Croup is a common cause of cough in the pediatric population. It is also referred to as laryngotracheitis. Croup is caused by a variety of viruses, often parainfluenza.
Epidemiology[]
- Affects ages 6months - 5 years of age
- M>F
- Often during Fall/Winter season
Clinical Presentation[]
- History: abrupt onset, barking cough, stridor, hoarseness, respiratory distress, symptoms worse at night and with agitation, often preceded by URTI
- Physical: ABCs, LOC, work of breathing - stridor, cyanosis, cardiac and resp examination
Westley Croup Score[]
- mild <4
- Moderate 4-6
- Severe >6
Investigations[]
- Clinical diagnosis. R/O other DDX. Consider soft tissue neck/CXR.
- Neck xray: steeple sign
- No viral testing
Differential Diagnosis[]
- Bacterial croup- includes laryngeal diphtheria, bacterial tracheitis, laryngotracehobronchitis and laryngotracheobronchopneumonitis
- High fever, toxic,r esp distress, poor response to treatment, elevated WBC
- Obtain bacterial cultures of tracheal secretions + blood cultures
- Investigations: AP neck: steeple sign, may mimic foreign body. W/ consultation direct laryngotracheobronchoscopy
- Mngt: ABCs, protect airway, consult ENT/ICU
- Epiglottis - etiology h.influenza type B (vaccination prevention), strep
- Clinical: fever, sudden onset, toxic, no barky cough, dysphagia, drooling, 'hot potato voice', resp distress
- Investigations: blood cultures, xray soft tissue lateral neck: thickening + thumb print sign
- Definitive diagnosis: direct laryngoscopy, nasopharyngoscopy
- Mngt: avoid agitation, Antibiotics, humidified blow by-oxygen, call for help (ENT/anesthesia), steroids are controversial
- Foreign Body
- Anaphylaxis
- Retropharyngeal abscess- deep neck infection secondary to local spread versus penetrating injury
- Risk: airway compromise, spread to mediastinum, abscess rupture --> asphyxiation/pneumonia
- Clinical: fever, malaise, dysphagia, trismus, neck stiffness, torticollis, muffled voice, resp distress, stridor, drooling, may be preceeded by URTI, tender unilateral cervical adenopathy, +/- bulge in posterior pharyngeal wall on inspection of oral cavity
- Investigations: CBC, blood cultures, lateral neck soft tissue Xray, CT (gold standard)
- Mngt: ABCs, consultation ENT/anesthesia, IV antibiotics, +/- surgical consultation for I+D, close monitored setting
- Heriditary angioedema
- Subglottic stenosis
- Caustic injury
- Peritonsillar abscess
- Complication of tonsillitis. Often secondary to Group B strep
- Clinical: may see uvula deviation
- Management: ABCs, Incision and drainage (definitive mngt), +/- Antibiotics
Management[]
- Droplet precautions
- ABC's, supplemental oxygen PRN
- Dexamethasone 0.6mg/kg (max 12mg) PO/IV/IM x 1 dose
- Reduces rate of intubation, hospitalization, return to ED, symptom duration
- +/- Racemic Epinephrine 2.25% 0.5mL in 3 mL normal saline by inhalation
- OR epinephrine 1:1000. Dose: 3mL (3mg) if <10kg or 5mL (5mg) if > 10kg
- +/- Budesonide 2mg by inhalation x 1 dose
- +/- acetaminophen/ibuprofen
- +/- IV fluids
- Consider transfer/admission if: severe respiratory distress, >2 epinephrine doses with no benefit, history of abnormal airway, prematurity, no improvement 4hours post steroids
- Supportive management: mist/humidifier (no strong evidence)
- NO ANTIBIOTICS, NO DECONGESTANTS
Prognosis[]
- Self limited. Most resolve in 48 hours.
Prevention[]
- Vaccinations: influenza, diphtheria
Resources[]
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