It has now been a full year since I started First10EM. Thank you to everyone who has helped me a long the way, and especially to everyone who has spent their time reading this blog. I never imagined that so many people would be interested in my emergency medicine education project. This is an updated version of the first ever post on First10EM.com
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. 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…
Immediately stop all procedures.
The key to reversal is application of CPAP with good 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, provide continuous positive airway pressure
While providing CPAP and applying pressure to Larson’s point, I ask my RT to prepare my intubation equipment for a potentially difficult airway. A nurse is asked to draw up a paralytic (either succinylcholine 1.5mg/kg or rocuronium 1.2mg/kg).
Key question: Is there desaturation? For the patient with already low oxygen saturation, proceeding immediately to paralysis and intubation is reasonable. If the oxygen saturation allows, start by deepening anesthesia. Propofol is the traditional agent, at a dose of 0.5mg/kg IV push.
If there is no response to deepening anesthesia, the next step is an IV paralytic. In anesthesia, this traditionally involves giving a low dose of succinylcholine to break the spasm. However, laryngospasm that is unresponsive to airway maneuvers and propofol is rare and using paralytics without intubating is unheard of in the emergency department. Personally, I think the best option at this point is to proceed with a classic RSI with a full dose of your paralytic of choice (succinylcholine 1.5mg/kg IV or rocuronium 1.2 mg/kg IV).
What do you do if you don’t have an IV? Personally, for a variety of reasons, I prefer to always have an IV in place for procedural sedation. However, if you decided to do a sedation with IM ketamine and the patient went into laryngospasm, I think the best option is to rapidly place an IV or IO and proceed with the above. Theoretically, you could give succinylcholine 4mg/kg IM, but I worry the response would be too slow for this scenario.
Extuabation is a risk factor for laryngospasm, so if you end up intubating a patient, I would consult with anesthesia to discuss the management plan.
The rate of laryngospasm in emergency department procedural sedation is about 1.1 per 1,000 in adults based on Bellolio 2016. As you can see from her note below, there is a yet to be published pediatric review that shows the rate is 3.9 per 1,000 in children. Almost all cases of laryngospasm were in cases where ketamine was used.
The laryngospasm notch:
There is a higher risk in children with upper respiratory tract infections and those exposed to smoking at home. This might be worth considering when choosing the ideal agent for sedation.
Gentle compression of the chest has also been described (aee Al-Metwalli reference below).
Other FOAMed Resources
Borshoff DC. The Anesthetic Crisis Manual. Leeuwin press; 2013.
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.
Bellolio MF, Gilani WI, Barrionuevo P. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 23(2):119-34. 2016. PMID: 26801209