The Management of Croup in the Emergency Room

Taken from a presentation at the
Continuing Professional Learning conference:"POGO 2005"
February 3 - 5, 2005
Dr. Vicki Cattell, MD, CRCP(C)

Incidence

Three precent of children under six years of age.

Etiology

Mostly entirely Viral. There is usually no role for antibiotics in management.

But...

In older children the causative organism may be Mycoplasma, which can be identified as a nasopharyngeal swab.

Diagnosis

• This is usually made on clinical grounds.
• Croup often has a prodrome of an Upper Respiratory Tract Infection.
• There is a distinctive 'barking' cough.
• Fever may or may not be present.
• Inspiratory Stridor may or may not be present
• Laboratory and radiology investigations generally do not contribute to the diagnosis.

But...

Chest x-ray can be useful to exclude a foreign body if the history raises suspicion of this, and to exclude other etiology in an older, toxic child.

Blood work is generally non-contributory if croup is evident on clinical grounds.

Management

The aim of croup management is to minimize turbulent air flow through the upper respiratory tract.

Mild to Moderate Croup

Decadron 0.6mg/kg in one dose to a maximum of 8.0 mg (or pediapred 1 mg/kg). This is given to all children with croup.

There is no advantage to giving more than one dose of either.

There is no advantage to giving pulmicort inhalation in place of or in addition to decadron.

JAMA, May 27 1998 Vol 279 "The clinical outcome of mild to moderate croup patients is as good after treatment with oral dexamethasone as it is after nebulized budesonide alone or after a combination of budesonide and dexamethasone."

Severe Croup

Suggested by:

• Anxious look
• Strodor at rest
• Low oxygen saturations

Find position of comfort the child.

Bring down temperature, using rectal suppository, if necessary.

"Rescue" with nebulized epinephrine:

• Racemic epinephrine 0.5cc in 4cc normal saline.
• 1:1000 epinephrine 5.0cc.
• May be repeated immediately if no improvement.
• Watch for three to four hours for rebound of symptoms.

Key Point

Consider alternative to croup if the child presents with:

• No cough
• Drooling
• Toxic appearance

Differential diagnosis: bacterial tracheitis or epiglottitis.

When to Refer

• If needing more than one dose of epinephrine.
• If you do not have facilities to observe for rebound.
• If oxygen saturations are low.
• If child is toxic looking or you suspect other diagnosis.
• If croup occurs early in the day it is likely to worsen.