Croup Flashcards
Definition
Inflammation of supraglottic tissues +/- tracheobrochial tree
Swelling of mucosa, thick/viscous/mucopurulent exudate->compresses upper airway
Etiolgy
Viral
Parainfluenza most commonly
Differential
Inhaled foreign body
Epiglottitis
Bacterial tracheitis
Age commonly affected
6mo-3 years
Clinical features
- barking cough
- inspiratory stridor
- may have associated widespread wheeze
- increased work of breathing
- may have fever, but no signs of toxicity
- may or may not have wheeze, hoarse voice
Signs (3 S’s)
Stridor
Supraglottic swelling
Seal bark cough
Assessment core
Minimal examination
Do not examine throat
Do not upset child
Recurrent croup- risk
Supraglottic stenosis
Down syndrome
Previous admission for severe
Features used to identify severity
Behaviour Stridor Respiratory rate Accessory muscle use Oxygen
Severity assessment- mild
Normal behaviour Barking cough, stridor only when active/upset Normal RR No accessory No oxygen required
Severity assessment- moderate
Some/intermittent irritability Some stridor at rest \+RR, tracheal tug, nasal flaring Mod chest wall retraction No oxygen
Severity assessment- severe
\+Irritability, lethargy Stridor at rest \++/-ve RR Tracheal tug Nasal flaring \++chest wall retraction Hypoxemia is late and significant sign of upper airways obstruction
Investiagtions
Investigations may not be done/necessary
Nasopharyngeal aspirate
CXR
Blood tests not usually indicated
Acute management
ABCD- get help Minimal handling Assess severity If O2 needed, consider severe airway obstruction Do not forcibly change childs position Defer IV access Avoid distressing further
Benefit of steroids
Decrease hospital stay
Decrease need for nebulised adrenline and other interventions
Management of mild-moderate
Prednisolone 1mg/kg, AND prescribe a second dose for the next evening.
OR
a single dose of Oral Dexamethasone 0.15mg/kg.
Observe for half an hour post administration. D/c once stridor free at rest
Management of severe, when improvement, then deterioration, no improvement
Nebulised adrenaline (1 mL of 1% adrenaline solution* plus 3ml Normal Saline, or 4ml of adrenaline 1:1000.)
(*some hospitals stock bottles of 1% adrenaline solution, often for ophthalmic use. If not available use 1:1000 vials)
AND
Give 0.6mg/kg (max 12mg) IM/IV dexamethasone, ?consider if can give orally
Improvement
If good improvement, observe for 4 hours post adrenaline. Consider discharge once stridor free at rest.
Improvement then deterioration
Give further doses of adrenaline. Consider admission/transfer as appropriate.
No improvement
Reconsider diagnosis. Acute upper airway obstruction.
When to consider consultation with local pediatric team
Severe airway obstruction
No improvement with adrenalin
Child has risk factors
When to consider transfer
No improvement with adrenalin
>2 doses neb adrenalin
Child requiring care above that which can be comfortably given at that hospital
Risk factors for severe croup
Downs Neurological Sub glottic stenosis Previous admission with severe uncommon->need to consider alternate diagnoses
Admit even if mild disease
How long after giving nebulised adrenalin do you need to observe patients
4 hours
Adrenalin can wear off, prior to effect of steroids and can then deteriorate
Patient advice overview
Signs and symptoms of croup
When to advise on return to hospital
When to advise calling an ambulance
Patient advice on signs and symptoms of croup
Hoarse voice
Barking cough
Stridor
Fever
Patient advise on when to return to hospital
Continuous stridor
Intercostal recession
Irritability
Patient advise on when to call the ambulance
Parents should be instructed to call an ambulance if:
The child’s face is very pale, blue, or grey (includes blue lips) for more than a few seconds
The child is unusually sleepy or is not responding
The child is having a lot of trouble breathing (e.g., the belly is sinking in while breathing, or the skin between the ribs or over the windpipe is pulling in with each breath; the nostrils may also be flaring in and out)
The child is upset (agitated or restless) while struggling to breathe and cannot be calmed down quickly
The child wants to sit instead of lie down
The child cannot talk, is drooling, or having trouble swallowing.
