Croup


- Stridor
- Barking, Seal-like Cough
- Fever
- Infant 6-36 months
Assessment of Croup Severity
Mild Moderate Severe
Occasional barking cough Frequent barking cough Frequent barking cough
No audible stridor at rest Easily audible stridor at rest Prominent inspiratory and occasionally expiratory stridor
Mild or no chest wall/subcostal retractions Chest wall/subcostal retractions at rest Marked sternal retractions
No agitation and distress Little or no agitation and distress Agitation
Treatment:

Dexamethasone 0.15 mg/kg PO/IM /IV
 
Treatment:

Dexamethasone 0.15 mg/kg PO/IM /IV
Racemic epinephrine (2.25%)
0.5 mL of 2.25% Neb
Treatment:

Dexamethasone 0.15 mg/kg PO/IM /IV
Racemic epinephrine (2.25%)
0.5 mL of 2.25% Neb

Background

Pathophysiology

History/Symptoms

Physical exam/Signs

Diagnostics

Differential Diagnosis

Treatment

  1. Initial
  2. Medical/Pharmaceutical
    Croup Pharmacotherapy
    Medication Dose Notes
    Dexamethasone 0.15–0.6 mg/kg PO/IM /IV
    (10 mg max)
    Give for mild, moderate, or severe croup. May crush pills and mix in juice or applesauce.
    May give IV solution PO without dilution.
    Racemic epinephrine (2.25%) 0.05 mL/kg/dose nebulized
    (max = 0.5 mL)
    Use for moderate or severe croup; may need repeat dose if severe.
    Heliox 70:30 mixture may prevent the need for intubation
    May be give with a maximum Oxygen of 40%
    β-Agonist  NOT EFFECTIVE
    Intubation:
    • Indicated in children progressing to asynchronous chest wall and abdominal movement, fatigue, and signs of hypoxia (pallor or cyanosis) and hypercarbia (decreased level of consciousness secondary to rising PaCO2).
    • Becoming increasingly uncommon (in only 1% to 3% of children admitted with croup) and performed as rapid sequence induction in a controlled setting with experienced personnel and equipment. 
    • Advisable to have a selection of endotracheal tubes of smaller sizes at hand, as subglottic edema may cause difficulty when intubating with a standard sized endotracheal tube

     

  3. Surgical/Procedural

Disposition

  1. Most can be discharged home
  2. Admit for
  3. Croup that lasts >7 days or recurs frequently should be investigated w/ physician

     
    Criteria for Discharge from ED in Patients with Croup
    3 hr since last epinephrine
    Nontoxic appearance
    Able to take fluids well
    Caretaker able to recognize change in child's condition and has adequate transportation to return if necessary
    Parents have a phone and no social issues for concern




 

ITE 2012, Q182.
A concerned father brings his 20-month-old daughter to see you because of the overnight onset of a “barky” cough along with hoarseness, a runny nose, and a fever to 100.8°F. She is an otherwise healthy child who is up to date on her vaccinations. During the course of the visit you observe her to be coughing intermittently, and on examination you note clear lungs with occasional stridor and no retractions. She is not tachypneic or tachycardic. Her oxygen saturation is 95% on room air.
Appropriate medical management of this patient includes which one of the following?

A) Inhaled albuterol (Proventil, Ventolin)
B) Inhaled epinephrine
C) Oral azithromycin (Zithromax)
D) Oral dexamethasone
E) Oral oseltamivir (Tamiflu)

ANSWER: D