Croup

Croup is a common cause of cough in the pediatric population. It is also referred to as laryngotracheitis. Croup is caused by a variety of viruses, often parainfluenza.

Epidemiology

 * Affects ages 6months - 5 years of age
 * M>F
 * Often during Fall/Winter season

Clinical Presentation

 * History: abrupt onset, barking cough, stridor, hoarseness, respiratory distress, symptoms worse at night and with agitation, often preceded by URTI
 * Physical: ABCs, LOC, work of breathing - stridor, cyanosis, cardiac and resp examination

Westley Croup Score

 * mild <4
 * Moderate 4-6
 * Severe >6

Investigations

 * Clinical diagnosis. R/O other DDX. Consider soft tissue neck/CXR.
 * Neck xray: steeple sign
 * No viral testing

Differential Diagnosis

 * Bacterial croup- includes laryngeal diphtheria, bacterial tracheitis, laryngotracehobronchitis and laryngotracheobronchopneumonitis
 * High fever, toxic,r esp distress, poor response to treatment, elevated WBC
 * Obtain bacterial cultures of tracheal secretions + blood cultures
 * Investigations: AP neck: steeple sign, may mimic foreign body. W/ consultation direct laryngotracheobronchoscopy
 * Mngt: ABCs, protect airway, consult ENT/ICU
 * Epiglottis - etiology h.influenza type B (vaccination prevention), strep
 * Clinical: fever, sudden onset, toxic, no barky cough, dysphagia, drooling, 'hot potato voice', resp distress
 * Investigations: blood cultures, xray soft tissue lateral neck: thickening + thumb print sign
 * Definitive diagnosis: direct laryngoscopy, nasopharyngoscopy
 * Mngt: avoid agitation, Antibiotics, humidified blow by-oxygen, call for help (ENT/anesthesia), steroids are controversial


 * Foreign Body
 * Anaphylaxis
 * Retropharyngeal abscess- deep neck infection secondary to local spread versus penetrating injury
 * Risk: airway compromise, spread to mediastinum, abscess rupture --> asphyxiation/pneumonia
 * Clinical: fever, malaise, dysphagia, trismus, neck stiffness, torticollis, muffled voice, resp distress, stridor, drooling, may be preceeded by URTI, tender unilateral cervical adenopathy, +/- bulge in posterior pharyngeal wall on inspection of oral cavity
 * Investigations: CBC, blood cultures, lateral neck soft tissue Xray, CT (gold standard)
 * Mngt: ABCs, consultation ENT/anesthesia, IV antibiotics, +/- surgical consultation for I+D, close monitored setting


 * Heriditary angioedema
 * Subglottic stenosis
 * Caustic injury
 * Peritonsillar abscess
 * Complication of tonsillitis. Often secondary to Group B strep
 * Clinical: may see uvula deviation
 * Management: ABCs, Incision and drainage (definitive mngt), +/- Antibiotics

Management

 * Droplet precautions
 * ABC's, supplemental oxygen PRN
 * Dexamethasone 0.6mg/kg (max 12mg) PO/IV/IM x 1 dose
 * Reduces rate of intubation, hospitalization, return to ED, symptom duration
 * +/- Racemic Epinephrine 2.25% 0.5mL in 3 mL normal saline by inhalation
 * OR epinephrine 1:1000. Dose: 3mL (3mg) if <10kg or 5mL (5mg) if > 10kg
 * +/- Budesonide 2mg by inhalation x 1 dose
 * +/- acetaminophen/ibuprofen
 * +/- IV fluids
 * Consider transfer/admission if: severe respiratory distress, >2 epinephrine doses with no benefit, history of abnormal airway, prematurity, no improvement 4hours post steroids
 * Supportive management: mist/humidifier (no strong evidence)
 * NO ANTIBIOTICS, NO DECONGESTANTS

Prognosis

 * Self limited. Most resolve in 48 hours.

Prevention

 * Vaccinations: influenza, diphtheria

Resources
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