Over-worried parents, or a potentially fatal pediatric illness?

When presented with a young child who does not appear particularly sick, it can be tempting to assume that the parents are just being over cautious.  Kids are tough, though, and sometimes identifying a pathology, especially early on, can require a little more legwork than in an adult patient.  Croup is a particularly dangerous childhood illness, and our little patients deserve this extra legwork.

Laryngotracheobronchitis (Croup)

One illness you absolutely can’t afford to miss in children is croup, which has the potential to become life-threatening if it is not recognized.  Croup is commonly caused by the parainfluenza virus, and children between 6 and 36 months are its usual target.

Typical signs and symptoms mimic those of an upper respiratory infection initially, later developing a characteristic seal-like barking cough.  This cough is the direct result of a constricted upper airway.  Inspiratory stridor may also be present, but in my experience, auscultation of the upper airways is usually the only way to find it.

Here is a video of one example of the tell-tale barking cough.

Note that this is only one example, and I recommend watching more videos on YouTube if you are not already familiar with the sound.

There is an obvious radiographic sign that indicates croup, known as steeple sign.  However, obtaining a chest film may not always be necessary, and if you are on an EMS unit, probably impossible.

What is scary about a child with croup, is that they may appear perfectly well upon initial observation.  They may be running around, playing, and having fun; until they display the ominous cough of a constricted airway.

The treatment for croup involves supportive care of the patient’s symptoms.   Nebulized racemic epinephrine typically causes immediate reduction in airway inflammation.   If your service does not carry racemic epinephrine (and it probably doesn’t) there is another method.   Undiluted Epi 1:1000 delivered via small volume nebulizer has been shown to work just as effectively, without adverse effects.  Whats more, is that standard L-Epinephrine has been shown to have a longer duration of action than racemic epinephrine.  As always, consult medical direction for guidance about dosing.

Steroids (particularly dexamethasone) are useful in reducing and preventing further airway constriction.  Above all, keep the child calm and comfortable.

If you would like to learn more about croup, and its treatment, check out this episode of the Ditch Doc EM Podcast: 5 Essential Steps in Managing Croup

 

References

Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Cochrane Review: Nebulized epinephrine for croup in children. Evidence-Based Child Health: A Cochrane Review Journal. 2012;7(4):1311–1354.

Croup. Background, Epidemiology. 2017 Nov 15 [accessed 2017 Dec 28]. https://emedicine.medscape.com/article/962972-overview

Diphtheria – Infectious Diseases. Merck Manuals Professional Edition. [accessed 2017 Dec 28]. https://www.merckmanuals.com/professional/infectious-diseases/gram-positive-bacilli/diphtheria

Eghbali A, Sabbagh A, Bagheri B, Taherahmadi H, Kahbazi M. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Fundamental & Clinical Pharmacology. 2015;30(1):70–75.

Hansen M, Meckler G, Lambert W, Dickinson C, Dickinson K, Guise J-M. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Childrens Safety Initiative-Emergency Medical Services. The American Journal of Emergency Medicine. 2016;34(3):599–601.

Hansen M, Meckler G, Lambert W, Dickinson C, Dickinson K, Guise J-M. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Childrens Safety Initiative-Emergency Medical Services. The American Journal of Emergency Medicine. 2016;34(3):599–601.

 

 

4 Replies to “Over-worried parents, or a potentially fatal pediatric illness?”

  1. The article states that using L-Epi is fine without adverse effects but don’t link any journal articles. Also could you explain why racemic Epi is preferred over standard epi?

    1. Hi Adam, thanks for your comment. There are several studies that evaluate the safety of L-Epi 1:1000 as a nebulized therapy, and here is a Cochrane review of some of those – https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014052/ I think that racemic epinephrine is really only preferred because that has been the standard therapy for so long now. Most studies which compare the two either find no significant difference between the two or find that L-Epi may be slightly better. This is great for EMS since L-Epi is usually carried by every level of provider. Thanks again for your comment!

      -Owen

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