Pediatric Office Emergencies – Croup Treatment Protocol

In the Patient with Croup: Transfer to ED/Call EMS when: (1)

1. Fatigue and listlessness, marked retractions, decreased or absent breath sounds, somnolence
2. Stridor at rest unresponsive to racemic epinephrine
3. No response to treatment and patient has high fever with toxicity
4. Oxygen saturation < 92%
5. Possible foreign body or caustic ingestion
6. Excessive drooling

If a child fails to respond to expected therapy [for croup] consider other etiologies (e.g., retropharyngeal abscess, bacterial tracheitis, subglottic stenosis, epiglottitis, foreign body). Obtain airway radiography, computed tomography (CT), and evaluation by otolaryngology or anesthesiology. (2)

Here is a link to the Croup Fact Sheet for Parents from the Royal Children’s Hospital Melbourne. (3)

What follows is the Croup Clinical Practice Guideline from the Royal Children’s Hospital Melbourne: (4)

Background:

– viral inflammation of upper airway, larynx, trachea and bronchi
– worse at night – peak night two or three

Differential Diagnoses see  Acute upper airway obstruction)

– Inhaled foreign body
– Epiglottitis
– Bacterial tracheitis

Assessment:

Children with croup should have minimal examination. Do not examine throat. Do not upset child further.

– barking cough
– inspiratory stridor
– may have associated widespread wheeze
– increased  work of breathing
– may have fever, but no signs of toxicity

Risk Factors for severe croup

– pre-existing narrowing of upper airways

• subglottic stenosis (congenital or secondary to prolonged neonatal ventilation)
• Down Syndrome

– previous admissions with severe croup
– uncommon <6 months, rare <3 months of age. Consider alternative diagnosis. Acute upper airway obstruction.

Assessment of Severity

MILD	MODERATE	SEVERE
Behaviour	Normal	Some/intermittent irritability	Increasing irritability and/or lethargy
Stridor*	Barking coughStridor only when active or upset	Some stridor at rest	Stridor present at rest
Respiratory Rate	Normal	Increased Resp rate Tracheal Tug Nasal Flaring	Marked increase or decrease Tracheal Tug Nasal Flaring
Accessory Muscle Use	None or minimal	Moderate chest wall retraction	Marked chest wall retraction
Oxygen	No oxygen requirement	No oxygen requirement	Hypoxemia is a late sign of significant upper airways obstruction

* The loudness of the stridor is not a good guide to the severity of the obstruction.

Investigations

• investigations including NPA, CXR, blood tests are NOT usually indicated and may cause the child distress and worsening of symptoms

Acute Management

• Children with croup need minimal handling . This includes limiting examination, nursing with parents. Supplemental oxygen is not usually required. If needed consider severe airways obstruction.

• Do not forcibly change a child’s posture – they will adopt the posture that minimises airways obstruction.

• Iv access should be deferred.

• Avoid distressing the child further.

Treatment:

Children with cough only do not require treatment.

Steroids have been shown to decrease the length of hospital stay, need for nebulised Adrenaline and other interventions. Drug Doses link

Mild to Moderate Croup

Prednisolone 1mg/kg, AND prescribe a second dose for the next evening.
OR
a single dose of Oral Dexamethasone 0.15mg/kg.

(NB. Oral dexamethasone suspension ONLY available in hospitals, NOT available at commercial pharmacies)

Observe for half an hour post steroid administration. Discharge once stridor-free at rest.

Severe croup

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

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.

Consider consultation with local paediatric team when:

– Severe airways obstruction.
– No improvement with nebulised adrenaline.
– Child has risk factors (see above)

Consider transfer when:

– No improvement following nebulised adrenaline.
– >2 doses of nebulised adrenaline are required.
– Children requiring care above the level of comfort of the local hospital.

Discharge requirements:

– Four hours post nebulised adrenaline (if given) and/or half an hour post oral steroid, and stridor free at rest

Parents should be advised and able to seek help if stridor at rest regardless of whether they have received steroids

Resources:

(1) The Complete Resource on Pediatric Office Emergency Preparedness. 2013. Springer. This excellent book is brief and to the point. The authors are from Texas Children’s Hospital and Texas Children’s Pediatrics. pp 27 – 28.

(2) The Harriet Lane Handbook, Twentieth Edition, Elsevier Saunders, 2015. Croup, pp 12 – 13.

(3) Croup Fact Sheet for Parents from the Royal Children’s Hospital Melbourne Kids Health Info Fact Sheets.

(4)  Croup Clinical Practice Guideline from the Royal Children’s Hospital Melbourne Clinical Practice Guidelines.