Severe croup- a short post

A little while ago, there was a little 15mo old, brought in by petrified parents, appearing to be peri-arrest  with severe croup. How severe? His eyes were rolling back, his belly was flopping in badly (I had never seen the belly working this hard), the colour of his skin was… next time you walk in the resus – look at the floor – that was the colour of his skin. The only noise he was making on inspiration was a high pitched squeal… He probably had less than a dozen breaths left in him…

Out came adrenaline with the neb… Literally 5 breaths later you could see that the tide had turned… From there on it was a breeze… Two hours later you could not tell this child was nearly dead when he came in.

Two points I made from this case:

It seemed it took an eternity for adrenaline to happen. There were five 1mL ampoules of 1:1000 to open which took probably around 45sec which feels like a really long time watching a child in extremis. We could probably chuck one ampoule in and start the neb, while the rest of the concoction is being prepared. This would save those agonising seconds of not being able to provide the much needed drug while waiting for the whole enchilada to to arrive. Here’s the catch with that though. The residual volume of a nebuliser device is betwen 0.5 and 1mL so you then need to add a few mL of Saline to your 1mL of 1:1000.

Giving parenteral steroids is another hurdle. The RCH CPG recommends oral steroids for mild croup but parenteral steroids for severe and in much bigger doses. [Editor’s note: As we know, steroids are very well absorbed orally and the onset of action is so slow that the difference between oral and parenteral administration is minimal, MP]. For the sake of saving the child from another distress and detirioration, I think this could be given orally, just squirted into the mouth once the dust is more or less settled (usually within the next 5-10min). Even with a most non-cooperative child, I found if I put medication in standard syringe, attach an IV canula to it and get the parents or the nurse to sneakily slip it into the mouth and drip it in drop by drop… I found this way I can even get as much as 10mL volume in a most non-cooperative child within max 5min instead of blasting it in and having it back on my or parent’s chest.

 

 

A do-it-on-the-run atomiser device in ED

Nowadays most places will have the legendary MAD device that allows delivery of atomised solutions. However if you find yourself in a tight spot where no clever gadgets are available you may find this simple device useful.

If you need to deliver medication as a spray, say for topical anaesthesia in a space with limited access (e.g. quinsy). You can fashion a simple device that will enable you to do that.

What you will need:

  • regular oxygen tubing
  • three-way connector
  • 22g IV cannula
  • 5mL syringe for connections
  • Syringe with your topical anaesthetic agent
The bits you will need

The bits you will need

The assembly is quite simple as shown in the picture.

Put it together

Put it together

You can use either oxygen or air – it does not matter. Once the gas is on, gently push the plunger in the syringe with medication and enjoy watching misty flow being delivered to the target.

Having the oxygen tubing inserted into the chamber of the 5mL syringe provides some safety, that is the tube will pop-out of the syringe when the pressure raises to ~40cmH2O.

A couple of small tips to make it easier:

  • Once you’re ready to use the device and it is connected to the gas supply – leave the gas off until you are ready to fire the juice – slowly turn the gas on. Make sure that the stopcock is in the correct position. If the flow is too high the oxygen tubing will pop out of the syringe, so start low. The optimal flow is 2-3L/min.
  • Make sure that you apply gentle counter pressure on the plunger of the syringe with medication, otherwise the gas will push it back and if the flow is too high – it will pop it out of the syringe and hit you in the eye.

Of course, you can always have the medication delivered through nebuliser if the area is in the oropharynx or mouth if your patient is compliant and spontaneously breathing.

Editor’s noteBig thanks to Dr Lev Veniaminov, EM Registrar, aka Greedylobster for his first contribution to the blog. Writing about one’s Magivered-up equipment adaptations is always a fraught matter. It should be noted that there is no TGA or FDA License for this application of an IV cannula, syringe and oxygen tubing. We can’t strictly recommend it and anyone using it takes the risk that it could all go pear shaped and they’d be on their own. That said, doctors have been coming up with their own adaptations to suit tricky situations for ever and Lev has described something he has had success with here. What you do with the information is up to you.