Quick Ref Guide

Full What0-18 Guide

Document Severity @ discharge:  Remember sometimes well children that it is appropriate to discharge can deteriorate. So ensure the reason for your decision is well documented, and the patient is safety netted.

Background

• Croup is a common cause of upper airway obstruction in young children.
• It is usually mild and self-limiting, though occasionally it may cause severe respiratory obstruction
• Croup, also known as laryngotracheobronchitis, is a clinical syndrome of a hoarse voice, barking cough and inspiratory stridor

Clinical Presentation

• Typical History: Child typically aged 6-36 months. Usually 2-3 days coryzal symptoms, often low grade fever, usually happy to eat and drink, often presents at night.
• Croup symptoms: Hoarse voice, barking cough, inspiratory stridor.
• Clinical examination: Non-toxic child, well-perfused, possible tracheal and intercostal recessions.
• Exclusion of other causes of upper airway obstruction (see Table).
• Only when all 4 criteria are satisfied should the clinical condition of croup be diagnosed

Other causes of upper airway obstruction to exclude

What to do

• Assess severity: appearance, degrees of respiratory distress, oxygen desaturation
• Disturb the child as little as possible: keep with parent, minimal monitoring (O2 sats only)
• Hypoxia (<92%):  move to resus, give oxygen immediately and call for help – this is a LATE SIGN
• Life threatening features: move to Resus and call for paediatric and anaesthetic support – start severe treatment, make preparations for intubation
• Severe features: use nebulised adrenaline (5ml 1:1000), oral or nebulised steroids, repeat as necessary and call for senior help
• Moderate features: oral steroids (dexamethasone 0.15mg/kg), refer to paeds for observation on PAU – if improves and meets discharge criteria – discharge with advice sheet
• Mild features: oral steroids, if meets discharge criteria – discharge with advice sheet

Other treatments

• Mist therapy: no benefits of mist therapy
• Oral and nebulised steroids: are as effective as each other and effect seen within 30 mins. Prednisolone as efficacious as Dexamethasone but second dose after 12 hours required
• Heliox: no benefit over standard treatments

Discharge Criteria

• Presence of mild symptoms during initial evaluation or after a period of observation
• Clinical diagnosis of croup i.e. no uncertain diagnosis
• Age > 6 months
• No known structural airway abnormality e.g. subglottic stenosis
• Patient taking adequate fluids
• If symptoms have not recurred within 4 hours of observation following treatment with epinephrine
• Parents can return child for care if respiratory distress recurs at home
• Parents have been advised when to seek medical intervention and have received the croup patient information leaflet

Reference:

Management of Croup in Children Over 3 Month (CHFT policy)