From the Guidelines
Racemic epinephrine can be safely administered to a 9-year-old without mandatory cardiac monitoring in most cases, but it is crucial to monitor vital signs before and after administration, including heart rate, respiratory rate, and oxygen saturation 1.
Key Considerations
- The typical dose is 0.5 mL of 2.25% racemic epinephrine solution diluted in 3 mL of normal saline, administered via nebulizer.
- This medication works by causing vasoconstriction in the upper airway, reducing edema and improving airflow.
- Potential side effects include tachycardia, tremors, and hypertension, which are typically mild and transient.
Special Circumstances
- If the child has underlying cardiac conditions, is experiencing severe respiratory distress, or requires multiple doses, cardiac monitoring would be appropriate 1.
- After administration, observe the patient for at least 2-3 hours to monitor for symptom rebound before discharge.
- If multiple doses are needed or symptoms persist, hospital admission should be considered for continued observation and treatment.
Monitoring
- The frequency of monitoring, including heart rate, temperature, respiratory rate, oxygen saturation level, and respiratory pattern, is determined by the child’s condition 1.
- Patients on oxygen therapy should have at least 4 hourly observations, including oxygen saturation.
From the Research
Racemic Epi and Cardiac Monitoring in 9-Year-Old
Overview of Racemic Epinephrine Use
- Racemic epinephrine is commonly used in the emergency department for severe respiratory distress in bronchiolitis or croup syndrome 2.
- The use of racemic epinephrine has been associated with improved symptoms in children with croup, with a significant reduction in croup scores 30 minutes post-treatment 3.
- However, the effect of racemic epinephrine is less remarkable in patients treated with dexamethasone, a potent corticosteroid 4.
Cardiac Monitoring and Potential Complications
- Myocardial infarction is a previously unreported complication of treatment with racemic epinephrine, highlighting the need for cardiac monitoring in patients receiving this treatment 2.
- A case study reported a pediatric patient who developed ventricular tachycardia and mild chest discomfort during racemic epinephrine treatment, which resolved spontaneously on discontinuation of the nebulization 2.
- The study suggests that persistently abnormal electrocardiograms and elevated creatine phosphokinase MB isoenzyme (CPK-MB) levels may indicate a myocardial infarction 2.
Factors Associated with Need for Additional Therapy
- Recent use of steroids within 1 day prior to presentation is associated with a greater need for more than two doses of racemic epinephrine during hospitalization 5.
- Patients hospitalized for croup with recent use of steroids prior to ED presentation have a greater need for more than two doses of racemic epinephrine during hospitalization 5.