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The Curious Incident of the Barking Cough in the Night Time: Croup in the ED

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The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

Author: Nikki Abela / Codes: CAP6, PMP2 / Published: 29/02/2016

The frosted windscreen that heralds the end of the night shift is not the only thing that reminds us that winter is here. Our paediatric emergency departments are bustling with the snuffles that this season brings, and, as if that wasnt enough, the seals come out at night to play. You know the ones, the 3-36 month olds with the barking cough that came on quite suddenly and woke everyone in the house with a jolt.

Presentation

Once you have heard the classic croupy cough, you wont forget it. But just in case you have, there are nifty videos like this one online to remind you. https://www.youtube.com/watch?v=Wvg7HFoKFtY The barking cough, stridor, coryzal symptoms and low-grade fever are typical of croup (a.k.a viral larygotracheitis). And the child will generally present in the evening or night/early hours of the morning, with a harsh sounding cough which came on within a few hours. They typically can improve slightly in the morning, and when they are taken out in the cold.

Differentials

Dont forget however, that there are other things that may sound similar to croup, so dont continue on autopilot without considering the differentials. If the child looks septic (if you dont know what a septic child looks like Ed Snelson gives us some insight here), or if they are sitting forward with their neck extended, start thinking of other causes. I really like the way Dont forget the Bubbles calls them The Big Four in their blog:

  1. Acute epiglottitis
  2. Bacterial tracheitis
  3. Foreign body
  4. Anaphylaxis

There are of course other differentials, including retropharyngeal abscesses, and for that I suggest you read the Dont forget the Bubbles link or the RCEM reference piece. Of course, common things like croup are common. If it sounds like croup, it probably is. But if you see enough kids with croup, one day it wont be, so dont get caught up with going through the motions and forgetting to think outside the box. Talking about the box, most croup is pretty easy to deal with, but that is not to say it is benign.

Severity Assessment

There are of course severity scores for croup, like the Westley score*.

*The Westley Score divides children with croup into four levels of severity:

  • Mild: 0-2
  • Moderate: 3-5
  • Severe: 6-11
  • Impending Resp Failure: 12-17

For the unlucky few, things can go wrong. But thankfully, most are on the mild-moderate scale and do well with steroids. Damian Roland has posted a nice video of a child with severe croup https://www.youtube.com/watch?v=Wvg7HFoKFtY

Management

Some departments encourage triage nurses, when confident in the recognition of a child with croup, to give a steroid. However, if theyre not sure, or the child isnt quite right then a medical review first is a must! But what steroid and how much? I hear you ask. Now that, my geeky friends, is a good question, which empem has already tried to answer. There have been a number of papers in favour of either prednisolone or dexamethasone. In my hospital, we have favoured 0.6mg/kg (up to a max of 12mg) of dexamethasone. Its in the hospital guideline where I work, so be sure to check yours. Dont get too comfortable though folks, because things can go wrong with croup, and it can be a severe, life-threatening illness. Practically speaking, if the child has marked increased work of breathing accompanying a stridor at rest then they should really be placed in an area where they can be observed and seen by a doctor immediately. (These are not the ones you want your triage nurses to be giving the dex to and waiting 2 hours in the waiting area). If they have a decreased level of consciousness, or low sats at rest, get the airway team involved early. If you are worried about impending airway obstruction, you really dont want to be calling the most junior anesthetist on call. Dont panic (or if you do, at least hide it), distract the child and give them nebulized adrenaline (5mg of the standard 1:1000 L-epinephrine). Put that local anaesthetic on early (EMLA/Ametop) in anticipation of needing IV access. Damian Roland reminds us that as calm as you are, is as calm as she’ll be‘. If the child is having a melt down, do what you can to keep them calm (sing soft kitty if you must). Remember, older children have more severe symptoms as they are more aware of the feeling of tracheal narrowing at the subglottic level, so keeping these kids calm is imperative. If shooting a syringe-full of dexamethasone down the throat of a distressed, vomiting child is going to make their severe croup worse, go for nebulized budesonide (2mg). Keep the child with severe croup on oxygen once the nebulizers are finished (you dont want them to go blue as soon as you turn your back).

Airway Management

If the anesthetist hasnt arrived and/or the child is too unwell to wait for the nebulisers to work, I send you my condolences my friend, as you are going to have to intubate and very few people would want to be in your shoes right now. If ever there was a time for the difficult airway trolley, this is it. Crash call your ENT colleague to stand by your side with the tracheostomy kit if possible, and make sure you have the most experienced personnel around you. Gas induction would be ideal to avoid the distress of an IV. Always anticipate needing a smaller ET tube than estimated for the childs age and consider having the kit set up for a potential needle cricothyroidotomy. As the guys in first10EM remind us

Isolated, reversible upper airway disease is a good indication for crash ECMO if that is an option to you (it isnt for me) and you are unable to secure the airway.

Luckily, most children do not progress to anywhere near this route, and most can be discharged home once the stridor settles (NEVER, EVER send a child home with stridor at rest). However, always safety net the parents to re-present if the stridor returns. Luckily, because the dexamethasone takes a good 2 hours to work, you can use this time to assess the direction of the disease trajectory your patient is taking. If its not going the right way, get the nebulized adrenaline ready, and start rehearsing because you may have to sing soft kitty (lyrics may be found here).

References/further reading:

  1. RCEMLearning: Croup.
  2. RCEMFOAMed: Recognising Paediatric Sepsis.
  3. RUSSELL, K.F., LIANG, Y., et al. (2011) Glucocorticoids for croup. Cochrane Database Systematic Review. Jan 19;(1):CD001955.
  4. LITFL: Time to Tighten those Sphincters.
  5. Don’t forget the Bubbles: Croup.
  6. Pedemmorsels: Croup.
  7. EMPEM: Croup, the Steroid Saga.
  8. First10EM: Management of Severe Croup.
  9. Live Diagnosis with Dr Paul: Croup.

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3 Comments

  1. Michael Harrison says:

    nice read

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