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<< An Evidence-Based Approach To The Evaluation And Treatment Of Croup In Children

Risk Management Pitfalls For Croup In Children

  1. “But I needed to document his blood pressure.”
    Avoid causing further agitation in a child with stridor. Observation of the child on the parent’s lap and an oxygen saturation monitor is all you need to do.
  2. “He’ll be fine. His saturations came right up with oxygen.”
    If a child requires oxygen to maintain adequate oxygen saturation, consider serious upper airway obstruction with impending respiratory failure or lower respiratory tract parenchymal involvement, such as laryngotracheobronchopneumonitis, or pneumonia.
  3. “This kid just had a barky cough yesterday. Why did his parents bring him back today?”
    Evidence shows that treating even mild croup with oral dexamethasone prevents repeat ED and other healthcare visits and improves sleep.
  4. ”The child vomited the dexamethasone. What do I do now?”
    Pay attention to the form of oral dexamethasone that is administered or dispensed in your practice setting. Many of the commercially available oral solutions of dexamethasone are quite dilute. This means that a child will have to take a large volume of medication. For example, a 10-kg child who is prescribed 0.6 mg/kg of the 0.5 mg/5 mL oral dexamethasone solution would have to ingest 60 mL of the solution to get his dose. Most of the studies on oral dexamethasone in croup have used the much more concentrated parenteral-injectable form of the drug given orally. The small volume is absorbed rapidly and is well tolerated, with vomiting in fewer than 5% of patients.57 In children with persistent vomiting, dexamethasone can be given IM or IV. Nebulized budesonide is another option when a child cannot tolerate oral medications.
  5. “Antibiotics can’t hurt…”
    Antibiotics should be reserved for suspected cases of bacterial tracheitis (high fever, toxic appearance, acute onset of stridor, poor response to epinephrine) or pneumonia (focal findings on auscultation such as crackles, wheezing, or infiltrate on chest radiograph). There is no role for antibiotic prophylaxis in croup.
  6. “This is the third time this kid has had croup this winter.”
    It is important to consider other causes of stridor in children with recurrent symptoms or who present with stridor in the absence of a viral prodrome or who do not improve with treatment with epinephrine.
  7. “She looked so good after that dose of epinephrine that I let her go…”
    Physicians should observe children who have been treated with epinephrine for at least 2 hours before discharging them home. The effects of epinephrine typically wear off after about 2 hours, and the child may develop recurrence of symptoms similar to the ones exhibited prior to treatment with epinephrine.
  8. “He still had symptoms 4 days later, so I gave him more dexamethasone.”
    There is no evidence to support the use of multiple doses of dexamethasone in the treatment of croup. Croup generally lasts 2 to 5 days. If a child is still having moderate symptoms days after receiving a dose of dexamethasone, other diagnoses must be considered, such as bacterial tracheitis or anatomic abnormalities of the airway.
  9. “They’re calling a code blue in radiology!”
    Children with signs of worsening upper airway obstruction should not leave the ED for diagnostic imaging. They may decompensate rapidly if they become upset or are laid down for radiographs.
  10. “What size endotracheal tube should I use?”
    If a child with signs of severe croup does not improve with nebulized epinephrine and/or if they show signs of increasing agitation or lethargy, they should be referred to a pediatric critical care unit. If intubation is necessary, it should be done under controlled circumstances by someone with expertise in managing difficult pediatric airways. It is advisable to start with a cuffed endotracheal tube a half-size smaller than would be predicted for the child’s age. It may be necessary to size down even more, depending on the degree of subglottic edema.

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Last Modified: 03/27/2017
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