hello everyone my name is Peter Entebbe and here for another edition of the head's heavy minute today is one of my favorite diagnoses in his croup croup and EMS causes a lot of stress and oftentimes I see a lot of the EMS providers giving albuterol for croup now we know that shouldn't be the case and oftentimes it's recommended to use racemic epi for croup now we know that a lot of us don't carry risk in a kepi it comes as 0.5 ml and then we're supposed to add 3 ml of normal saline and put it into a nebulizer so I would say that there's really no need for this because it's another trick that you can use and that is using epi one to a thousand straits directly into the nebulizer so what I'm going to recommend is epinephrine 1 to 1000 which is also known as one milligram per ml and you take 3 ml's of that and you put it directly into the nebulizer so let me show you what I mean so here's epi 1 to a thousand I have three MLS better take that out I'm gonna insert it right into myNet eliezer close it off and now I'm ready to treat croup and so there's one additional thing that we haven't talked about yet which is that nan utilize the FB not only could be used for croup like we just talked about but another thing I like to use it for is asthma and so some of you listening may say well haven't heard of that before but let's take a look at the physiology of that so epi we know hits both the beta 2 receptors and the Alpha receptor specifically let's talk about alpha 1 so for beta 2 we know this is the smooth muscle relaxation and for alpha one this is a vasoconstrictor so at lower dosages it hits the beta tube so it does the same exact thing as albuterol would do for asthma and then the alpha one the vasoconstrictors that's where it's helping for crew and so oftentimes if you ever really sick asthmatic who is circling the drain you may have to intubate them I often like to give them some a little alpha one support either by giving them epi I am or what have you so in this particular case you can kill two birds with one stone by giving epi one to a thousand that will help the asthmatic from with a smooth muscle relaxation perspective and from a vasoconstriction perspective so consider using it for nitrous croup but for asthma and again you're carrying it today all you have to do is add it to your nebulizer thanks for another addition of the heads heavy minute I'm dr. Peter Entebbe