Croup: The Daily PANCE Blueprint
A 2-year-old boy has had a runny nose and low-grade fever for two days. Tonight he developed a harsh, barking cough and noisy breathing that is worse when he cries. His temperature is 100.8°F and oxygen saturation is 97%. He has inspiratory stridor at rest and mild suprasternal retractions. He is drooling-free, handles his secretions, and lies flat comfortably, and his lungs are clear. A frontal neck radiograph shows subglottic narrowing (the "steeple sign"). Which of the following is the most appropriate management?
A. Intramuscular epinephrine
B. Oral amoxicillin
C. Dexamethasone plus nebulized racemic epinephrine
D. Immediate intubation in the operating room
E. Nebulized albuterol
Answer and topic summary
The answer is C. Dexamethasone plus nebulized racemic epinephrine
A barking, seal-like cough with inspiratory stridor after a couple of days of coryza in a toddler is croup — acute laryngotracheobronchitis, usually from parainfluenza virus, which inflames the subglottic airway at the cricoid ring, the narrowest point of a young child’s airway. That is exactly what produces the “steeple sign” of subglottic narrowing on a frontal neck film. Because he has stridor at rest, this is moderate croup, and the treatment is dexamethasone plus nebulized racemic epinephrine: a single dose of dexamethasone (0.6 mg/kg, oral or IM) reduces airway edema for days and is given to every severity of croup, while racemic epinephrine works within minutes for stridor at rest and buys time — observe for 3 to 4 hours afterward for rebound. The traps are all in the differential. Epiglottitis is the one you cannot miss, and this child does not have it: he would be toxic, drooling, refusing to lie flat, sitting in the tripod position, with a muffled “hot potato” voice and no barking cough. Bacterial tracheitis looks like croup that fails to improve and then turns septic. Antibiotics treat neither croup nor its viral cause, albuterol treats lower airway bronchospasm rather than subglottic edema, IM epinephrine is for anaphylaxis, and intubation is reserved for impending respiratory failure. Mild croup with no stridor at rest goes home on dexamethasone and humidified air.
View blueprint lesson
Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Pulmonary ⇒ ⇒
