Credit:
Dr Dave Burbulys from Pediatric Emergency Medicine Lecture Series at Harbor-UCLA
Dr Debra Weiner and Nancy Shaffer RN at Emergency Department, Boston Children’s Hospital
CC: Stridor
HPI:
Pertinent positives/negatives:
vaccines UTD
no hx of cardio-pulmonary comorbidities
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Complaint specific findings on exam:
_Barking cough
_ inspiratory stridor
_ expiratory stidor
_ stridor at rest
_stidor with activity/agitation
_ no cyanosis
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ED COURSE:
MDM (with A/P):
_
presentation is most consistent with
croup given stridor and no lower respiratory symptoms in appropriate age group (less than 10 years old).
Diagnostically:
Considered CXR.
_ Given classic hx for croup, no CXR indicated. routinely indicated.
_ Given atypical hx for croup, CXR obtained to eval for other etiologies in ddx:
_ classic pencil/steeple appearance of subglottic trachea characteristic of croup
DDx (I considered that there is a small but finite risk for the following processes. The patient’s presentation does not meet our criteria (reasonable level of consistency with characteristic findings) for being reasonable for additional pursuit of these entities at this time (which are detailed parenthetically below):
Croup
(age: 6 mo – 3 yr,
clinically: URI prodrome, croupy cough, horase voice, insp stridor
CXR: steeple sign
pathogens: parainfluenza, RSV
Tx: steroids/aerosolized epi
Epiglottitis
(age: 5 – 7 yr,
lack of immunizations, rapid progression of high fever, toxicity, drooling, stridor
CXR: thumbprint sign
pathogens: GAS, strept, Staph, H influenzaTx: intubation, abx
Bacterial Tracheitis
(age: 3- 5 yr,
prodrome of croup, develop to i/e stridor, marked distress
CXR: shaggy tracheal air column
Tx: intubation, +/- abx)
Given not infant, less likely
laryngomalacia (infants <6 mo old, onset early after birth w/in weeks, assoc w/o infectious sx, failure to thrive)
vocal cord paralysis (infants, onset early after birth in weeks, assoc w/o infectious sx, failure to thrive)
Given no hx of aero-esophageal foreign body,
unlikely FB as precipitant for stridor.
Assessment of Croup Severity:
Westley Croup Score:
_ <= 5, therefore mild to moderate croup
_ >= 6, therefore severe croup
Assessment: mild-moderate croup (Croup score 0-5)
_given no stridor at rest, dexamethasone 0.3 mg per kilogram administered. Of note evidence suggests no difference in outcome from PO versus IM dexamethasone . Given no stridor at rest, Served in the emergency department for two hours and given continued improvement of symptoms , patient appropriate for outpatient monitoring with family and return precautions.
_ given stridor at rest, dexamethasone 0.6 mg per kilogram administered. Of note PO versus IM has no difference in outcome. Racemic epinephrine administered. As is usual and my practice I administer up to two doses and watch the patient for two hours in the emergency department to ensure no rebound effect.
Dispo: Home
_ Westley croup score at time of discharge <=2, suggestive of marked improvement and meets our criteria for outpatient monitoring by family with strict return precautions.
-Given patient is improved clinically, no stridor at rest at two hours after the last intervention, free of retractions, has f/u, the patient is appropriate for discharge to home.
-Pt does not meet criteria for requiring admission for croup i.e. (no seve resp distress/failure, no unusual sx (hypoxia/hyperpyrexia, no dehydration, no persistence of stridor at rest after aerosolized epi and steroids, no persistence of tachycardia or tachypnea, no complex past medical hx (prematurity, pulmonary, cardiac dz, no poor response to epinephrine no oxygen saturation < 95%, n toxic appearance, no high fever with absence of
barky cough, no drooling, no sniffing
position
barky cough, no drooling, no sniffing
position
Assessment: severe croup (Croup score >=6)
Dexamethasone 0.6 mg per kilogram administered. Of note PO versus IM has no difference in outcome.
Racemic epinephrine administered.
O2 supplemental
On monitor
IV access established
continued observation for potential for requirement for intubation
Dispo: Admitted
– Given stridor at rest after >2 raceimic epi treatments and/or pt meets does not meet criteria for safe discharge (no seve resp distress/failure, no unusual sx (hypoxia/hyperpyrexia, no dehydration, no persistence of stidor at rest after aerosolized epi and steroids, no persistence of tachycardia or tachypnea, no complex past medical hx (prematurity, pulmonary, cardiac dz).
– Admitted-given patient has continued stridor at rest, additional racemic epinephrine administered and patient admitted to ICU for close observation and continued treatment.