Acute management of croup in the emergency department

Question 1

What percentage of ED visits in children <2yo were related to croup?

Answer 1

3.2-5.1%

Question 2

What percentage of children presenting to ED with croup require hospitalization?

Answer 2

6%

Question 3

What percentage of children with croup who are hospitalized require endotracheal intubation?

Answer 3

0.4-1.4%

Question 4

What percentage of children who are intubated for croup die?

Answer 4

0.5%

Question 5

What is the etiology of croup?

Answer 5

1. Parainfluenza type 1 and 3
Others viruses:
2. Influenza A and B
3. Adenovirus
4. RSV
5. Metapneumovirus

Question 6

What is the pathophysiology of croup?

Answer 6

Generalized airway inflammation and edema of the upper airway mucosa secondary to viral infection resulting in narrowing of the subglottic region and airway obstruction

Question 7

What are the classical croup symptoms?

Answer 7

1. Rapid onset
2. Barky cough
3. Inspiratory stridor
4. Hoarseness
5. Respiratory distress
6. Preceding URTI symptoms

Question 8

What is the typical age range for croup?

Answer 8

6m to 3yo

Question 9

What is the typical duration of symptoms for croup?

Answer 9

3-7d, usually gone after 48h

Question 10

What are the DDx of croup?

Answer 10

1. Bacterial tracheitis
2. Retropharyngeal, parapharyngeal, peritonsillar abscesses
3. Epiglottitis
4. Aspiration or ingestion of a foreign body
5. Acute allergic reaction (anaphylaxis or angioneurotic edema)

Question 11

What are the characteristics of bacterial tracheitis?

Answer 11

1. High fever
2. Toxic appearance
3. Poor response to nebulized epinephrine

Question 12

What are the characteristics of retropharyngeal, parapharyngeal, and peritonsillar abscesses?

Answer 12

1. High fever
2. Neck pain
3. Sore throat
4. Dysphagia
   Followed by:
5. Torticollis
6. Drooling
7. Respiratory distress
8. Stridor

Question 13

What are the characteristics of epiglottitis?

Answer 13

1. Absence of barky cough
2. Sudden onset of high fever
3. Dysphagia
4. Drooling
5. Toxic appearance
6. Anxious appearance
7. Sitting forward in the “sniffing” position

Question 14

What are the characteristics of aspiration or ingestion of a foreign body?

Answer 14

1. Croupy cough
2. Choking episode
3. Wheezing
4. Hoarseness
5. Biphasic stridor
6. Dyspnea
7. Decreased air entry

Question 15

What are the characteristics of acute allergic reaction?

Answer 15

1. Rapid onset of dysphagia
2. Wheezing
3. Stridor
4. Possible cutaneous allergic signs, such as urticarial rash

Question 16

What are recommendations regarding general care?

Answer 16

1. Make comfortable
2. Avoid frightening the child
3. Do NOT use mist tents
4. No evidence for use of humidified air
5. Antipyretics for fever and discomfort

Question 17

What are the recommendations for corticosteroid use in croup?

Answer 17

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

Question 18

What are the benefits associated with corticosteroid use in croup?

Answer 18

1. Fewer return visits to hospital
2. Fewer admissions to hospital
3. Unlikely to require further treatment

Question 19

What are the recommendations for epinephrine use in croup?

Answer 19

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

Question 20

What are the recommendations for heliox?

Answer 20

Decreasing airflow turbulence in narrowed airways in croup and is used in severe cases to avoid intubation.

No evidence so not routinely recommended

Question 21

What are the recommendations for antibiotic use in croup?

Answer 21

<1:1000 cases of croup have bacterial infection. Do not use

Question 22

What are the recommendations for beta-2-agonist bronchodilators in croup?

Answer 22

Not indicated

Question 23

What are indications to consult ENT?

Answer 23

1. Croup symptoms persistently severe despite treatment
2. Multiple croup episodes
3. Present outside the usual age range

Question 24

What are the features of mild croup?

Answer 24

1. Occasional barky cough
2. None or minimal stridor at rest
3. None to mild indrawing
4. No distress, agitation or lethargy
5. No cyanosis

Question 25

What are the features of moderate croup?

Answer 25

1. Frequent barky cough
2. Easily audible stridor at rest
3. Visible indrawing at rest
4. No to limited distress, agitation or lethargy
5. No cyanosis

Question 26

What are the features of severe croup?

Answer 26

1. Frequent barky cough
2. Prominent inspiratory and occasionally expiratory stridor
3. Marked or severe indrawing
4. Substantial lethargy may be present
5. No cyanosis

Question 27

What are the features of impending respiratory failure?

Answer 27

1. Barky cough often not prominent due to fatigue
2. Audible stridor at rest but maybe quiet or hard to hear
3. May not be marked indrawing
4. Lethargy or decreased LOC
5. Dusky or cyanotic without supplemental oxygen

Question 28

When should you consider hospital admission?

Answer 28

1. If received steroids >4h ago and:
2. Continued moderate respiratory distress (without agitation or lethargy)
3. Stridor at rest
4. Chest wall indrawing

Question 29

When should you consider pediatric ICU?

Answer 29

1. Recurrent severe episodes of agitation and lethargy

2. Poor response to nebulized epinephrine with severe disease or impending respiratory failure