Chris “Willko” Wilkinson (SCAT paramedic) shared this handy trick of the trade during a recent simulation session.
Road primary job to a school where a 6 year old girl is in severe respiratory distress with known asthma. On arrival sats are 85% on a non rebreather, RR40, poor air entry bilaterally and responding only to pain. Minimal response to IM adrenaline (Review of adrenaline in asthma)
Airway secured by rapid sequence intubation. We see a good CO2 trace but she is very hard to bag.
How can we deliver salbutamol to the bronchioles of this patient in the prehospital setting?
Options in our kit:
- Salbutamol metered dose inhaler but patient is intubated
- 5mg IV salbutamol but no infusion pump.
- 5 x 5mg salbutamol nebules but no T-piece in our interhospital pack.
- Sabutamol Metered Dose Inhaler
- 30ml Syringe
- Patient connector with suction port from an Adult Oxylog 3000 disposable circuit
The patient connector is the most distal piece from an adult Oxylog 3000 disposable circuit.
Putting it together
- Attach the Oxylog patient connector to the ETT and continue bagging the patient SLOWLY (to prevent hyperinflation)
- Pull the plunger out of the syringe
- Put the Salbutamol cartridge in the syringe barrel and replace the plunger
- Spray salbutamol through the suction port of the oxylog patient connector in synchrony with bagging
Here’s a 2 minute video showing how to do it in real time
A bolus dose is 10mcg/kg every 15min (critical care drugs)
That’s 250mcg in this 25kg 6 year old. So we could dilute 5mg in 50ml giving us 5omcg/ml and bolus 5ml every 15min.
The infusion dose is 5-10 mcg/kg/min (RCH drug doses online).
So if we put 5mg in 250ml of saline and run it in over 20 minutes we will be getting about 250mcg/min but our transport time may be longer than this and we run a greater risk of causing hypokalaemia.
However the evidence for IV salbutamol is not great and some question whether we should be using it at all. Nonetheless I would probably use it for this child IF I could find the dose, figure out an appropriate dilution and run it at a safe rate without the aid of an infusion pump. A review of the management of life threatening asthma was recently published in the British Journal of Anaesthesia