Croup

Question 1

A previously well 3 year old girl is seen in the emergency department late one evening having woken from sleep with a barking cough and respiratory distress. on arrival to the emergency department she continues to have mild respiratory distress with stridor at rest.

Answer 1

Impression
Clinical picture is indicative of croup, given the waking at night, barking cough and stridor at rest. There are several life-threatening causes of stridor that I would want to rule out in this case, and would take an A to E emergency approach to assessment given the sx of airway obstruction.

DDx for stridor:
- FBI
- bacterial tracheitis
- epiglottitis
- other infective: LRTI, URTI
- non-infective: asthma exac, anaphylaxis

Question 2

Croup - Assessment

Answer 2

Assessment
- call paeds for review
- assess patient using an A to E approach
- key is to not aggravate or distress child which could further obstruct airway with crying and swelling, therefore keep patient in comfortable position and don’t do any invasive assessments until definitive mx

A - patent, maintaining, stridor
B - Resp exam; added breath sounds, reduced air entry - need to limit assessment. Assess level of stridor - soft stridor is more concerning as potentially less air getting through. WOB?. If severe the nebuliser adrenaline and corticosteroids IV.
C as per
D - tone, AVPU, signs of toxicity

Question 3

Croup - Hx

Answer 3

History
- sx: cough, wheeze, wob, dyspoea, productive, colour, volume, etc
- Ddx: immediate choking, playing with small toys, fevers, sweats, rigors, hoarse voice, pain, irritable
- RISKS: preceding viral/URTI illness, sick contacts
- PMHx: Asthma, previous respiratory illnesses?
- paeds history: pregnancy, birth, development, immunisations,

Question 4

Croup - Ex

Answer 4

Examination
- general appearance + vitals
- resp exam: auscultate for stridor, air entry, barking cough, hoarseness of voice, may be widespread wheeze swell

Question 5

Croup - Ix

Answer 5

Investigations
Is a clinical diagnosis, no investigations are indicated. Only if suspicious of and investigating the other differential causes.

Question 6

Croup - Mx

Answer 6

Management
- call paeds for consult
- MERT if significant stridor, obtunded and HD unstable
- consider NETS retrieval to tertiary centre if unstable and not responding to systemic corticosteroids and NEBS
- paeds/anaesthetics for ?intubation and PICU admission if not improving.

Main points
- minimal handling to prevent exacerbation of symptoms
- keep child with carer to avoid distress

Definitive
- systemic corticosteroids: oral dexamethasone 0.15mg/kg or pred 1mg/kg, can consider nebuliser budesonide if oral meds not tolerated, or IM hydrocort.
- 0.6mg/kg if severe (which is in this case), IV in this case
- +/- nebuliser adrenaline if moderate to severe stridor, 5 mLs of 1:1000 into the nebuliser
- escalate to intubation if non-improvement after nebs and dex
- 02 support if hypoxic

Supportive
- can be discharged if stridor free at rest and 4 hrs post neb or 30 mins post oral steroids.
- safety-netting, parent education.
- documentation