Croup Clinical Pathway — Inpatient | Children's Hospital of Philadelphia

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Related Pathway

Croup, ED

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

MODERATE/SEVERE SYMPTOMS

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

Discharge Criteria

Any of the following:
- Anxiety, restlessness
- Stridor at rest
- Moderate, severe WOB
- Hypoxemia

Racemic Epinephrine

Assess immediate response

MINOR IMPROVEMENT

NOT IMPROVED/WORSENING

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

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;

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.