Acute Stridor (Adult)

Stridor means critical upper airway narrowing — by the time it is audible the airway is >50% obstructed. Causes: anaphylaxis, neck haematoma, laryngeal oedema, infection (epiglottitis), tumour, bilateral vocal cord palsy, foreign body. Call for…

Emergency Airway Compromise Pathway

The pathway

1 · Recognise & call for help

Inspiratory stridor = upper airway obstruction
Emergency call: anaesthetics + ENT immediately
Do not leave the patient

2 · Position & oxygen

Sit up, 15L NRB
Keep the patient calm — do not force examination, never sedate
Continuous SpO2 + senior nursing presence

3 · Treat the cause fast

Anaphylaxis → IM adrenaline 500mcg
Post-thyroid/neck surgery haematoma → open the wound at the bedside (skin + deep sutures)
Infection → IV antibiotics + steroids

4 · Medical adjuncts

Nebulised adrenaline 5ml 1:1000 (repeatable)
IV dexamethasone 6.6mg
Heliox as a bridge if available

5 · Definitive airway

Theatre — senior anaesthetist ± awake fibreoptic
ENT scrubbed for surgical airway (double setup)
Failed intubation → front-of-neck access

6 · Post-event

ITU care
Investigate cause: nasendoscopy, imaging once safe
Document airway grade + alert for future anaesthetics

Drugs

Drug	Dose	Route	Notes
Adrenaline (nebulised)	5ml of 1:1000	NEB	Reduces mucosal oedema in minutes. Short-lived — repeat as needed.
Adrenaline (IM)	500mcg (0.5ml 1:1000)	IM	If anaphylaxis is the cause. Repeat at 5 min.
Dexamethasone	6.6mg	IV	Reduces airway oedema over hours.
Hydrocortisone	200mg	IV	Alternative steroid if dexamethasone unavailable.

When to escalate

Any stridor — anaesthetics + ENT emergency call, immediately,Post-neck-surgery swelling — open the wound, call the surgeon,Falling SpO2, silent chest, exhaustion, agitation — peri-arrest,Drooling/odynophagia (epiglottitis) — do NOT examine the throat, theatre for airway

Reference: DAS Difficult Airway Guidelines / BAETS post-thyroidectomy haematoma guidance

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