In current pandemic situation, nebulized epinephrine is being withheld for those with croup. What management is recommended, should the patient (without hx of asthma) deteriorate (apnea/silent chest) ? Is epinephrine IM an acceptable route? If not, what is the rationale?

With regards to epinephrine route of administration in croup: nebulized epinephrine works in croup to alleviate the laryngeal edema, by local effect. If given systemically (IM) it may alleviate the edema, similar to anaphylaxis. However, the IM injection can cause the child distress which can worsen their edema and tip them into apnea/arrest. In this situation, you should patch to the BHP for direction, as any treatment now falls outside your Medical Directives.

If the child is in extremis (apneic, silent chest) prepare for impending cardiac arrest. You may even consider asking for IM epinephrine should the child arrest (PCP scope of practice, ACPs should follow their Medical Cardiac Arrest Medical Directive). Make sure to consider other potential causes of stridor, including foreign body aspiration, in which case the treatment is removal of the foreign body, and anaphylaxis, wherein IM epinephrine is indicated in pre-arrest and during arrest.

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