Management of croup in outpatient and emergency department settings

This figure summarizes our suggested approach to managing children with croup in the ED or outpatient setting based upon the severity of symptoms. Clinical scoring systems can be used to assess croup severity. The most commonly used scoring system is the Westley croup score, which assesses level of consciousness, cyanosis, stridor, air entry, and retractions. This figure is intended for use in conjunction with other UpToDate content. For additional details, including information about the Westley croup score and a discussion of the evidence supporting the efficacy of these treatments, refer to UpToDate topic on management of croup.

ED: emergency department; ETT: endotracheal tube; IM: intramuscular; IV: intravenous; PICU: pediatric intensive care unit.

* Signs of impending respiratory failure include: fatigue and listlessness, profound retractions, decreased or absent breath sounds, depressed level of consciousness, tachycardia out of proportion to fever (note that tachycardia may also be caused by epinephrine), and/or poor color (cyanosis or pallor).

¶ The oral liquid preparation of dexamethasone (1 mg/mL) has a foul taste. Solutions for injection are more concentrated (4 mg/mL or 10 mg/mL) and can be given orally mixed with syrup. Alternatively, oral tablets can be crushed and mixed with syrup or pureed food.

Δ Dosing and administration are as follows:

Racemic epinephrine: 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25% solution diluted to 3 mL total volume with normal saline (in the United States and some other countries, single-use preservative-free bullets (ampules) of racemic epinephrine for nebulized administration are commercially available).
L-epinephrine: 0.5 mL/kg per dose (maximum of 5 mL) of a 1 mg/mL (1:1000) preservative-free solution (this is the parenteral preparation of epinephrine used for IM injection [eg, for anaphylaxis]).

Administer by nebulizer over 15 minutes. Use of either product is acceptable and may be determined by availability and institutional protocol. Nebulized epinephrine has an onset of effect within 10 minutes. Refer to UpToDate topic on management of croup for additional details.

◊ A single dose of nebulized budesonide, if available, may provide an alternative to IM or IV dexamethasone for children with vomiting and no IV access.

§ For children requiring inpatient admission for croup, the level of care (inpatient ward versus PICU) is determined by croup severity. PICU care is warranted for children with any of the following:

Respiratory failure requiring endotracheal intubation
Persistent severe symptoms requiring frequent nebulized epinephrine dosing
Underlying conditions placing the child at high risk for progressive respiratory failure (eg, neuromuscular disease or bronchopulmonary dysplasia)

¥ Poor response to nebulized epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis. Refer to UpToDate topic on evaluation and diagnosis of croup for a guide to the differential diagnosis.

Graphic 100747 Version 10.0

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Management of croup in outpatient and emergency department settings