An updated version of this post is available here.
Case
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…
My approach
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)
Notes
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
Laryngospasm after Ketamine on Resus.me
The best treatment for laryngospasm is simple, fast, and free
Laryngospasm treatment options on OpenAnesthesia.org
References
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.
2 thoughts on “Laryngospasm”
Shortly after this post went online, I became involved in a great conversation about laryngospasm on twitter. Many thanks specifically to @Anaesthesia_AGB for some very insightful comments. I am going to summarize a few of the points here:
I was gently chastised by these expert anesthesiologists for jumping straight to RSI in the event that PEEP, Larson’s point pressure, and propofol did not work. The anesthesiologists out there see this all the time, and use a low dose of succinylcholine to break the spasm. I think in a non-critically desaturating patient, that makes a lot of sense, and I will consider trying it myself. I have never seen a case of laryngospasm that did not resolve with basic airway maneuvers and Larson’s point pressure, so I have to give a lot of credit to the experience of those who see this more frequently.
However, I did not go back and change my original post for two reasons. First, I think that if I ever push succinylcholine in the ED without following it with an endotracheal tube, my nurses might mutiny on me. More importantly, however, is another point that came up during the twitter discussion. Laryngospasm requiring paralytics is extremely rare. The twitter anesthetists seemed to estimate that they might see a case every 3 years or so doing full time anesthesiology. Therefore, in an ED setting, with infrequent sedations, I might see such a severe case of laryngospasm only once in my career. By the time I am get around to remembering the details of this twitter conversation, that sats will have already started to fall. Part of the reason for first10em is to simplify the very worst situations, so that I can remember the steps under stress. So if I end up performing one extra RSI in my career that could have been prevented with a lower dose of succinylcholine, but the patient is alive and happy, so be it.
Aside from the debate about when to perform RSI, the experts seems to agree that the most important steps are pressure on Larson’s notch, PEEP, and propofol. Those three steps will get you out of trouble the vast majority of the time.
Another interesting question raised was: once you get to the point of performing an RSI, what do you do about extubating these patients? Extubation is a known risk factor for laryngospasm, and the patient was just intubated for laryngospasm. I would definitely be asking my local anesthetist for advice if this ever comes up. One suggestion was to perform an awake extubation after a dose of IV lidocaine. Obviously I would have all my difficult airway equipment available at the bedside.
Chime in if you have any other thoughts…