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.
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. 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.