Viral Croup vs Epiglottitis vs Bacterial Tracheitis Flashcards
A 2-year-old girl presents to the emergency room with fever, cough, runny nose, stridor and difficulty breathing. Temperature is 101, RR 30, there is audible stridor and a barky cough. The chest is clear, and the child does not look toxic. What other history is important?
- Nature of the onset? Was it sudden or gradual? What was the child doing when the symptoms started? a. Acute onset of stridor is suggestive of what? Foreign Body Aspiration 2. Has the child had a recent URI? Viral Croup 3. What is the immunization history? Epiglottitis (most cases are caused by H. flu) 4. Is there a past history of croup Spasmodic croup (some children have recurrent bouts of croup) 5. Is there a history of prior intubation? Subglottic stenosis (if child has been intubated, they may have residual changes)
During a follow-up appt for an 8-month-old with recent URI, you note the patient has inspiratory stridor and a barky cough. When assessing the patients ears with the otoscope, the patient begins to cry, and the stridor is worsened. What diagnosis is HIGHEST on your differential?
Answer: Viral croup (early signs: no stridor at rest, with mild stridor when agitated; examine patient when they are quiet and relaxed to best judge difficulty of breathing)
What is the CHARACTERISTIC FINDING of a patient with viral croup that has progressed?
Answer: barking seal cough, inspiratory stridor, and retractions at rest
What is the MOST COMMON causative organism in viral croup?
Answer: parainfluenza virus (also, RSV, rhinovirus, adenovirus, influenza A/B, M.pneumoniae)
T or F: Diagnostic imaging should be ordered to diagnose a patient with viral croup
Answer: False (classic presentation of croup does not require CXR)
In a patient with atypical presentation of viral croup (absence of the classic barking seal cough + other symptoms present in croup), the FNP should order a CXR. What findings would you expect to see?
Answer: steeple sign without irregularities (indicates subglottic narrowing)
A patient with viral croup (barking cough and no stridor at rest) would be
appropriate for what type of treatment plan?
Answer: supportive therapy (oral hydration, no tests or procedures); 1 single dose of
dexamethasone 0.15mg/kg PO or 0.6mg/kg IM (improve symptoms and permits early d/c from ED; patient can be discharged from ED if symptoms resolve in <3hr
A patient with viral croup (stridor at rest, retractions, air hunger, and cyanosis) would
require what treatment plan?
Answer: administer humidified O2 (decreasing O2 sat), neb racemic epi (0.5ml of 2.25% solution diluted in sterile saline – delivers rapid onset within 10-30min), 1 dose of dexamethasone 0.6mg/kg IM; if recurrent epi tx is needed - MUST ADMIT TO HOSPITAL FOR OBSERVATION AND CONTINUED NEB TX PRN
What sign(s) could differentiate epiglottitis from viral croup? SELECT ALL THAT APPLY!
A: high fever
B: inspiratory stridor
C: cough
D: drooling
A: high fever
D: drooling
Answer: A, D (epiglottitis has high fever, NO COUGHING, drooling, muffled voice, and dysphagia)
A 4-year-old presents to your clinic with 120HR, 39.9C temp, and muffled voice. This patient is sitting on the exam table leaning forward with nose in the air. What differential diagnosis should be ruled out?
In a pediatric patient with suspected epiglottitis, should diagnostic imaging be ordered to confirm the diagnosis?
The FNP has made the diagnosis of epiglottitis. What is your immediate expected intervention? SELECT ALL THAT APPLY!
A: have the child lay down on the examination table, awaiting transport to ED
B: minimal handling to protect the airway
C: visually inspect airway
D: consult for intubation of the patient
Answer: B & D
B: minimal handling to protect the airway
D: consult for intubation of the patient
Answer: B & D
After intubation, what should be obtained?
In bacterial tracheitis, what KEY symptom would set this apart from epiglottitis or croup?
If untreated, bacterial tracheitis will progress to what?
What are the typical lab findings in a patient with bacterial tracheitis?
Answer: elevated WBC with left shift; lateral neck XR show normal epiglottis with
severe subglottic and tracheal narrowing; irregularity of contour of proximal tracheal
mucosa
Bacterial CAP chest xray
Frontal View: typical alveolar consolidation in the right upper lobe.
Note that the fissures are not displaced, indicating that there is little
volume loss. A right pleural effusion is also present
Viral CAP chest xray
Frontal View: Bilateral parahilar peribronchial opacities are
typical of viral lower respiratory tract infections.
MYCOPLASMA PNEUMONIA
M. pneumoniae
> 5 YEAR OLD
SLOW ONSET Fever, dry cough
PROGRESSES to sputum production
CXR: Bronchopneumonic infiltrates middle/lower lobes
Normal WBC w/diff
Supportive measures + IV abx Azithroymcin
