What is the next step for a patient who presents with normal vitals after strangulation, but then develops stridor in the Emergency Department (ED)?

Immediate Airway Management for Post-Strangulation Stridor

This patient requires immediate preparation for definitive airway management with endotracheal intubation, as stridor following strangulation indicates progressive upper airway edema that can rapidly deteriorate to complete obstruction. 1, 2

Immediate Actions

Assemble Expert Team and Equipment

• The most experienced available operator must manage this airway given the high-risk nature of traumatic upper airway injury with evolving edema 1, 2
• Move to a controlled setting with full monitoring and rescue equipment immediately available 2
• Have videolaryngoscopy ready as first-line device, as it maximizes first-pass success in edematous airways 1, 2
• Prepare for front-of-neck access (FONA) with scalpel technique immediately available before attempting intubation, as this airway may rapidly progress to "cannot intubate, cannot oxygenate" 1, 2

Medical Temporizing Measures

• Administer inhaled racemic epinephrine immediately to temporarily reduce airway edema while preparing for intubation 1
• Consider systemic corticosteroids, though their benefit is primarily for post-extubation stridor prevention rather than acute traumatic edema 1
• Keep patient upright to optimize airway patency and reduce work of breathing 3

Intubation Approach

Technique Selection

• Use modified rapid sequence intubation (RSI) as the most appropriate technique for patients with airway obstruction 2
• Preoxygenate thoroughly, though this may be limited by patient distress 3
• Have vasopressors immediately available, as hemodynamic instability is common during RSI in critically ill patients 3

Medication Considerations

• Ketamine 1-2 mg/kg IV is preferred as it maintains cardiovascular stability and preserves airway reflexes better than other induction agents 3
• Use rocuronium for neuromuscular blockade to ensure full paralysis before laryngoscopy, preventing coughing and further airway trauma 3
• Avoid succinylcholine if significant time has passed since injury due to potential hyperkalemia risk 4

Equipment Strategy

• Videolaryngoscopy should be first-line to maximize visualization in an edematous, potentially distorted airway 1, 3, 2
• Have a bougie immediately available to facilitate tube passage through the narrowed airway 3
• Prepare smaller endotracheal tubes than predicted as strangulation causes significant laryngeal edema that narrows the glottic opening 3
• Limit intubation attempts to maximum 3 before transitioning to FONA 3

Critical Pitfalls to Avoid

• Do not delay intubation waiting for the patient to "improve"—stridor following strangulation indicates progressive edema that will worsen, not resolve spontaneously 1, 3
• Do not attempt awake intubation in a distressed patient with evolving airway obstruction, as this will worsen obstruction 1
• Do not use excessive positive pressure ventilation immediately post-intubation, as this can cause hemodynamic collapse 3
• Do not transfer the patient to another location (e.g., operating room) if they are deteriorating—bring the team and equipment to the patient 1

Rationale for Aggressive Approach

Strangulation causes direct laryngeal trauma with progressive edema that typically worsens over the first 24 hours post-injury 1. While the patient currently has normal vital signs, stridor indicates at least 50% airway narrowing and represents impending complete obstruction 5, 6. Post-extubation stridor occurs in 25-75% of pediatric cases but is rare in adults unless there is significant airway injury 1. The development of stridor in this context is therefore highly concerning and warrants immediate definitive airway management before complete obstruction occurs.

The cuff leak test mentioned in guidelines is designed for predicting post-extubation stridor in ventilated patients 1, not for managing acute traumatic airway obstruction, and is therefore not applicable to this scenario.