1. Prepared by Shane Barclay MD
Laryngospasm
Prepared by Shane Barclay MD

2. Why discuss this topic?
Although laryngospasm is rare in the ER, if not recognized and treated immediately it can be life threatening.

3. Definition
Laryngospasm is a closure of the true vocal cords along with the epiglottis covering the cords which in turn results in partial or complete airway obstruction.

4. Causes
Local
- extubation/intubation - foreign body – secretions, blood etc - reflux or aspiration - ENT procedures or airway manipulation
2. Systemic - drugs - tetanus

5. Causes
In family practice laryngospasm will usually ‘present’ with the patient coming in saying that he/she had experienced an episode of acute shortness of breath and choking. Patients will usually experience this after bending over or during the night. The cause is reflux where acid comes up the esophagus causing the larynx to go into spasm. Although terrifying for the patient, these episodes usually resolve spontaneously.

6. Causes
However, if working in the Emergency Department and if using Ketamine for procedures, you may see this as an albeit RARE complication of ketamine. As well, ketamine induced laryngospasm may not resolve immediately on its own. So, being aware of what laryngospasm is and how it is treated is very important.

7. Ketamine as a Cause
Incidence is only around 0.4% in children given Ketamine. Incidence in adults is difficult to find in the literature but is likely similar. Of children experiencing laryngospasm related to Ketamine use, only a small proportion require intubation.

8. Clinical presentation
Laryngospasm may be preceded by a high pitched “crowing” that is an inspiratory stridor. This is then followed by complete airway obstruction and apnea. It can occur without any obvious clinical warning signs other than oxygen desaturation and apnea.

9. Clinical presentation
Complete airway obstruction will then result in: No airway sounds Loss of EtCO2 waveform and drop in oxygen saturation. No chest wall movement. Inability to manually ventilate the patient even with bag mask valve. A chin lift, jaw thrust will not help.

10. Management
Administer 100% oxygen with bag valve mask to apply positive pressure to try to open the vocal cords.
Use suction to clear any secretions.
Attempt to break the laryngospasm by applying pressure to the ‘laryngospasm notch’ or “Larson’s notch”. (see below)
Try deepening sedation with low dose Propofol.
If unsuccessful, try low dose succinylcholine ( mg/kg).

11. Management
6. If unsuccessful, use full dose succinylcholine (1-2 mg/kg) and perform intubation. 7. Be prepared for bradycardia (especially in children) and use atropine if needed. 8. Laryngospasm can be brief and may be preceded by an inspiratory gasp. This may be your time for intubation. 9. Using a chest wall compression may help open the vocal cords to assist in intubation.

12. Larson’s notch
“This notch is behind the lobule of the pinna of each ear. It is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone, and cephalad by the base of the skull.”
Or see the diagram on the next slide!

13. Larson’s notch

14. How to avoid laryngospasm In children
Avoid ketamine in children under 3 months of age.
Do not use in children with active URTI.
Do not use in children with asthma.
Ensure adequate sedation for procedure.

15. How to prepare for laryngospasm
Follow check list for procedural sedation ie: monitors, BVM, airway cart etc all on hand!

16. The end