CCS Interactive Case 18 Flashcards
16 month old M, ED, progressive barking cough, noisy breathing for 10 hours. Symptoms preceded by runny nose, began 2 days ago, seems to have a sore throat. Vaccinations up to date. No foreign object ingestion. Good appetite. Vital signs reveal a low-grade fever, otherwise normal.
DDx and first steps?
Viral croup
Bacterial croup, epiglottitis, tracheitis, peritonsillar abscess, foreign body ingestion
Order pulse ox and oxygen before proceeding to exam (99% on RA)
Complete exam (skip rectal)
Infant in no distress with injected conjunctivae, coryza, barking cough, inspiratory stridor
Next?
Dx viral croup
Limited work-up - CBC, neck x-ray, CXR
Begin treatment - stridor at rest -> moderate-severe -> oral steroids and nebulized epinephrine
Most common causes of viral croup?
Parainfluenza, virus, RSV, adenovirus
Define mild croup
Barking cough
No stridor at rest
No retractions
Rx mild croup
Cool humidified mist and oxygen (relieves airway edema, decreases viscosity of mucus)
Monitor for development of bronchospasm in susceptible children
Oral dexamethasone
Define moderate-severe croup?
Stridor at rest
Moderate-severe retractions
Anxious/agitated
Rx moderate-severe croup
Add nebulized epinephrine (beware tachycardia)
If no improvement, admit
In all cases?
If bacterial infection suspected, add ABX (2nd generation cephalosporin like cefuroxime)
Arrange OP follow-up
Sequence
Order pulse ox stat, oxygen
Exam: complete except rectal/genital
Order: CBC w/diff stat, neck-x-ray stat, BMP, humidified air, dexamethasone oral continuous, epinephrine inhalation, continuous
Advance clock one hour to obtain results and reevaluate the patient - symptoms persist on humidified air
Request interval f/u history and focused exam every 1-2 hours
Symptoms improve
Observe 3-4 hours, send home if stable
Reevaluate case in 4 hours
Case ends
Final orders: cancel oxygen, epinephrine, humidified air, counsel parent
Dx - viral croup
