SPUC Clinical Advisor

“Fever and cough.”  “Cough and fever.”  “Bad cough.”  “Difficulty breathing.”  Winter (aka Respiratory Season) in urgent care is here with a vengeance!  When you are in the midst of a busy night at urgent care and all of the chief complaints (and patients!) are starting to blend together, it is important to tease out which patients need immediate intervention versus expectant care and reassurance. Croup is one clinical syndrome which has a broad spectrum of presentations. The parent says their child is wheezing…but is that stridor you hear? The oxygen saturation is normal, but does that mean there is no treatment necessary? If a child sounds like they have croup, but is febrile and unimmunized, what other things must you consider in your differential?

The answers to your clinical questions about croup can be found at http://www.urgentcarepeds.org/clinical/.

Here’s a look at our Croup Clinical Advisor:

Croup

ALERTS

  • Epiglotitis
  • Bacterial tracheitis
  • Peritonsilar/Retropharyngeal abscess
  • Foreign body
  • Anaphylaxis/allergic reaction
  • Upper airway injury
  • Congenital anomalies

AGE OR PREGNANCY CONSIDERATIONS

  • < 4 years = typical presentation
  • Chronic croup can remain in older children

DIFFERENTIAL DIAGNOSIS

  • Epiglotitis
  • Peritonsilar/Retropharyngeal abscess
  • Laryngomalacia
  • Foreign body
  • Anaphylaxis/allergic reaction
  • Upper airway injury

EVALUATION

HISTORY

  • Onset and timing of cough, presence of stridor and hoarseness, level of distressed breathing, presence of drooling, alleviating factors, associated symptoms (fever, congestion, coryza).
  • Progression of symptoms since onset
  • Nocturnal worsening of symptoms
  • History of croup
  • History of wheezing/RAD/Asthma
  • History of congenital airway anomalies
  • Irritability, poor feeding/hydration – Infants/young children
  • Recent exposures – daycare

PHYSICAL EXAM

  • HEENT – Uvula position, peritonsilar/retropharyngeal space
  • Respiratory – RR, O2 saturation
  • Cardiovascular – HR, hydration, perfusion
  • Neuro – Mental status, irritability

Diagnostic Findings

  • HEENT – Congestion, coryza
  • Respiratory – Tachypnea, hypoxia if severe
  • CV – Tachycardia, decreased perfusion
  • Neuro – Fussiness

Concerning Findings

  • Stridor at rest
  • Drooling
  • Anxious appearance/distress

DIAGNOSTIC TESTS & INTERPRETATION

Lab Tests

  • RSV
  • Influenza
  • Parainfluenza

Imaging

  • AP/lateral neck films – “steeple sign”
  • Neck CT – if concern for abscess
  • Additional Chest films – if concern for foreign body

Diagnostic Testing

  • N/A

MANAGEMENT

TRANSFER/ADMISSION CONSIDERATIONS

  • Severe distress/anxious appearance
  • Toxic appearance
  • Persistent hypoxia
  • Airway foreign body

CROUP TREATMENT

First Line

  • Dexamethasone PO/IM
  • Nebulized Racemic Epinephrine
    • Must monitor and reassess two hours after administration for rebound edema

Second Line

  • Prednisone

Supportive

  • Humidified air/Cool air (saline neb, steamy shower, outside air)
  • Fever relief

FOLLOW UP

Outpatient Referral

  • PCP in 24 hours
  • ENT if chronic severity

Written instructions should include:

Anticipatory Guidance

  • Importance of increased fluids
  • Use of humidified air/cool air

Activity, Diet

  • Activity as tolerated
  • Increase fluids

Signs and Symptoms to Return

  • Drooling
  • Stridor at rest
  • Wheezing/respiratory distress
  • Persistent fever
  • Lethargy

PROGNOSIS, COMPLICATIONS

  • Self-limited illness
  • Typically responds well to steroids
  • Can progress to respiratory emergency in severe cases
  • Can exacerbate asthma in predisposed patients

REFERENCES:

Fleisher G, Ludwig S. (Eds.). Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, 2010.

Hay, W., Levin, M., Deterding, R., Abzug, M. (Eds.). Current Diagnosis & Treatment – Pediatrics. 22nd ed. New York: McGraw Hill, 2014.

Engorn, B. & Flerlage, J. (Eds.). (20th ed., 2015). The Harriet Lane Handbook. Philadelphia: Saunders.

Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier, 2011.

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