Croup – Physiomi

Patient Care

Precautions and Safety: Isolation: Contact and Droplet
Activity: Activity as Tolerated

Diet

For child who has been recently moderately or severely distressed: Clear Fluids
During periods of moderate to severe respiratory distress: NPO
For mild croup: Regular Diet

Respiratory Care

Supplemental oxygen need should prompt urgent physician assessment and concern for possible progressive upper airway obstruction.

O2 Therapy – Titrate to maintain saturation above 92%. Place the patient on supplemental oxygen to maintain oxygen saturation level greater than 92% AND notify physician of NEW oxygen requirement immediately.

Monitoring

For mild symptoms consider vital sign monitoring every 4 hours and more frequent for moderate or severe symptoms.

Vital signs (Temperature, Pulse, Respiratory Rate, Blood Pressure, oxygen saturation) every _____hours.

Consider continuous oxygen saturation monitoring if moderate to severe respiratory distress is present.

Oxygen saturation monitoring: Continuous
Notify MD immediately if:
- oxygen required to maintain oxygen saturation greater than 92%
- increased stridor or increased work of breathing
- there is ongoing stridor at rest following a nebulized epiNEPHrine dose
Intake and output: Monitor fluid volume intake and output every shift

Investigations

Laboratory and radiological assessments are not necessary to make the diagnosis of croup. The diagnosis can be reliably made based on the clinical presentation in combination with a careful history and physical examination.

Croup is a clinical diagnosis

IF considering alternate diagnoses: Lateral soft tissue neck film may be helpful for making an alternative diagnosis of retropharyngeal abscess or bacterial tracheitis in the rare case of children with croup-like symptoms

NOTE: Patients should be monitored during Diagnostic Imaging by personnel experienced with managing a difficult airway.

X-ray nasopharynx / soft tissue 1 view (GR Naso/ Soft Tis Neck, 1 projection)

Medications

Dexamethasone

Every child with croup should receive an initial dose of dexamethasone as soon as the diagnosis is suspected/made (typically given in the ED).

dexamethasone (recommended dose 0.6 mg/kg/dose, Max 10 mg) _________ mg _________ (specific route; PO recommended; IM or IV only if PO not possible) ONCE

Repeat dexamethasone doses should be ordered AS NEEDED on a case by case basis (e.g. ongoing symptoms requiring epinephrine administration). Dosing frequency (e.g. every 24 hours) of repeat doses should also be considered on a cases by case basis.

Nebulized epinephrine

Use for stridor occurring at rest AND accompanied by perceived distress or discomfort or increased work of breathing.

Standing or PRN nebulized epinephrine orders should not be ordered in the inpatient setting. Repeat doses may be needed in varying frequencies but should be ordered after discussion/assessment of the child to help the clinician be aware of/gauge severity and the possible need for further consultations or interventions to support airway safety.

May be repeated back to back in children with severe distress/ near respiratory failure but requires frequent re-evaluation.

Contraindications: Caution should be exercised when used in children with narrow angle glaucoma or cardiac abnormalities (consider cardiorespiratory monitor during administration). Use repeated doses of nebulized epinephrine within short time frames with caution given reports of cardiac damage.

epiNEPHrine 1 mg/mL neb solution 5 mL (5 mg) via nebulizer ONCE, STAT

Budesonide:

Consider in child with severe croup, or child with persistent vomiting

Nebulized budesonide is not routinely indicated for the treatment of croup. More commonly causes agitation than oral administration and more expensive than dexamethasone. Budesonide may be mixed with epinephrine and administered simultaneously.

budesonide (recommended dose 2 to 4 mg per dose) mg inhaled every 24 hours.

Antipyretics/Analgesics:

acetaminophen liquid (recommended dose 15 mg/kg//dose) mg PO/PR every 4 hours PRN for discomfort. (Maximum 75 mg/kg/day, 1000 mg/dose AND 4 grams/day whichever is less)
ibuprofen liquid (recommended dose10 mg/kg/dose) ___ mg PO every 6 hours PRN for discomfort. (Maximum 400 mg/dose, less than 6 months, acetaminophen is preferred)