Case Presentation & Conclusion
A previously healthy 2-year-old boy presents to your ED on an early winter evening after the sudden onset of a barking cough and trouble breathing. His parents are concerned because of a “whistling” sound he is making when he cries. He has had rhinorrhea and a low-grade fever for the past 36 hours. Upon arrival at triage, he is mildly tachypneic with a respiratory rate of 32 breaths per minute. His oxygen saturation is 94% on room air, his axillary temperature is 38.4oC, and his heart rate is 135 beats per minute. On examination, he is restless, fussy, and unable to settle down on his mother’s lap. You can clearly hear inspiratory stridor punctuated by a barking cough, and you notice moderate intercostal retractions. The rest of your physical exam is within normal limits. What are your first steps towards treating this child? What clinical criteria will you use to discharge this patient home? What discharge instructions will you give the parents?
You determined that your patient had viral croup with moderate symptoms. The nurse moved him into a quiet room with the lights dimmed. He remained seated on his mother's lap, and, with her help, he was given a nebulized dose of racemic epinephrine 0.5 mL of 2.25% solution diluted in 2.5 mL of saline, for a total volume of 3 mL. An oral dose of dexamethasone 0.6 mg/kg was given to him as soon as possible. He responded quickly to the nebulized epinephrine, with resolution of his stridor and retractions. He remained in the ED for 2 hours of observation. At the 2-hour mark, he showed no signs of respiratory distress, although he continued to have an intermittent, barky cough. His parents received written instructions regarding home treatment of croup and signs of respiratory distress, and the family was discharged home.