Croup

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Epidemiology

- 3 mo - 3 yrs (6-24 mo common)

- fall & winter

- Parainfluenza (50%), RSV, adenovirus, influenza, measles, HSV,

Mycoplasma pneumonia.

In non-immunized, poss Diphtheria --> give Erythromycin IV & Diphtheria antitoxin

- 6pm to 6am

- Spasmodic croup age 1-5yrs


Diagnosis

r/o Foreign Body

2-3 day hx URI, then abrupt onset barking cough

Inspiratory Stridor

low fever 37.7 - 38.8

NO drooling or dysphagia

lasts 3 - 5 days, up to 1 wk

Steeple sign on AP (25% epiglotitis can show this too)


Work-Up

Consider CXR

Consider nasal washings for RSV, parainfluenza, influenza.


Treatment

CROUP SCORE (also see Med Rules)

I. STRIDOR

    0 None
    1 Only c agitation
    2 Mild @ rest
    3 Severe at rest

II. RETRACTIONS

    0 None
    1 Mild
    2 Moderate
    3 Severe

III. AIR ENTRY

    0 Normal
    1 Mild decrease
    2 Mod decrease
    3 Marked decrease

IV. COLOR

    0 Normal
    1
    2
    3 Cyanotic at rest

V. LEVEL OF CONSCIOUSNESS

    0 Normal
    1 Restless when disturbed
    2 Restless when un-disturbed
    3 Lethargic


MANAGEMENT (Viral)

<4: Mild

    1. Mist
    2. Outpt

5-6: Mild-Mod

    1. Mist
    2. Racemic epi*
    3. Dexameth**
    4. Outpt if (after 3hr OPs):
         a. Improved in ED
         b. >6 mo old
         c. Reliable family
         d. No rest stridor
         e. Access to F/U
         f. Benign PMH
         g. VS nl

7-8: Moderate

    1. Racemic epi*
    2. Dexameth**
    3. Admit

>9: Severe

    1. Racemic epi*
    2. Dexameth**
    3. Intubtion?
    4. PICU


  • Racemic Epi 0.25-0.75mg in 2.5ml NS

if 1:1,000 (L-epi) use 2.5-5.0mL (= 5mg)

May repeat Q20-30 min x 3

DON'T USE if Cardiac Muscular Outflow Obstruction or Tetralogy of Fallot.


    • Dexamethasone 0.6 mg/kg IV/IM/PO


      • Intubation: Use ET tube 1-2 sizes smaller than usual (swelling)


Spasmodic Croup

-presents suddenly, without URI prodrome

-often resolve spontaneously before ED c cold night air, shower water vapor.


Treatment

Outpt

cool mist / cool air / shower vapor

2- 4 ml Nebulized NS or

Racemic Epi 0.25-0.75ml in 2.5ml NS


Source

4/14/06 DONALDSON (adapted from Lampe, Rosen)