Dr Hector Thomson

Emergency Registrar

Peer review: Dr Binula Wickramarachchi
Croup is one of the diseases we own. This is the quintessential paediatric ED reg condition. Often the triage nurse will give the dex before you’ve even seen the patient. But have you thought about what you are going to do if the dex doesn’t work?

🤓 Geek note – the word ‘stridor’ comes from the Latin verb ‘stridere’, which means to ‘make a harsh or shrill sound’

WHAT ELSE COULD IT BE?

It is very easy to get early diagnostic closure in these patients. You’re busy. The department has 50 waiting, you’re buzzing from two red bulls and a 7/11 coffee and if you just throw some dex and info handouts in the direction of the coughing, they will probably get better.

But it is important to have a cognitive stop point.

I especially try to stop and rethink the diagnosis in kids who have:

  • Wrong age (<6 months or >6 years old)
  • Repeated episodes
  • Past history (especially pre-maturity, cardiac/respiratory disease)
  • No response to nebulised adrenaline
  • No preceding coryza

Make sure you ask:

  • Time course
  • Vaccination status
  • Previous episodes
  • Recent steroids
  • Drooling/dysphagia/voice changes
  • Posturing

Differentials

The differentials can be broken down into acute causes and congenital abnormalities. Our job is to think about the zebras. Ask about antenatal history and previous episodes of stridor.

Acute:

  • Bacterial infection: bacterial tracheitis, acute epiglottis, diptheria, retropharyngeal abscess
  • Mechanical: foreign body
  • Allergic: anaphylaxis

Chronic:

  • Laryngomalacia/tracheomalacia
  • Subglottic stenosis
  • Cord paresis
  • Vascular rings
  • Tracheo-oesophageal fistula
  • Mediastinal mass

TREATMENT

There is ongoing debate about the dose and type of steroid. 0.15mg/kg is not inferior to 0.6mg/kg but this is only up for debate in the kid with mild or moderate croup, in the sick kid don’t be an EBM stickler, big sick gets the big dose. Account for spitting out and difficulties drawing up. Always just round up.

Where I work at the moment, we give the injectable dexamethasone 8mg in 2ml, which seems to go down pretty easy.

RCH Guidelines - Croup Management Algorithm

COVID CROUP

A retrospective analysis from a single centre in Boston found much higher incidence of croup among kids infected with Omicron than with any other variant in the COVID-19 pandemic. Anecdotally I have found COVID croup to be more severe needing multiple adrenaline nebs and some even needing intubation. Very small case series seem to support this. Won’t you just kick it all off again if you shove a swab down their throat? The general practice at the moment is to swab the kids who have been stridor free for a while with the cop out of “until deemed safe to do so by a senior clinician.”

OBSERVATION

The vast majority of croup kids will go home from the waiting room. Never send a child home if they have stridor at rest and always give written and verbal instructions to the parent before discharge. The more severe cases will need a period of observation to ensure they don’t need further adrenaline while the steroids kick in. Most patients who receive two or more doses of adrenaline in the ED don’t end up having any further interventions in the inpatient setting. PICU should be informed of anyone you’ve given multiple nebs to, but don’t expect them to be whisked upstairs straight away. Given these kids present overnight, a good strategy is to just watch them in short stay until the morning. This is especially so if they have pre-existing abnormal airways, previous severe croup, co-morbidities or live far away. I would also observe COVID croup until daylight hours, but this has no evidence base. Some guidelines suggest admitting children who have had one or more adrenaline nebs, but I find this a bit silly as they hardly ever need any intervention the next day. The gen paeds team send them home on their morning ward round and ED is the place they need to be if they aren’t quite right yet anyway (be nice to your med regs!).

INTUBATION

So, what do you do when the 2nd adrenaline neb is running and the kid still looks absolutely rubbish? Intubation may be required, but this is uncommon. From 2005 to 2012 there were 185 admissions to ICU at RCH for croup, which represents 1.7% of all ED presentations. 35% of the children admitted to ICU were intubated, with half the intubations occurring in a referral hospital. The indications for intubation are:

  • exhaustion
  • respiratory failure (Type 1 or 2)
  • decreased level of consciousness and unable to protect airway
  • imminent complete airway obstruction

This will be an extremely stressful resus so you need to have a standardised, calm approach to turning this around. Even if it feels chaotic, you do have time to do this properly and turn the kid around so they won’t need some plastic.

CALL FOR HELP: Co Registrars + PICU + Anaesthetics + ENT + On call Consultant

  • This will be overnight so it may take time for the troops to arrive

CALM: Keep the room calm and keep the kid calm

  • Sit on the parents’ lap
  • Turn off any loud alarms
  • Put on Bluey (this is not the time for other inferior shows)

OPTIMISE: Nebulise adrenaline 5ml of 1:1000 back-to-back + Dexamethasone 0.6mg/kg

  • Try to give PO but the sick kid probably won’t swallow – give it IM as you won’t have a drip yet
  • I put EMLA on the sick ones on arrival but it probably won’t have time to work
  • Consider nebulised budesonide 2mg stat
  • Oxygen can be wafted or given but try not to piss the kid off – the problem is obstruction

MONITORING: Sneak a sats probe onto the toe and tape it in place

  • Don’t bother with the BP cuff at the start it will piss them off
  • Before you intubate get 3 lead ECG and BP monitoring on

EQUIPMENT AND DRUGS: Ideally bring a gas machine to the patient rather than putting the patient in a lift

  • Use a checklist and use drugs you are comfortable with in an emergency
  • Video laryngoscopy calms the room down when they see you can see the cords
  • Heliox is an option but I don’t know many people who have this in ED
  • Cuffed tube 0.5mm smaller than usual, but also have smaller sizes ready

TECHNIQUE: Ideally this is a gas induction by a senior anaesthetist with ENT scrubbed

  • If crashing/delay to help – perform your usual RSI with the most senior operator

FAILURE: Plan for failed intubation

  • Verbalise your plan and announce this is a difficult intubation
  • Designate someone to be ready for jet ventilation
  • If you have crash ECMO this might actually be a legit bail-out plan given it is a reversible upper airway disease
Paediatric FONA

So remember:

  • Not all stridor is croup
  • Ask about preceding coryza, missing foreign bodies and vaccination status
  • Adrenaline nebulisers will get you out of trouble most of the time
  • Be a bit more cautious with COVID croup
  • Mentally rehearse your plan for critical croup

References

FOAMed Resources
  1. First10 EM
  2. Don’t Forget The Bubbles
  3. Life in the Fast Lane
  4. Core EM
Guidelines
  • Royal Children’s Hospital (Melbourne) Clinical Guidelines – Croup
Literature
  1. Pfleger A, Eber E. Management of acute severe upper airway obstruction in children. Paediatr Respir Rev. 2013;14:(2)70-7. PMID: 23598067
  2. Rudinsky SL et al. Inpatient Treatment after Multi-Dose Racemic Epinephrine for Croup in the Emergency Department. J Emerg Med. 2015 Oct;49(4):408-14. PMID: 26242923
  3. Gates  A, Gates  M, Vandermeer  B, Johnson  C, Hartling  L, Johnson  DW, Klassen  TP. Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD001955. DOI: 10.1002/14651858.CD001955.pub4. Accessed 28 April 2021
  4. Chub-Uppakarn S, Sangsupawanich P. A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. Int J Pediatr Otorhinolaryngol. 2007 Mar;71(3):473-7. doi: 10.1016/j.ijporl.2006.11.016. Epub 2007 Jan 8. PMID: 17208307
  5. Tyler A, McLeod L, Beaty B, et al. Variation in Inpatient Croup Management and Outcomes. Pediatrics. 2017;139(4):e20163582. doi:10.1542/peds.2016-3582
  6. McEniery J, Gillis J, Kilham H, Benjamin B. Review of intubation in severe laryngotracheobronchitis. Pediatrics 1991;87(6):847–53
  7. Borland ML, Babl FE, Sheriff N, Esson AD. Croup management in Australia and New Zealand: a PREDICT study of physician practice and clinical practice guidelines. Pediatr Emerg Care. 2008 Jul;24(7):452-6. doi: 10.1097/PEC.0b013e31817de363. PMID: 18580704
  8. Gelbart B, Parsons S, Sarpal A, Ninova P, Butt W. Intensive care management of children intubated for croup: a retrospective analysis. Anaesth Intensive Care. 2016 Mar;44(2):245-50. doi: 10.1177/0310057X1604400211. PMID: 27029657
COVID Croup
  1. COVID-19-associated croup in children Brewster RCL, Parsons C, Laird-Gion J, et al. Pediatrics. Published online March 8, 2022. doi:10.1542/peds.2022-056492
  2. Venn AMR, Schmidt JM, Mullan PC. Pediatric croup with COVID-19. Am J Emerg Med. 2021 May;43:287.e1-287.e3. doi: 10.1016/j.ajem.2020.09.034. Epub 2020 Sep 15. PMID: 32980228; PMCID: PMC74902
Hector Thomson

Hector Thomson

Emergency Registrar

Hector (the one on the left) is an Emergency Medicine Advanced Trainee at The Alfred. He’s still clinging to the basic science knowledge he gained during primary exam prep and enjoys shoulder dislocations, trauma, rugby union, fresh pasta and good gin. He doesn’t like vague allergies or cats.