimics a natural cough. A cough generates a burst of airflow that can dislodge a foreign body; the back blow does the same thing mechanically. Land the blow off-center and a chunk of the force dissipates into muscle and soft tissue instead of the rib cage.
Why the heel of the hand and not a fist? A closed fist concentrates force into a small area and can bruise ribs or soft tissue without improving the shockwave to the airway. The heel of the hand spreads the impact across a wider surface while still delivering enough energy to matter. It also keeps your wrist in a neutral position, which reduces your own risk of a sprain when you strike.
Keep your fingers relaxed and slightly separated, and let the hand land flat. If your fingers curl under and the knuckles contact first, that's a fist by another name. The flat, firm contact is what converts your arm movement into useful pressure inside the chest.
How Five Firm Blows Between the Shoulder Blades Actually Work
The mechanism is simple physics dressed up in anatomy. A sudden compression of the chest raises intrathoracic pressure; that pressure pushes air up and out through the trachea. If a piece of food or a small object is sitting in the airway, the rush of air can carry it loose. Back blows do this from the outside, and they work best on a partially obstructed airway where some air still moves.
The recommended pattern is five blows, then a check. After the fifth blow, look in the mouth and see whether the object has come loose. If the person is still choking, move to abdominal thrusts (the Heimlich maneuver) for five repetitions, then alternate back to five more back blows. That back-and-forth cycle continues until the obstruction clears or the person becomes unresponsive — at which point you call emergency services and begin CPR.
Firmness is where bystanders hesitate. A tentative tap won't generate the pressure change you need. The blow should be firm enough that the person feels it, delivered with your whole forearm rather than a wrist flick. You are not trying to injure the person; you are trying to make their chest behave like a bellows for a second.
Watch the victim's face and listen for air movement. A cough, a wheeze, or a sudden gasp means something shifted. If the person goes silent and limp, the airway is fully blocked and the situation has escalated — that's your cue to call emergency services and start CPR if they're unresponsive.
How to Aim Back Blows on Adults, Children, and Infants
Adults and children old enough to stand get the same treatment: stand slightly behind and to one side of them, support their chest with one hand, and lean them forward so their upper body is roughly parallel to the ground. Gravity helps here — the airway tilts toward the floor, and the object has a shorter path out. Then deliver the five blows to the interscapular zone.
Infants under one year old are different, and this is the placement detail most people miss. Lay the baby face-down along your forearm, with your hand supporting the jaw and head, and keep the head lower than the torso. The back blows land between the shoulder blades — but gently, with the heel of your hand, at a force calibrated to an infant's small frame. Five blows, then flip the baby face-up and give five chest thrusts, alternating.
Children over one year can usually be leaned forward over your knee if they're small enough, or held standing if they're larger. The target stays the same: the flat upper-mid back, between the shoulder blades. Resist the urge to swing harder because the child is small — the correct force for a child is less than for an adult, but still firm enough to move the chest.
For a pregnant or obese adult, you can't easily lean them forward over a knee, but the back blow placement stays the same. Support the chest, lean them forward at the waist as far as comfortable, and aim between the shoulder blades. The American Red Cross and American Heart Association both teach this same interscapular target across all age groups, with force and positioning adjusted rather than the landing zone.
The Five Placement Mistakes That Weaken the Maneuver
| Mistake | What happens | Correct placement |
|---|---|---|
| Striking the neck or base of the skull | Risk of injury, no airway pressure | Mid-back, between shoulder blades |
| Hitting the lower back over the kidneys | Bruising risk, wasted force | Upper-mid back, not below the rib cage |
| Using a closed fist | Concentrated force, higher injury risk | Heel of the hand, flat contact |
| Striking while the victim is upright | Airway stays vertical, object has no exit path | Lean the person forward first |
| Aiming at one shoulder blade | Force dissipates into muscle | Midline, directly over the spine gap |
The lower-back error deserves a closer look because it's the one that shows up in real-world accounts. The kidneys sit at roughly the level of the lowest ribs, and a hard blow there can cause bruising or, in rare cases, more serious injury. If your hand lands below the bottom of the shoulder blades, you've drifted too low. Reset your aim upward.
The upright-victim error is subtler. A person who is choking will often stand rigid and panicked, and a rescuer who strikes them while they're vertical is fighting gravity. The object has nowhere to go. The lean-forward position isn't optional — it's part of the technique, and it's why the Red Cross teaches the chest-support hand before the first blow.
Striking one shoulder blade instead of the midline is common when the rescuer is standing to one side. Your arm naturally arcs toward the side you're on. Compensate by reaching across slightly so the heel of your hand lands on the centerline.
Positioning First, Striking Second: The Lean-Forward Setup
Before your hand moves, your other hand does the work. Stand behind the choking person, slightly to one side, and place one arm across their chest. That supporting arm does two jobs: it holds them steady and it gives you a hinge point for leaning them forward. Then bend them at the waist until their upper body is roughly horizontal.
This is the step that changes outcomes. A forward-leaning torso turns the airway into a downward-sloping tube, and a downward-sloping tube lets gravity assist every blow. The person's own weight against your supporting arm keeps them in position, so you're not fighting them between strikes.
For a larger person or someone in a chair, the same principle applies with adjustments. Lean them forward over the back of the chair if they're seated, or support their chest and tip them at the waist if they're standing. The target doesn't move — it's still between the shoulder blades.
One practical note: tell the person what you're about to do if there's time. "I'm going to give you five blows on the back — lean forward." A panicked choking victim may resist being pushed; a warning reduces the chance they fight you and throws off your aim.
Why the Back Blow Comes Before the Abdominal Thrust
Guidance from the American Red Cross and the American Heart Association puts back blows first in the choking sequence for conscious adults and children, followed by abdominal thrusts. The reasoning is mechanical: back blows are less invasive, they work on partial obstructions, and they carry a lower risk of internal injury than thrusts. If five blows clear the object, you never need to compress the abdomen at all.
Abdominal thrusts remain essential, and the two techniques are meant to alternate. Five back blows, five abdominal thrusts, check the mouth, repeat. Thinking of them as competitors is the wrong frame — they're a tag team, and the back blow gets first billing because it's gentler and often sufficient.
There's an important exception for infants. Abdominal thrusts are not used on infants under one year because of the risk of organ injury; the infant sequence is five back blows followed by five chest thrusts, using two fingers on the center of the chest. That's a placement difference worth memorizing if you care for young children.
For pregnant or obese adults, rescuers often substitute chest thrusts for abdominal thrusts because there's no room to position hands on the abdomen. Back blows still come first, and the interscapular target is unchanged.
What Changes With Age, Size, and the Victim's Position
Force scales with body size; placement doesn't. An adult gets firm blows that move the chest wall noticeably. A small child gets less force, delivered with the same flat hand on the same mid-back spot. An infant gets gentle blows with the heel of the hand while cradled face-down along your forearm.
Position changes the setup, not the target. A standing adult leans forward at the waist. A seated adult can lean over the chair back. A child can drape over your knee. An infant lies along your forearm with the head lower than the body. In every case, your hand lands between the shoulder blades.
The one situation where placement gets genuinely tricky is a victim who is much taller or shorter than you. If you can't reach their mid-back comfortably, kneel or stand on a stable surface to bring your striking hand to shoulder-blade level. Don't strike downward at a steep angle just because your arm is short.
If the person becomes unresponsive mid-sequence, the back blows stop. Lower them to the ground, call emergency services if you haven't, and begin CPR. Back blows are for a conscious choking victim; an unresponsive victim needs chest compressions, which serve a different mechanical purpose.
The Two Errors That Cause the Most Harm
The first harmful error is striking too hard in the wrong place. Force aimed at the neck, the lower back, or the side of the rib cage can cause injury without helping the airway. The interscapular midline is forgiving because the rib cage and spine distribute the force; the neck and flanks are not.
The second is hesitating so long that the victim deteriorates. A rescuer who worries about hurting the person may deliver feather-light taps that do nothing, wasting the critical seconds before the obstruction worsens. The standard is firm, not violent — enough to move the chest, delivered flat and centered.
There's a third error that's less about force and more about sequence: giving back blows to someone who is coughing forcefully. A strong cough means the airway is partially open and the person is moving air; the best move is to encourage coughing and stay ready. Back blows are for a choking person who can't cough, speak, or breathe effectively.
Panic also degrades technique. If you're rattled, you may forget the lean-forward step, strike with a fist, or lose count. Counting out loud — "one, two, three, four, five" — keeps the rhythm and signals to anyone nearby that you know what you're doing.
Back Blows vs. Abdominal Thrusts: A Side-by-Side Comparison
| Dimension | Back blows | Abdominal thrusts |
|---|---|---|
| Target | Mid-back, between shoulder blades | Just above the navel, below the breastbone |
| Hand position | Heel of one hand, flat | Fist with other hand wrapped over it |
| Direction of force | Downward and inward through the chest | Upward and inward under the diaphragm |
| First-line for conscious adult | Yes | Second, after five blows |
| Used on infants under one year | Yes | No — chest thrusts instead |
| Primary injury risk | Bruising if off-target | Internal injury if too high or too hard |
Use back blows first for a conscious choking adult or child, and for any infant. Reach for abdominal thrusts when five back blows haven't cleared the object. The two are designed to alternate, not to replace each other.
The comparison also clarifies a common question: which is more effective? Neither is universally superior; they attack the obstruction from different directions. Back blows push air up from a compressed chest; thrusts shove the diaphragm upward to create a stronger burst. Together they cover more ground than either alone.
Practicing the Placement Before You Need It
The best time to learn where the interscapular zone is happens in a class, not an emergency. A CPR and first aid course gives you a manikin and an instructor who corrects your hand placement in real time. The American Red Cross and American Heart Association both offer courses that cover choking response for adults, children, and infants.
At home, you can rehearse the geometry without striking anyone. Have a willing adult stand in front of you; place your supporting arm across their chest and lean them forward. Then rest the heel of your free hand flat between their shoulder blades and note where it lands relative to the spine and the bottom of the scapulae. That muscle memory transfers under stress.
Counting and alternating deserve practice too. The five-and-five rhythm — five back blows, five thrusts, check, repeat — is easy to state and easy to fumble. Rehearse it out loud until the sequence is automatic.
Refresh the skill periodically. Guidelines from major resuscitation bodies update on a multi-year cycle, and a technique you learned a decade ago may have been refined. Check the current guidance from the Red Cross or AHA before relying on memory.
If you want a single takeaway to carry: flat hand, heel first, between the shoulder blades, victim leaning forward. That combination is the whole maneuver in one line.
FAQ
Can you give back blows to someone who is coughing?
No — a forceful cough means air is still moving, so encourage the person to keep coughing and stay with them. Back blows are for someone who cannot cough, speak, or breathe effectively. If the cough weakens or goes silent, that's when you step in.
What if the choking person is much taller than you?
Kneel on a stable chair or step, or ask them to sit, so your hand reaches shoulder-blade level. Striking upward from below your own shoulder height throws off the angle. The target stays between the shoulder blades regardless of your relative heights.
Do you give back blows to a pregnant woman?
Yes, back blows come first, with the same interscapular target. For the follow-up thrusts, rescuers typically substitute chest thrusts for abdominal thrusts because there's no room to position hands on the abdomen. Lean her forward at the waist as far as comfortable.
How hard should the blows be?
Firm enough to move the chest wall noticeably, delivered with your whole forearm rather than a wrist flick. For an infant, use gentle force scaled to the baby's size. The standard is firm, not violent — a tentative tap won't generate the pressure change needed.
What happens after five back blows don't work?
Check the mouth for the object, then give five abdominal thrusts (or chest thrusts for an infant or pregnant adult). Alternate five blows and five thrusts until the object clears or the person becomes unresponsive. If they go limp, call emergency services and start CPR.
Is it dangerous to hit someone's back when they're choking?
The interscapular midline is relatively forgiving because the rib cage and spine distribute force. The real dangers come from off-target strikes — the neck, the lower back over the kidneys, or the flanks. Flat, centered blows reduce injury risk.
Should you use a fist or an open hand for back blows?
Use the heel of an open hand, not a fist. A fist concentrates force into a small area and raises injury risk without improving the pressure wave to the airway. The flat heel of the hand spreads the impact while still delivering useful energy.
Can back blows clear a complete airway obstruction?
Sometimes, but not reliably — a fully blocked airway may need the thrust sequence to follow. That's why the guidance alternates five back blows with five abdominal or chest thrusts. Persistence through the full cycle matters more than any single blow.
This article is general educational information, not a diagnosis or treatment plan. Choking response technique varies by age and condition, so confirm current guidance with a qualified local first aid instructor or your national resuscitation council before relying on it in an emergency. If someone is in immediate danger, call your local emergency number right away.