Racemic Epinephrine

1. Indications
   1. Moderate to Severe Croup
   2. Respiratory Syncytial Virus (Bronchiolitis)
2. Mechanism
   1. Alpha-adrenergic effect
   2. Mucosal Vasoconstriction decreases subglottic edema
   3. Rapid response in croup (within 10-30 minutes)
      1. Consider Croup Differential Diagnosis if no response
   4. Effect dissipates in 2 hours
3. Pharmacokinetics
   1. Effect onset within 10-30 minutes
   2. Effects last 90 to 120 minutes
4. Precautions
   1. Avoid too frequent use due to tachyphylaxis
   2. Observe 2-4 hours after Racemic Epinephrine
      1. Patient may go home safely if no worsening in 2-4 hours
      2. Typically admit patient if requires a repeat Epinephrine neb
5. Dose
   1. Nebulizer mix
      1. Racemic Epinephrine (2.25%)
         1. Dose: 0.05 ml/kg (maximum 0.5 ml in children)
            1. Child under 6 months: 0.25 ml
            2. Child: 0.5 ml
         2. Adolescent: 0.75 ml
      2. Normal Saline 2.0 to 3.5 ml
   2. Alternative option
      1. L-Epinephrine 0.5 ml/kg (maximum 5 ml) of 1:1,000 via nebulizer
   3. Frequency of dosing
      1. Nebulized Epinephrine may be repeated in 30 minutes
      2. Monitor Heart Rate closely with repeat dosing
6. Efficacy: Bronchiolitis
   1. Significantly more effective than Beta-agonist
   2. Reduced hospital admissions significantly
   3. Reduced time spent in emergency room significantly
   4. References
      1. Menon (1995) J Pediatr 126:1004-7