CroupMatthew Stajcer PGY1 FM Community

(Renfrew)

Case #1 - Hx22 Month Old male infantDeveloped sudden onset ‘weird’ cough for 1/7Slightly hoarse voiceFever 38.5Funny breathing noise when breathing inRhinorrhea

Case #1 - ExamAlert, Warm well perfused, mild WOB at restHEENT - TM N, Tonsils mild swelling

no lymphadenopathy, rhinorrhea +Chest - inspiratory wheeze, no creps, barking coughCVS = N, Abdo = NT 38.5, RR 44, Sa02 91%, HR 140

?Stridor and Weird Cough

Respiratory noise - inspiratory

Weird Cough - Barking

Case #1Differential Dx:Acute epiglottitis (Much more rare since H. Flu vaccine)

●Peritonsillar and retropharyngeal abscesses

●Foreign body aspiration or ingestion

●Allergic reaction

●Upper airway injury

●Congenital anomalies of the upper airway

●Laryngeal diphtheria

●Acute angioneurotic edema

Case #1 - Croup Etiology (Laryngotracheobronchitis)- Parainfluenza Virus

- (1,2,3)- RSV- Adenovirus

Case #1 - SeverityScoring System - Westley Croup Score

●Level of consciousness: Normal, including sleep = 0; disoriented

= 5

●Cyanosis: None = 0; with agitation = 4; at rest = 5

●Stridor: None = 0; with agitation = 1; at rest = 2

●Air entry: Normal = 0; decreased = 1; markedly decreased = 2

●Retractions: None = 0; mild = 1; moderate = 2; severe = 3

Mild ≤2, Mod 3-7, High ≥8

Our 22 month old = 4 or 5

Back to Case #1Summary so far:1/7 hx fever, barking cough, stridortachypnea and stridor on examlooks like he is tiring

Croup - treatmentFast: Racemic Epinephrine neb

(Beware rebound after ~2 hours)Slow: PO/IV steroid

(Make sure they dont puke it up)if receiving multiple nebs - consider admission

Croup - Investigations?CXR - only if abnormal tx response/?other causeLabs - very rarely needed.

CXR Steeple Sign -->

← Subglottic Narrowing

SequelaePneumoniaRepeated Symptoms (5%)Hypoxia/Respiratory Failure

Croup - SummaryStridor + barking cough = croup

(most likely)If stridor at rest - likely needs treatment

= Epi Neb (x1) and PO Steroid (one dose)No need for Labs/XR if patient responds to tx

References● http://emedicine.medscape.com/article/962972-clinical● http://www.uptodate.com/contents/croup-clinical-features-evaluation-and-diagnosis

?source=search_result&search=croup&selectedTitle=2~58● http://www.sickkids.ca/Nursing/Education-and-learning/Nursing-Student-Orientatio

n/module-two-clinical-care/vitals/● http://emedicine.medscape.com/article/763612-overview#a4● Toronto Notes 2014● CHEO Croup e-learning module