Acute management of croup in the emergency department Flashcards
What percentage of ED visits in children <2yo were related to croup?
3.2-5.1%
What percentage of children presenting to ED with croup require hospitalization?
6%
What percentage of children with croup who are hospitalized require endotracheal intubation?
0.4-1.4%
What percentage of children who are intubated for croup die?
0.5%
What is the etiology of croup?
1. Parainfluenza type 1 and 3 Others viruses: 2. Influenza A and B 3. Adenovirus 4. RSV 5. Metapneumovirus
What is the pathophysiology of croup?
Generalized airway inflammation and edema of the upper airway mucosa secondary to viral infection resulting in narrowing of the subglottic region and airway obstruction
What are the classical croup symptoms?
- Rapid onset
- Barky cough
- Inspiratory stridor
- Hoarseness
- Respiratory distress
- Preceding URTI symptoms
What is the typical age range for croup?
6m to 3yo
What is the typical duration of symptoms for croup?
3-7d, usually gone after 48h
What are the DDx of croup?
- Bacterial tracheitis
- Retropharyngeal, parapharyngeal, peritonsillar abscesses
- Epiglottitis
- Aspiration or ingestion of a foreign body
- Acute allergic reaction (anaphylaxis or angioneurotic edema)
What are the characteristics of bacterial tracheitis?
- High fever
- Toxic appearance
- Poor response to nebulized epinephrine
What are the characteristics of retropharyngeal, parapharyngeal, and peritonsillar abscesses?
- High fever
- Neck pain
- Sore throat
- Dysphagia
Followed by: - Torticollis
- Drooling
- Respiratory distress
- Stridor
What are the characteristics of epiglottitis?
- Absence of barky cough
- Sudden onset of high fever
- Dysphagia
- Drooling
- Toxic appearance
- Anxious appearance
- Sitting forward in the “sniffing” position
What are the characteristics of aspiration or ingestion of a foreign body?
- Croupy cough
- Choking episode
- Wheezing
- Hoarseness
- Biphasic stridor
- Dyspnea
- Decreased air entry
What are the characteristics of acute allergic reaction?
- Rapid onset of dysphagia
- Wheezing
- Stridor
- Possible cutaneous allergic signs, such as urticarial rash
What are recommendations regarding general care?
- Make comfortable
- Avoid frightening the child
- Do NOT use mist tents
- No evidence for use of humidified air
- Antipyretics for fever and discomfort
What are the recommendations for corticosteroid use in croup?
In all patients with croup (mild to severe): Dexamethasone 0.6mg/kg/dose PO/IM x 1
Works within 2-3h and lasts 24-48h
What are the benefits associated with corticosteroid use in croup?
- Fewer return visits to hospital
- Fewer admissions to hospital
- Unlikely to require further treatment
What are the recommendations for epinephrine use in croup?
Nebulized epinephrine for moderate to severe croup: 0.5mL racemic epinephrine OR 5mL 1:1000 L-epinephrine
Works within 10-30min, and lasts 1-2h
What are the recommendations for heliox?
Decreasing airflow turbulence in narrowed airways in croup and is used in severe cases to avoid intubation.
No evidence so not routinely recommended
What are the recommendations for antibiotic use in croup?
<1:1000 cases of croup have bacterial infection. Do not use
What are the recommendations for beta-2-agonist bronchodilators in croup?
Not indicated
What are indications to consult ENT?
- Croup symptoms persistently severe despite treatment
- Multiple croup episodes
- Present outside the usual age range
What are the features of mild croup?
- Occasional barky cough
- None or minimal stridor at rest
- None to mild indrawing
- No distress, agitation or lethargy
- No cyanosis
What are the features of moderate croup?
- Frequent barky cough
- Easily audible stridor at rest
- Visible indrawing at rest
- No to limited distress, agitation or lethargy
- No cyanosis
What are the features of severe croup?
- Frequent barky cough
- Prominent inspiratory and occasionally expiratory stridor
- Marked or severe indrawing
- Substantial lethargy may be present
- No cyanosis
What are the features of impending respiratory failure?
- Barky cough often not prominent due to fatigue
- Audible stridor at rest but maybe quiet or hard to hear
- May not be marked indrawing
- Lethargy or decreased LOC
- Dusky or cyanotic without supplemental oxygen
When should you consider hospital admission?
- If received steroids >4h ago and:
- Continued moderate respiratory distress (without agitation or lethargy)
- Stridor at rest
- Chest wall indrawing
When should you consider pediatric ICU?
- Recurrent severe episodes of agitation and lethargy
2. Poor response to nebulized epinephrine with severe disease or impending respiratory failure
