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Diagnosis and Management of Croup Summary of the Alberta Clinical Practice Guideline, March 2003 Diagnosis ã The characteristic clinical features of a child with croup are a seal-like barky cough, hoarseness, and often include fever, irritability, stridor and chest wall indrawing of varying severity. Children with croup should not drool or appear toxic. FEATURES SUGGESTING A DIFFERENT DIAGNOSIS  High fever, toxic appearance, and poor response to epinephrine suggest bacterial tracheit
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  Diagnosis and Management of Croup Summary of the Alberta Clinical Practice Guideline, March 2003 Diagnosis ã The characteristic clinical features of a child with croup are a seal-like barky cough, hoarseness, and often include fever, irritability, stridor and chest wall indrawing of varying severity. Children with croup should not drool or appear toxic. FEATURES SUGGESTING A DIFFERENT DIAGNOSIS  High fever, toxic appearance, and poor response to epinephrine suggest bacterial tracheitis  Sudden onset of symptoms with high fever, absence of barky cough, dysphagia, drooling, anxious appearance, and sitting forward in “snifng position” suggest epiglottitis  Other potential causes of stridor which are rare but should be considered include foreign body lodged in upper esopha-gus, retropharyngeal abcess, and hereditary angioedema ã The vast majority of children with croup can be diagnosed based on a careful history and physical examination, and do not require either laboratory or radiological assesssment to accurately establish a diagnosis. 1,2  ã Make children with croup comfortable and avoid agitating with unnecessary procedures. Provide blow-by oxygen to children in respiratory distress.ã Also administer epinephrine   via nebulization to children with severe respiratory distress (as evidenced  by sternal wall indrawing and agitation). 3 ã Administer one oral dose of dexamethasone to all children diagnosed with croup. Consider nebulized  budesonide in children who are too sick to tolerate oral administration of medications. 4 ã Antibiotics, sedatives and oral decongestants are not recommended.ã Mist tents, wanes, or steamers should not be used. ã Admit children who have signicant respiratory compromise (sternal wall indrawing, easily audible stridor at rest)  persisting 4 or more hours after corticosteroid administration . Consider admission if sig- nicant parental anxiety exists; if the parents have brought the child to the ED repeatedly for croup symptoms; if the child’s family resides a long distance from hospital or has inadequate transportation; or if there are other reasons that might result in inadequate follow-up.ã Children admitted to hopsital should have frequent monitoring of their respiratory status. Intravenous uids are usually only required in children with severe respiratory distress. Administer epinephrine if severe respiratory distress reoccurs. Contact the closest pediatric intensive care unit if epineprhine is administered more than every two hours.ã Intubation may be necessary in a small number of hospitalized patients. Cardiopulmonary arrest can occur in patients not adequately monitored and managed. Bacterial tracheitis can cause precipitous deterioration. Pneumonia is a rare complication.ã The majority of children can be managed as outpatients. Children may be safely discharged home if they have not been treated with epinephrine in the past two hours, they do not have stridor at rest, they do not have signicant chest wall indrawing, and the parent or caregiver can easily return for care if respiratory distress reoccurs at home. ã Provide parents/caregivers with written instructions and provide advice on when to return for medical care. ã Most children with croup do not require specic follow-up. Follow-up with a primary care provider should occur in patients who have had stridor > 1 week  . Investigations  ED Care (for drug dosages see over) AdmissionsComplications Discharge Supportive CareFollow-up  Notes: 1. If laboratory tests are obtained, they should be deferred while patient is in respiratory distress and should be well justied.2. Lateral and anteroposterior (AP) soft tissue neck lm may be helpful in establishing an alternative diagnosis in patients with atypical disease. 3. Administration of epinephrine does not mandate admission to hospital. 4.. Although nebulized budesonide has been shown to be equivalent to oral dexamethasone, it is substantially more expensive. Potential exceptions include a child who has persistent vomiting or a child with severe respiratory distress.  Administered by the Alberta  Medical Association  For complete guideline refer to the TOP Website: www.topalbertadoctors.org  July 2003  Reviewed January 2008 2008 Update  ALGORITHM: CROUP IN THE OUT-PATIENT SETTING  Based on severity at time of initial assessment  MILD (without   stridor or signicant chest wall indrawing at rest) MODERATE (stridor and chest wall indrawing at rest without   agitation) SEVERE (stridor and indrawing of the sternum associated with agitation or lethargy)  Give oral dexamethasone 0.6mg/kg of body weight  Educate parents - Anticipated course of illness- Signs of respiratory distress- When to seek medical assessmentMinimize intervention  Place child on parents lap  Provide position of comfortGive oral dexamethasone 0.6mg/kg of body weightObserve for improvement  Patient improves as evidenced  by no longer having: - Chest wall indrawing - Stridor at rest  Educate parents (as for mild croup)  Discharge home May discharge home without further observation  Minimize intervention (as for moderate croup)  Provide ‘blow- by’ oxygen (optional unless cyanosis is  present)   Nebulize epinephrine   - Racemic epinephrine 2.25% (0.5 mL in 2.5 mL saline)  or   - L-epinephrine 1:1,000 (5ml)  Give oral dexamethasone (0.6 mg/kg of body weight); may repeat once - If vomiting, consider administering budesonide (2mg) nebulized with epinephrine - If too distressed to take oral medication, consider administering budesonide (2mg) nebulized with epinephrinePoor response to nebulized epinephrineGood response to nebulized epinephrineObserve for 2 hours?Repeat nebulized epinephrineContact pediatric ICU for further management  Persistent mild symptoms.  No recurrences of: - Chest wall indrawing - Stridor at rest  Provide education (as for mild croup) Discharge Home Reocurrence of  severe respira-tory distress:  Repeat nebulized epinephrine  If good response continue to observe* Consider hospitalization  (general ward) if:  Received steroid ≥  4 hours ago  Continued moderate  respiratory distress ( without   agitation or lethargy) - Stridor at rest - Chest wall indrawing (If the patient has recurrent severe episodes of agitation or lethargy contact pediatric ICU) >>>>>>>>> >>>>> >>>    No or minimal improve-ment by 4 hours, consider hospitalization (see below)* > >
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