Linking To And Excerpting “Managing laryngospasm in the emergency department” From First 10EM With Links To Additional Resources

In addition to today’s resource, please see:

  • Comprehensive Review of Laryngospasm, from Update In Anesthesia, acessed 2-2-2025.
    • “INTRODUCTION:
      Perioperative laryngospasm is a life threatening
      complication during the perioperative period with an
      incidence of 0.78-5% depending on the surgical type,
      patient age, pre-existing conditions and anesthetic
      technique.1
      It is defined by a sustained closure of the vocal cords
      as a primitive protective airway reflex to prevent
      tracheobronchial aspiration after an offending
      stimulus. The prolongation of this initial beneficial
      reflex after the stimulus has ceased, results in
      inadequate ventilation due to airway obstruction.
      It occurs most frequently during intubation or
      extubation due to a superficial level of anesthesia.2
       The diagnosis can only be made if the closed glottis
      and vocal cords are visualized which is not possible in
      the great majority of cases. So usually it depends on
      the anesthesiologist’s clinical judgement. [Emphasis added]Clinical signs
      include inspiratory stridor, paradoxical respiratory
      movements, suprasternal and supraclavicular
      retractions and rapidly decreasing oxygen saturation.
      As the obstruction progresses to a complete airway
      obstruction, the chest movements may be excessive
      but there is no movement of the reservoir bag and no
      capnogram reading. Desaturation is the most common
      manifestation. Other manifestations are bradycardia
      (6%), negative pressure pulmonary oedema (4%),
      cardiac arrest (0.5%), pulmonary aspiration (3%),
      arrhythmias and death.3

Today, I review, link to, and embed  “Managing laryngospasm in the emergency department” from First 10EM With Links To Additional Resources.

All that follows is from the above resource.

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

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. 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

Immediately stop all procedures.

The key to reversal is application of CPAP with good basic airway maneuvers.

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 All Postsor 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.

Notes

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.

Image from Larson’s original paper, reproduced from LITFL #FOAMed Medical Education Resources (LITFL) / CC BY-NC-SA 4.0

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

Laryngospasm on LITFL

Laryngospasm after Ketamine on Resus.me

The best treatment for laryngospasm is simple, fast, and free

Laryngospasm treatment options on OpenAnesthesia.org

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