A 2-year-old boy presented to the emergency department with a barky cough, retractions, and stridor after a couple days of upper respiratory infection and fever. On examination he had retractions, barky cough, and stridor but did not appear toxic. The most likely diagnosis was laryngotracheobronchitis (croup). He was treated with nebulized racemic epinephrine, which resolved his stridor, and oral dexamethasone. After 2 hours of observation with improved symptoms, he was discharged home with instructions to return if symptoms recurred and advice on fever management and sleep positioning.

1. CASE
PRESENTATION
DR. ASIF IQBAL

2. HISTORY
 he is 2 years old. His parents bring him to your ED with a history of
“barky” cough. He has had an antecedent upper respiratory
infection for a couple of days with a runny nose and a temperature
of 38.2°C. On arrival in the ED, he has retractions, a “barky” cough,
and stridor but does not look toxic. He also has vomiting after
episodes of coughing.

3. PHYSICAL EXAMINATION
 Pulse-
 Temp-
 Rr-
 Spo2 at presentation-
 Cvs exam-nad
 Cns exam-alert ,conscious
 Res system-

4. DIFFERENTIAL
DIAGNOSIS
 The MOST LIKELY diagnosis in this child
is: A) Epiglottitis. B)
Laryngotracheobronchitis. C) Bacterial
tracheitis. D) Retropharyngeal abscess. E)
Gastroenteritis.

5. SO WHAT IS THE DX AMONG THEM?
The correct answer is B. This represents laryngotracheobronchitis (aka croup).
Typically, patients have an antecedent URI with a low-grade fever, a barky
cough, and stridor, which are usually worse at night. Answer A is incorrect
because patients with epiglottitis generally do not have an antecedent URI, but
they do have a much higher temperature with sudden onset of symptoms and a
toxic appearance. Answer C is incorrect. Patients with bacterial tracheitis do have
an antecedent URI but then develop a second stage of the illness (eg, a biphasic
illness) with sudden onset of high fever, purulent sputum production, and
stridor. These patients look toxic. Answer D is incorrect. A retropharyngeal
abscess occurs in conjunction with high fever, drooling, refusal to swallow, and
toxic appearance. Answer E is incorrect. This child has posttussive emesis.
Gastroenteritis does not include the other features found in this child with
croup.

6.  I decided to treat this patient in the ED.
 All of the following are appropriate treatments EXCEPT:
 A) Racemic epinephrine. B) Antibiotics. . C) Dexamethasone 0.6
mg/kg IM. D) Humidified oxygen.

7.  The correct answer is B. One would not want to use antibiotics in
this patient. This is a viral illness, usually parainfluenza virus. All the
other answers are appropriate treatments. Of particular note is
answer * I give the patient nebulized epinephrine, and his stridor
resolves. I now need to decide what to do with this patient.

8.  I told the parents that since the child had nebulized
epinephrine: He must be observed for 2 hours in the ED to make
sure his symptoms do not recur.
 Admission after nebulized epinephrine was the rule. The thinking
about this has changed.
 Now, 2-hour observation is considered sufficient. There is no
“rebound effect.” The patient may return to his pretreatment state
but will not get worse as the result of the epinephrine treatment.

9.  I decided not to do a radiograph of this child’s neck to aid in the
diagnosis (as this is not necessary nor advocated in most cases)
 But if you want to do—which sign will u expect-on cervical
radiograph?
 A) Thumb sign. B) Sign of Lesser-Trélat. C) Spine sign. D)
Retropharyngeal space swelling. E) Steeple sign.

10.  The correct answer is E. Radiographs in croup show the “steeple
sign” which is a subglottic narrowing of the trachea from edema,
giving it a steeple-like appearance. The thumb sign (answer A), is
seen in epiglottitis. The sign of Lesser-Trélat (answer B) is the
sudden development of numerous seborrheic keratoses in a
patient with internal malignancy—it is rare, not seen in children,
and nearly useless knowledge. The spine sign (answer C) is loss of
progressive radiolucency of the spine on lateral chest radiograph.
This is seen when something is overlaying the lower thoracic spine
making it appear more dense, classically an infiltrate indicative of
pneumonia. Retropharyngeal space swelling (answer D) is seen in
retropharyngeal abscess.

11.  The patient is breathing a little easier after the nebulized
epinephrine and has received acetaminophen for his fever. He is
drinking a little and does not appear significantly dehydrated.

12.  Which of the following is the MOST appropriate treatment for this
patient? A) Prednisone 1 mg/kg PO once. B) Prednisone 2 mg/kg
PO followed by a taper. C) Dexamethasone 0.2 mg/kg IV once. D)
Dexamethasone 0.6 mg/kg PO once. E) Dexamethasone 5 mg/kg
IM once.

13.  The correct answer is D. The most appropriate treatment is
dexamethasone 0.6 mg/kg with a maximum dose of 10 mg.
Dexamethasone is chosen because of its relatively long half-life
that allows it to remain active during the duration of the illness
(about 3 days). The least invasive route is recommended, and oral
dexamethasone is appropriate in patients tolerating PO intake. The
other answer choices are not appropriate for treating croup.

14.  HELPFUL TIP: 0.3 mg/kg and 0.15 mg/kg of dexamethasone are as
effective as 0.6 mg/kg. For some reason, the authors cannot make
the leap to 0.15 mg/kg, so we use 0.3 mg/kg.

15.  I treated the child as noted above with epinephrine and
dexamethasone. His oxygen saturation improves to 96% on room
air. His stridor and retractions are resolved.

16.  Pt was given antipyretics paracetamol for fever,encouraged oral
intake,advised family members to avoid smoking at home.advised
to keep child head elevated (propped up in bed with an extra
pillow) and parents asked to stay in close proximity at night
time.and to bring hospital if symptoms recurrs.

17. WHY DISCHARGE ?
 Discharge or Admission criteria:
 • Discharge to home o No stridor at rest o Minimal or no retractions o Pulse ox ≥ 93% on RA o
Tolerating PO intake o Reliable caretaker, able to return if necessary o Required 0 or 1 racemic epi neb in
ED o If received racemic epi, observe for at least 2 hours prior to discharge
 • Admit to inpatient floor o Recurrence of stridor within 2 hour observation period, requiring second
dose of racemic epi o Ongoing stridor at rest or other distress not improving with racemic epi o Poor PO
intake/dehydration o Concerns about caretaker’s ability to assess situation or return if needed o Strongly
consider in age < 6 months
 Admit to PICU o Severe croup poorly responsive to racemic epi o Worsening condition despite epi and
dexamethasone o Use of heliox o Signs of impending respiratory failure, including declining
consciousness, severe distress, desaturation

18.  The usual dose in infants weighing 10 kg is 5 mg, which may be given as 5 mL of 1:1000 solution of l-
epinephrine or as 0.5 mL of 2.25% solution (22.5 mg/mL) ofracemic epinephrine solution, which
contains 5 mg of l-isomer. The latter is diluted with isotonic saline to a 3- to 5-mL volume.
 What is the difference between racemic epinephrine and epinephrine?
 RACEMIC OR L-EPINEPHRINE FOR CROUP. Aerosolized racemic epinephrine, composed of equal
amounts of the D- and L-isomers of epinephrine, is effective in treating croup. ... Both forms
of epinephrine caused significant transient improvement in the children, with no significant difference
between the groups over time.
 Dosage of epi—1:1000: 0.5 ml/kg maximum dosage 5 ml via nebuliser
 Onset upto 30 minutes duration 2 hours

19.  Thank you for hearing