Date Published

October 23, 2015

Updated For

ALS PCS Version ALS PCS Version 5.2


Question: A patient meets the Croup Medical Directive but has a fever, do you give Epi via nebulizer or not? I thought in the past this was dealt with but I am not able to source this through the Ask MAC website.


 Croup is a common pediatric viral respiratory illness, most commonly caused by the parainfluenza viruses.  As it is a viral respiratory illness, it is not uncommon for patients to present with a fever in addition to a seal-like barking cough, inspiratory stridor and a variable degree of respiratory distress.  Although croup is often a mild and self limited disease, upper airway obstruction may result in severe respiratory distress and even death. Administering nebulized epinephrine when indicated can have a dramatic impact on respiratory symptoms very quickly (1). Although concurrent/suspected febrile fever or in the setting of a declared respiratory illness outbreak by the local medical officer of health is a contraindication for nebulized salbutamol, this is not the case with epinephrine for croup.  Unlike salbutamol, which can also be administered via the MDI, epinephrine can only be administered via the nebulized route to be effective for croup.  If fever were a contraindication for its administration, then many patients would not receive this treatment in the prehospital setting, as many will likely present with fever.  This being said, it is important to take the necessary precautions and protect yourselves using the appropriate PPE as the virus is spread via respiratory droplets/secretions.

  1. Bjornson et al. Nebulized epinephrine for croup in children. Cochrane Database of Systematic Reviews 2013, Issue 10 Art.



Epinephrine (Epi)

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