A feisty 3 year old tripped, cut her lip, and is now politely refusing your colleague’s attempts at suturing. You hear these polite refusals from across the department, and wander over to offer your help with a procedural sedation. After moving to an appropriate room, going through the pre-sedation checklists, and tracking down all the folks that are required to be present, you give a dose of ketamine (1mg/kg IV). Just as you are about to entertain the room with your latest cheesy joke, you hear a loud squeaking. You glance at the patient and recognize significant respiratory muscle contraction and stridor. A quick glance at the monitor shows a flat CO2 tracing. Oh no, laryngospasm…
Any potential causative procedure is stopped
Basic Airway Maneuvers
- Apply a modified jaw thrust maneuver, where the pressure is applied near the top of the ramus of the mandible in the “laryngospasm notch” aka “Larson’s point”
- Using a bag valve mask with a PEEP valve and 100% oxygen, manual ventilation with continuous positive airway pressure is attempted
While performing the above procedure, an RT or a nurse is asked to prepare all intubating equipment in preparation for a potentially difficult airway.
A nurse is asked to prepare the medications that might be required: succinylcholine 1.5mg/kg or rocuronium 1.2 mg/kg
If propofol is already drawn up (ie, was being used for the sedation), push 0.5 mg/kg IV
If no response to the above, or desaturation necessitates, proceed to rapid sequence intubation by pushing a full dose paralytic (succinylcholine 1.5mg/kg IV or rocuronium 1.2 mg/kg IV)
If there is no IV in place when laryngospasm occurs, but paralysis is required you could give succinylcholine 4mg/kg IM, but I think onset is probably overall faster to just start an IO.
Many sources say you might only need a small dose of succinylcholine. Personally, I think that is I am giving a paralytic, I am likely going to be intubating, so I will just give the full dose.
Image from Larson’s original paper, reproduced from LITFL
There is a higher risk in children with upper respiratory tract infections and those exposed to smoking at home. Consider this when choosing ketamine as sedation agent.
Gentle compression of the chest has also been described (aee Al-Metwalli reference below).
Other FOAMed Resources
Al-Metwalli RR, Mowafi HA, Ismail SA: Gentle chest compression relieves extubation laryngospasm in children. J Anesth 2010; 24:854–7. PMID: 20976504
Butterworth JF, IV, Mackey DC, Wasnick JD. Chapter 19. Airway Management.In: Butterworth JF, IV, Mackey DC, Wasnick JD. eds. Morgan & Mikhail’s Clinical Anesthesiology, 5e. New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com/content.aspx?bookid=564&Sectionid=42800551
Larson CP. Laryngospasm – the best treatment (letter). Anesthesiology. 1998 Nov;89(5):1293-4. PMID: 9822036
Orliaguet GA, Gall O, Savoldelli GL, Couloigner V. Case scenario: perianesthetic management of laryngospasm in children. Anesthesiology. 2012 Feb;116(2):458-71. PMID: 22222477
Salem MR, Crystal GJ, Nimmagadda U. Understanding the mechanics of laryngospasm is crucial for proper treatment. Anesthesiology. 2012 Aug;117(2):441-2. PMID: 22828433.