Inpatient Pathway for the Evaluation/Treatment
of the Child with Croup
  • SIGNS OF IMPENDING
    RESPIRATORY FAILURE:
  • Change in mental status
  • Severe retractions
  • Hypoxia
  • Poor response to racemic epinephrine
  • Call CAT team
Review ED Care, History and Physical
Observe and Assess PE, VS q 1 hour x 2
MILD/MODERATE SYMPTOMS
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MODERATE/SEVERE SYMPTOMS
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  • Any of the following:
    • Barky cough, hoarse voice
    • No stridor at rest
    • Mild coarse stridor
    • Stridor only during agitation/activity
    • No or mild WOB
Observe Minimum of 8 Hours
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  • Any of the following:
    • Anxiety, restlessness
    • Stridor at rest
    • Moderate, severe WOB
    • Hypoxemia
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Racemic Epinephrine
Assess immediate response
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MINOR IMPROVEMENT
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NOT IMPROVED/WORSENING
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  • Reassess PE, VS q 1 hour x 2
  • Alternate RN/RT
  • Additional racemic epinephrine as needed
  • Persistent symptoms > 24 hours
  • Consider repeat dexamethasone
  • Call MD to bedside
  • Consider:
    • Repeat racemic epinephrine
    • Alternative diagnoses
    • ICU consult/CAT call
Improved
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  • No stridor or mild stridor
  • No or minimal respiratory distress
  • Minimal retractions
  • Able to tolerate PO feeding
  • TREATMENT CONSIDERATIONS
  • Dexamethasone
    • 0.3 mg/kg, MAX 8 mg
  • Racemic Epinephrine
    • 2.25% solution
    • 0.5 mL in 3 mL NS
  • CONSIDER ALTERNATIVE DIAGNOSES
  • 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
  • Toxic appearance
  • Drooling, difficulty swallowing, severe anxiety
  • Asymmetry of the respiratory exam
  • FURTHER DIAGNOSTIC TESTING
Posted: September 2014
Reviewed: January 2017, December 2018
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;