What is the best next step for a patient with throat pain and stridor after strangulation?

Rapid Sequence Intubation

This patient requires immediate rapid sequence intubation (RSI) to secure the airway before complete obstruction occurs. 1

Why RSI is the Correct Answer

Stridor following strangulation indicates at least 50% airway narrowing and represents impending complete obstruction that will worsen, not improve spontaneously. 1 The development of stridor in this clinical context signals progressive laryngeal edema from direct trauma that typically worsens over the first 24 hours post-injury. 1 Delaying definitive airway management while attempting temporizing measures risks progression to a "cannot intubate, cannot oxygenate" scenario. 1

Why Other Options Are Inadequate

BiPAP (Option A)

• BiPAP provides positive pressure ventilation but does not secure the airway against progressive edema 1
• In a patient with evolving upper airway obstruction from trauma, positive pressure may worsen distress and precipitate complete obstruction 1
• This temporizing measure wastes critical time when definitive airway control is needed 1

Cricothyrotomy (Option B)

• Front-of-neck access should be immediately available as rescue, but is not the first-line intervention 1, 2
• RSI should be attempted first by the most experienced operator with videolaryngoscopy before proceeding to surgical airway 1, 2
• Cricothyrotomy is reserved for "cannot intubate, cannot oxygenate" scenarios after failed intubation attempts 1

Nebulized Racemic Epinephrine (Option C)

• While racemic epinephrine should be administered to temporarily reduce airway edema, it is a temporizing measure only while preparing for intubation, not definitive management 1, 3
• The patient already has stridor with tachypnea, indicating significant obstruction that will not resolve with epinephrine alone 1
• Epinephrine provides only transient relief (30-60 minutes) and does not address the underlying progressive edema 3

Optimal RSI Approach for This Patient

Pre-Intubation Preparation

• The most experienced available operator must manage this airway given the high-risk nature of traumatic upper airway injury with evolving edema 1, 2
• Videolaryngoscopy should be first-line to maximize visualization in the edematous, potentially distorted airway 1, 2
• Front-of-neck access equipment with scalpel technique must be immediately available before attempting intubation 1, 2
• Smaller endotracheal tubes than predicted should be prepared as strangulation causes significant laryngeal edema narrowing the glottic opening 1
• A bougie should be immediately available to facilitate tube passage through the narrowed airway 1

Pharmacologic Strategy

• Ketamine 1-2 mg/kg IV is the preferred induction agent as it maintains cardiovascular stability and preserves airway reflexes better than other agents 1
• Rocuronium should be used for neuromuscular blockade to ensure full paralysis before laryngoscopy, preventing coughing and further airway trauma 1
• Vasopressors should be immediately available as hemodynamic instability is common during RSI in critically ill patients 1
• Preoxygenation should be thorough, though this may be limited by patient distress 1

Concurrent Temporizing Measures

• Nebulized racemic epinephrine should be administered immediately while preparing for intubation to temporarily reduce airway edema 1, 3
• The patient should be kept upright to optimize airway patency and reduce work of breathing 1

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
• Do not attempt awake intubation in a distressed patient with evolving airway obstruction, as this will worsen obstruction 1
• Limit intubation attempts to a maximum of 3 before transitioning to front-of-neck access 1
• Do not use excessive positive pressure ventilation immediately post-intubation, as this can cause hemodynamic collapse 1
• Do not transfer the patient to another location if deteriorating — bring the team and equipment to the patient 1