Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Croup

Signs of Respiratory Failure
Resuscitation Room
Difficult/Critical Airway Pathway
  • Any of the following:
    • Barky cough, hoarse voice
    • No stridor at rest
    • Mild coarse stridor
    • Stridor only during agitation/activity
    • No or mild WOB
  • Any of the following:
    • Anxiety, mental status changes
    • Stridor at rest
    • Moderate, severe WOB
    • Hypoxemia
Discharge Criteria
  • No or minimal coarse stridor at rest
  • No or minimal retractions
  • Able to tolerate PO feeding
Hourly assessment PE, VS
Observe for 2 hours
Dexamethasone: 0.3 mg/kg, MAX 8 mg
Racemic Epinephrine: 2.25% solution, 0.5 mL in 3 mL NS
  • Age < 6 months, or > 6 years
  • Poor response to treatment
  • Duration of stridor > 4 days or cough > 10 days
  • Non-elective intubation in past 6 months
  • Prolonged intubation
  • Recurrent croup
  • 2nd episode within 30 days
  • > 3 episodes in the last 12 months
Continued or Recurrent Stridor
Racemic Epinephrine
  • Not improved
Admit to EDECU/General Pediatrics
  • Admit to PICU
Consider Alternative Diagnoses
Further Diagnostic Testing
Posted: September 2014
Reviewed: December 2020
Authors: J. Piccione, MD; M. Mittal, MD; J. Seiden, MD; B. Jenssen, MD; M. Dunn, MD; R. Hughes, PharmD; K. Cohn, MD;
E. Hysinger, MD; A. Buzi, MD; E. Walker, RT; M. F. Duff, RT; J. M. Malpass, RT; S. M. Gaines, RN