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Crisis Card

Laryngospasm

Larson's maneuver + CPAP. Sux 10–20 mg IV breaks refractory cases.

Pressure on Larson's notch + jaw thrust + CPAP 40 cmH₂O

Recognize

  • Inspiratory stridor or silent airway
  • Tracheal tug, paradoxical chest/abdominal movement
  • Loss of EtCO₂ tracing, desaturation
  • Bradycardia, central cyanosis

Doses

Succinylcholine IV
10–20 mg IV
Succinylcholine IM
4 mg/kg
If no IV
Propofol
0.5–1 mg/kg IV
Atropine (peds)
0.02 mg/kg IV
Pre-sux in infants
CPAP
Tight mask, 40 cmH₂O O₂

Sequenced Actions

  1. 1
    Stop the stimulus
    • Pause surgery, remove oropharyngeal stimulation
    • Increase FiO₂ to 100%
  2. 2
    Open the airway + CPAP
    • Jaw thrust + head tilt + oral or nasal airway
    • Larson's maneuver: firm bilateral pressure on the laryngospasm notch — behind the angle of the mandible, in front of the mastoid
    • CPAP via tight mask seal at 100% O₂, often need 40 cmH₂O
  3. 3
    Suction
    • Clear blood, mucus, vomit from oropharynx
  4. 4
    Deepen anesthesia
    • Propofol bolus (0.5–1 mg/kg)
    • Consider IV lidocaine 1–2 mg/kg
  5. 5
    Succinylcholine
    • 10–20 mg IV (low-dose, often breaks laryngospasm without full paralysis)
    • If no IV: 4 mg/kg IM (deltoid or thigh)
    • Pretreat children with atropine 0.02 mg/kg if bradycardic
  6. 6
    Reintubate vs. continue with mask
    • If oxygenation restored and surgery brief: continue with mask/LMA
    • If patient remains apneic or surgical needs require: intubate
    • Prepare for surgical airway if persistent CICV
  7. 7
    Watch for NPPE
    • Negative Pressure Pulmonary Edema can follow laryngospasm (esp. young healthy males)
    • Frothy pink secretions, hypoxia, ↑ A-a gradient
    • Treat supportively with PEEP, diuresis; usually self-limited within 24 h
    • Consider PACU monitoring 4+ h after significant laryngospasm

Common Pitfalls

  • Failing to use Larson's maneuver — it works far more often than propofol alone.
  • Forgetting to suction first — blood/mucus may be the trigger.
  • Pressing too low (on the carotid) instead of on the mandibular notch.
  • Discharging too quickly — NPPE may evolve over hours.

References & Further Reading

  1. 1
    Textbook

    Gaba DM, Fish KJ, Howard SK, Burden A. Crisis Management in Anesthesiology. 2nd ed. Philadelphia: Saunders/Elsevier; 2014.

  2. 2
    WebOpen source

    Stanford Anesthesia Cognitive Aid Group. Stanford Anesthesia Emergency Manual. emergencymanual.stanford.edu.

  3. 3
    Textbook

    Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

  4. 4
    Textbook

    Adriano A, Morris R, eds. 2021 CA-1 Tutorial Textbook (15th Ed.). Stanford University Medical Center, Department of Anesthesiology.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.

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