A comparison of Australasian jurisdictional ambulance services’ paramedic clinical practice guidelines series: Adult anaphylaxis

IntroductionThis article forms part of a series that seeks to identify interjurisdictional differences in the scope of paramedic practice and, consequently, differences in patient treatment based on which jurisdiction a patient is geographically located within at the time of their complaint. Methods The current Clinical Practice Guidelines of each Australasian domestic jurisdictional ambulance service (JAS) were accessed during June 2020 and updated in August 2021. Content was extracted and verified by 18 paramedics or managers representing all 10 JASs. ResultsAll JASs use intramuscular adrenaline as a first-line agent for adult anaphylaxis. Beyond this, significant differences exist in all treatments: five services provide nebulised adrenaline; 10 services provide adrenaline infusions (one requires doctor approval; one provides repeat boluses); six services provide nebulised salbutamol; two services provide salbutamol infusions (one requires doctor approval; one provides repeat boluses); five services provide nebulised ipratropium bromide; eight services provide corticosteroids (two restricted to intensive care paramedics (ICPs)); five services provide antihistamines for non-anaphylactic or post-anaphylactic reactions; four services provide glucagon (one requires doctor approval); magnesium is infused by ICPs in two services; 10 services allow unassisted intubation in anaphylactic arrest; one service allows ICPs to provide sedation-facilitated intubation or ketamine-only breathing intubation; eight services allow rapid sequence induction (two restricted to specialist roles). ConclusionThe JASs in Australasia have each created unique treatment clinical practice guidelines that are heterogeneous in their treatments and scopes of practice. A review of the evidence underlying each intervention is appropriate to determining best practice.

Insulin glucose infusion versus nebulised salbutamol versus combination of salbutamol and insulin glucose in acute hyperkalaemia in the emergency room: protocol for a randomised, multicentre, controlled study (INSAKA)

IntroductionHyperkalaemia is a common electrolyte disorder and can be life-threatening. In the emergency room (ER), interventions aim to protect patients from the immediate dangers of elevated serum potassium by redistributing potassium ions from the bloodstream into the cells via intravenous insulin or nebulised beta2-agonists. However, to date, evidence for acute management of hyperkalaemia is limited. The aim of this randomised controlled trial is therefore to compare three strategies, namely insulin/glucose intravenous infusion, nebulised salbutamol or a combination of nebulised salbutamol and insulin/glucose intravenous infusion to reduce serum potassium concentration at 60 min as a first-line treatment in patients admitted to the ER with serum potassium concentrations superior or equal to 6 mmol/L.Methods and analysisINSAKA is a prospective, multicentre, controlled, open-label, parallel-group, randomised in a 1:1:1 ratio clinical trial. Patients will be eligible for randomisation if they have serum potassium concentrations superior or equal to 6 mmol/L measured in the ER. Patients will receive either: (1) 10 mg of nebulised salbutamol, (2) 10 units of short-acting insulin in an intravenous bolus with 500 mL of 10% glucose or (3) 10 units of short-acting insulin in an intravenous bolus with 500 mL of 10% glucose combined with 10 mg of nebulised salbutamol. The primary endpoint will be the mean change in the absolute serum potassium level from baseline to 60 min measured in mmol/L. We plan to include 525 patients.Ethics and disseminationThe INSAKA trial will be conducted in accordance with the International Council on Harmonization Good Clinical Practices. All trial documents and procedures have been reviewed and approved by the Ethics Committee Sud Méditerranée III (approval ID number: 19.07.16.36428). The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media and the internet.Trial registrationEudraCT number: 2019-002710-39, Clinicaltrials.gov identifier: NCT04012138.

Congenital adrenal hyperplasia with salt-wasting crisis and arrhythmia: a case study

We report a case of a 10-day-old male infant who presented to the emergency department with severe electrolyte imbalance and life-threatening arrhythmia. The parents reported a 3-day history of poor feeding and lethargy. On examination, he was bradycardic (heart rate of 65 beats/min) with signs of dehydration. His ECG showed broad complex bradycardia. Blood gas showed metabolic acidosis with hyponatraemia and hyperkalaemia. A probable diagnosis of congenital adrenal hyperplasia (CAH) with salt-wasting crisis was made and treatment was commenced. He was given saline bolus, nebulised salbutamol, calcium gluconate and hydrocortisone. Following the above interventions, his heart rate rose to 150 beats/min with a regular sinus rhythm within a period of 40 min. The diagnosis of CAH secondary to 21-hydroxylase deficiency with mutation in CYP21A2 was confirmed by genetic studies. He was discharged home with hydrocortisone, fludrocortisone and sodium chloride.

Comparison of clinical efficacy of nebulised salbutamol and salbutamol metered dose inhaler in children with mild or moderate exacerbation of bronchial asthma

Background: Bronchial asthma is the commonest chronic disease in industrialized nations. Aerosol therapy has revolutionized the treatment of bronchial asthma in children as in adults. Even though nebulisation is a simple technique, it is expensive and there is a need for power source. The aim of the study was to compare the clinical efficacy of nebulised salbutamol and salbutamol metered dose inhaler (MDI) in children with mild or moderate exacerbation of Bronchial asthma.Methods: This study was a hospital based randomized control study carried out between March 2009 to December 2009 on children attending OP or casualty of Government Medical College, Alappuzha with mild or moderate exacerbation of bronchial asthma.Results: 60 subjects were selected for the study out of which 30 were assigned to salbutamol MDI group and the other 30 to salbutamol nebulisation group. After the administration of drug, all the studied variables showed significant improvement in both groups (p value <0.001). Percentage predicted PEFR increased by about 27% in nebulisation group and 26% in MDI group; however this difference was not statistically significant (P value = 0.99).Conclusions: In this study we concluded that the efficacy of salbutamol in mild or moderate acute exacerbation of asthma was similar when the drug is delivered either by nebuliser or MDI with spacer.