Episode 163.0 – Croup
Core EM - Emergency Medicine Podcast
English - May 20, 2019 14:09 - 6 minutes - 8.61 MB - ★★★★★ - 128 ratingsMedicine Health & Fitness Homepage Download Apple Podcasts Google Podcasts Overcast Castro Pocket Casts RSS feed
A look at one of the most common and potentially concerning upper respiratory infections in children.
Host:
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Croup.mp3
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One Comment
Tags: Airway, Infectious Diseases, Pediatrics
Show Notes
Background
Croup is a viral infection starts in the nasal and pharyngeal mucosa but spreads to the larynx and trachea
Subglottic narrowing from inflammation
Dynamic obstruction
Barking cough
Inspiratory stridor
Causes:
Parainfluenza virus (most common)
Rhinovirus
Enterovirus
RSV
Rarely: Influenza, Measles
Age range: 6 months to 36 months
Seasonal component with high prevalence in fall and early winter
Differential
Bacterial tracheitis
Acute epiglottitis
Inhaled FB
Retropharyngeal abscess
Anaphylaxis
Presentation & Diagnosis
Classically a prodrome of nonspecific symptoms for 1-3 days with low grade fevers, congestion, runny nose.
Symptoms reach peak severity on the 4th day
“Steeple sign” on Xray (subglottic narrowing) present in only 50% of patients with croup
Assess air entry, skin color, level of consciousness, for tachypnea, if there are retractions / nasal flaring (if present at rest or with agitation) & coughing
“Westley Croup Score” (https://www.mdcalc.com/westley-croup-score)
Chest wall retractions
Stridor
Cyanosis
Level of consciousness
Air entry
A look at one of the most common and potentially concerning upper respiratory infections in children.
Host:
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Croup.mp3
Download
One Comment
Tags: Airway, Infectious Diseases, Pediatrics
Show Notes
Background
Croup is a viral infection starts in the nasal and pharyngeal mucosa but spreads to the larynx and trachea
Subglottic narrowing from inflammation
Dynamic obstruction
Barking cough
Inspiratory stridor
Causes:
Parainfluenza virus (most common)
Rhinovirus
Enterovirus
RSV
Rarely: Influenza, Measles
Age range: 6 months to 36 months
Seasonal component with high prevalence in fall and early winter
Differential
Bacterial tracheitis
Acute epiglottitis
Inhaled FB
Retropharyngeal abscess
Anaphylaxis
Presentation & Diagnosis
Classically a prodrome of nonspecific symptoms for 1-3 days with low grade fevers, congestion, runny nose.
Symptoms reach peak severity on the 4th day
“Steeple sign” on Xray (subglottic narrowing) present in only 50% of patients with croup
Assess air entry, skin color, level of consciousness, for tachypnea, if there are retractions / nasal flaring (if present at rest or with agitation) & coughing
“Westley Croup Score” (https://www.mdcalc.com/westley-croup-score)
Chest wall retractions
Stridor
Cyanosis
Level of consciousness
Air entry
Management
Mild Croup
Occasional barking cough, but no stridor at rest and mild to no retractions
Tx: Single dose of dex
Has been shown to improve severity and duration of symptoms
Route is not particularly important, whether it’s PO, IV or IM
Chosen route should aim to minimize agitation in the patient that might worsen their condition
May be managed at with supportive care
Humidifiers (NB: there isn’t good evidence supporting the use of humidifiers)
Antipyretics
PO fluids
Moderate Group
May have stridor at rest, mild-moderate retractions but no AMS and will not be in distress.
Tx: Dex + Racemic Epinephrine
Racemic epinpehrine will start to work in about 10 minutes
Effects last for more than an hour
Severe group
Receives the same initial therapy as the moderate group with dex and race epi
Pts with worrisome signs: stridor at rest, marked retraction, cyanosis and/or lethargy
Heliox (a combinations of 70-80% helium + 20-30% oxygen) may be attempted
There is limited evidence to support the role of heliox in croup,
NB: Pt may require higher levels of oxygen than the 20-30% mixture may provide
Intubation
Anticipate edema narrowing the airway
Consider starting with a tube that is 0.5 to 1 mm smaller than size typically used
Disposition:
Patients without stridor at rest or respiratory distress can be generally discharged from the ED
If epinephrine is given, patients should be monitored for 2-4 hours for reemergence of symptoms as the medication wears off
Take Home Points
Croup usually affects children within the age range of 6 months to 36 months with the most common cause being parainfluenza virus
Given the symptom overlap, we must consider more concerning diagnoses, including bacterial tracheitis, in these patients, especially if they are ill appearing or traditional therapies are ineffective
All patients benefit from a one-time dose of dexamethasone and, if racemic epinephrine is given, the patient should be observed for at least 3 hours
If intubation is required, anticipate a narrowed airway
Parent Article: https://coreem.net/core/croup/ by Dr. Pankow
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