Laryngospasm

Background

• An uncontrolled or involuntary muscular contraction of the vocal folds.
• Reflex is normally triggered when the vocal cords or the area of the trachea below the vocal folds detects the entry of water, mucus, blood, or other substance.
• Associated with ketamine (0.3%)
  • Usually associated with large doses or rapid IV push

Causes

• Ammonia toxicity
• Medications
  • Ketamine
  • Doxapram
• Hypocalcemia
  • Hyperparathyroidism
• Acute tetanus
• Ludwig's angina
• Acute laryngospasm
• Submersion injury
• Pulmonary chemical agents
• Pepper spray
• Smoke inhalation injury
• Caustic cocktail

Clinical Features

• Apnea may be the only sign in complete closure
• Partial closure can manifest as stridor, guttural noises, and paradoxical chest movement

Differential Diagnosis

• Oversedation
• Failure of respiratory drive

Evaluation

Workup

• Typically not indicated

Diagnosis

• Typically a clinical diagnosis

Management

Apply pressure inwardly and anteriorly to the point labeled "Pressure Point" (Larson's Point) while applying a jaw thrust to relieve laryngospasm

• Jaw thrust
• Place pressure on Larson's notch
• If jaw thrust and pressure are not sufficient, bag valve mask with PEEP
• If above do not resolve laryngospasm, sedate more deeply (propofol is the traditional choice, 0.5mg/kg)
• If deeper sedation does not resolve laryngospasm, paralyze and intubate
• In pediatric patients, consider gentle chest compressions

Disposition

• Observation for 2-3 hours after resolution for development of post-obstructive pulmonary edema, bradycardia (consider atropine), or aspiration

See Also

• Ketamine
• Procedural Sedation

Airway Pages

• Pre-intubation
  • Predicting the difficult airway
  • Bag valve mask ventilation
    • Oropharyngeal airway
    • Supraglottic airway
  • Apneic oxygenation
    • EBQ:ED Preoxygenation
• Induction
  • Critical care quick reference
  • Rapid sequence intubation
  • Delayed sequence intubation
• Intubation
  • Intubation (peds)
  • Direct laryngoscopy
  • Video Laryngoscopy
  • Bougie
  • The difficult airway
  • Advanced airway adjuncts
    • Supraglottic airway
  • Non-traditional intubation
    • Awake intubation
    • Nasal intubation
    • Blind digital intubation
• Surgical airways
  • Surgical cricothyrotomy
  • Needle cricothyrotomy
  • Pediatric jet ventilation
• Post-intubation
  • Mechanical ventilation (main)
  • Deterioration after intubation (DOPE)

External Links

• 5minuteairway: Beating Laryngospasm
• emDOCs: Laryngospasm
• First10EM: Managing Laryngospasm