Succinylcholine Dosing for Pediatric Laryngospasm
For pediatric laryngospasm, administer succinylcholine 2 mg/kg IV for infants and small children, or 1 mg/kg IV for older children and adolescents; if IV access is unavailable, give 3-4 mg/kg IM (maximum 150 mg total dose). 1
Intravenous Dosing
The IV route is preferred when access is available, as it provides the most rapid onset (approximately 1 minute to neuromuscular blockade). 1
Age-Specific IV Dosing:
- Infants and small pediatric patients: 2 mg/kg IV 1
- Older pediatric patients and adolescents: 1 mg/kg IV 1
- Neonates and infants up to 6 months: May require 2-3 mg/kg IV 1
- Infants up to 2 years: May require 1-2 mg/kg IV 1
The American Academy of Pediatrics provides similar age-stratified recommendations: <1 month: 1.8 mg/kg, 1 month to 1 year: 2.0 mg/kg, 1-10 years: 1.2 mg/kg, >10 years: 1.0 mg/kg 2, 3
Intramuscular Dosing (When IV Access Unavailable)
When a suitable vein is inaccessible during laryngospasm, administer succinylcholine 3-4 mg/kg IM, with a maximum total dose of 150 mg. 1
IM Administration Details:
- Onset time: Approximately 2-3 minutes 1
- Maximum dose: Do not exceed 150 mg total 1
- Clinical effectiveness: Despite slower onset compared to IV, clinical experience demonstrates satisfactory results for treating laryngospasm 4
Alternative IM Routes:
- Intralingual/submental approach: May be considered with digital massage of injection site, which can reduce time to effect (mean 133 seconds vs 265 seconds without massage) 5
- Intraosseous route: Probably superior to IM and comparable to IV in terms of onset time 4
Critical Management Considerations
Airway Management is Primary:
Before administering any medication, attempt basic airway maneuvers: 6
- Apply 100% oxygen
- Perform jaw thrust and gentle positive pressure ventilation
- Consider gentle chest compression technique (73.9% success rate in relieving laryngospasm without medication) 7
When Succinylcholine is Contraindicated:
If succinylcholine cannot be used, rocuronium 1.0 mg/kg IM may provide an alternative, though with slower onset. 8 One case report demonstrated successful treatment of pediatric laryngospasm with IM rocuronium 1.0 mg/kg, achieving mask ventilation within one minute 8
Essential Safety Precautions:
- Have atropine immediately available to prevent bradycardia, especially in children 2
- Be prepared for immediate intubation and ventilatory support 2
- Monitor for hyperkalemia risk in patients with undiagnosed myopathies, particularly boys <9 years old 2
- Ensure dantrolene availability for malignant hyperthermia treatment 2
Common Pitfalls to Avoid
- Do not underdose: Pediatric patients often require higher weight-based doses than adults due to larger volume of distribution 1
- Do not delay IM administration: If IV access is not immediately available and laryngospasm persists despite airway maneuvers, administer IM succinylcholine promptly rather than continuing unsuccessful IV attempts 4
- Do not forget post-treatment monitoring: Duration of hypoxia should be minimized; SpO2 <90% for >2 minutes increases risk of complications 8
- Do not mix with alkaline solutions: Succinylcholine is acidic (pH 3.0-4.5) and incompatible with solutions pH >8.5 1