smLacerationLipKetamine1What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED?

Answer = 0.3%

A child with laryngospasm can be a scary thing to manage. There’s no way to predict whether a child is going to get it.

You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don’t work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first?


Trick of the Trade

Laryngospasm notch maneuver

NotchThis maneuver, mentioned in the anesthesia literature, is more based on a single physician’s longitudinal experiences (Dr. Philip Larsen, Professor of Clinical Anesthesiology at UCLA). Anecdotally, many pediatricians and anesthetists use it. I haven’t found any published studies on this maneuver though. Interestingly though, I’ve found it mentioned in 2 EM blogs by Life In The Fast Lane and Dr. Bearemy from earlier this year. Better late than never for me, I suppose.


Firmly push the soft tissue just behind the earlobes of the patient’s ears. Be sure not to go too inferiorly along the ramus of the mandible. You want to push at a point as superior as you can go in this notch. Push both sides firmly inward towards the skull base. Simultaneously, push anteriorly similar to a jaw-thrust maneuver. This should break the laryngospasm within 1-2 breaths.

It’s unclear about the mechanism behind why this works. Here are some theories:

  • You are just performing a jaw-thrust maneuver. 
  • You are providing a deep painful stimuli, which causes the vocal cords to relax. 
  • You are stimulating deep cranial nerves which happen to also stimulate the vagus nerve. 

Anyone have success with this maneuver in the pediatric patient? It would be a great case report publication. Nothing in the literature at this point. 

Read the original online commentary by Dr. Philip Larson in the Anesthesiology journal.


Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD