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.

 

 

Cardiogenic shock and thromobolysis (with some more challenges thrown in)

It is mid afternoon in your busy regional ED when the triage nurse calls for help. A 57 year old woman who drove herself to hospital managed to tell her that she has been having awful pain in her chest when she collapsed, collecting her forehead on the windowsill on the way down. You poke your head through the triage window to see her looking up at you from the floor, clearly not well.

By the time you unstick your head from the triage window the patient has been moved onto a gurney. She is awake but with a clouded conscious state (confused mumbling, eyes open but not fixing and focusing, localising to pain) and his vitals are HR 40, BP 60/-, RR 26 with end of the bed wheeze, SpO2 not readable, afebrile. She is bathed in sweat and pale.

This is her 12 lead ECG

Image

What to do? Read on and see what you think.

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