Pediatric Croup Management (CPS 2017)

Algorithm Steps

1. ▶

   Start

   Suspected Pediatric Croup

   Child with barking cough, stridor, hoarse voice

   1. ●

      Action

      Assess Severity (Westley Score)

      Clinical assessment

      • MILD (0-2):
      • • Occasional barking cough
      • • No stridor at rest, no retractions
      • MODERATE (3-7):
      • • Frequent barking cough
      • • Stridor at rest, mild-mod retractions
      • • No agitation/distress
      • SEVERE (8-11) or >11:
      • • Stridor at rest, severe retractions
      • • Decreased air entry
      • • Agitation, lethargy, cyanosis
      1. ●

         Action

         All Patients: Dexamethasone

         Single dose corticosteroid

         • DEXAMETHASONE 0.6 mg/kg PO/IM
         • • Maximum dose: 10-16 mg (typically 10mg)
         • • Oral preferred if tolerated
         • • Single dose is effective
         • Lower dose (0.15-0.3 mg/kg) may be equally effective
         • Onset: 2-3 hours
         • Duration: 24-48 hours
         1. ✓

            Outcome

            Mild Croup

            Discharge after dexamethasone

            • Observe 30-60 min post-dexamethasone
            • Educate parents on warning signs
            • Return if stridor at rest or worsening
            • No further treatment needed
            • Humidified air NOT proven effective
         2. ●

            Action

            Moderate Croup

            Add observation, consider nebulized epi

            • Give dexamethasone (if not already)
            • Minimize disturbance (keep child calm)
            • If stridor at rest persists:
            • • Nebulized epinephrine
            • • L-epinephrine (1:1000): 0.5 mL/kg (max 5 mL)
            • • OR Racemic epinephrine 2.25%: 0.05 mL/kg (max 0.5 mL)
            • Observe 2-4 hours after epinephrine
            1. ◆

               Decision

               Status After Epinephrine?

               Observe 2-4 hours for rebound

               1. ✓

                  Outcome

                  Improved - Discharge

                  Safe for home

                  • No stridor at rest after observation
                  • Able to take fluids
                  • Parents understand warning signs
                  • Return precautions:
                  • • Stridor at rest returns
                  • • Increased work of breathing
                  • • Decreased oral intake
                  • • Fever develops (consider bacterial)
               2. ●

                  Action

                  Not Improved - Admit

                  Hospital admission

                  • Persistent stridor at rest
                  • Required multiple doses of epinephrine
                  • Hypoxia
                  • Inadequate oral intake
                  • Parental concern/reliability
                  • Consider ICU if:
                  • • Respiratory failure
                  • • Need for repeated epinephrine
                  • • Consider alternative diagnosis
         3. ⚠

            Warning

            Severe Croup

            Urgent treatment required

            • Keep child calm (on parent's lap)
            • Minimize interventions that cause distress
            • NEBULIZED EPINEPHRINE immediately
            • • L-epinephrine: 0.5 mL/kg (max 5 mL)
            • • May repeat in 15-20 min if needed
            • DEXAMETHASONE 0.6 mg/kg PO/IM
            • OXYGEN if SpO2 <92%
            • Prepare for possible intubation
            • Heliox if available and trained