Another night shift in the emergency department and you are 25 minutes into the history of a patient with 17 chief complaints when your phone rings. “You are needed in resus 3”. Initially, it feels good to be called away for a ‘real emergency’. However, when you lay eyes on the little girl, you kick yourself for that thought. Her mother says she has had a mild cough and runny nose for a few days, but tonight she developed a very harsh, barking cough and noisy breathing. Now she is barely making noise at all. The one year old in front of you is using every accessory muscle she has, breathing at least 60 times a minute, and the monitor shows an oxygen saturation of 88%.
Call for help. Although emergency physicians are the masters of emergency airways, this is not a child you want to intubate on your own. Call anaesthesia and ENT. Anaesthesia for a possible a gas induction and ENT in case a tracheostomy is required.
Try to keep the child calm. One way to make things worse is to make the child cry or scream, which can cause further airway obstruction. Allow the child to sit on a parent’s lap in whatever position seems to be the most comfortable.
The toughest decision is going to be the timing of the IV. If you upset the child too much, she could deteriorate very quickly. On the other hand, the IV not only allows you to give steroids and possibly IV epinephrine, it is essential if you are forced to intubate outside of the operating room. If reasonable (i.e. the child does not require immediate RSI), hold off until other therapies have been started. Apply EMLA to make the eventual IV less traumatic.
There are two key priorities in managing the patient with severe croup: 1) Reduce the airway edema and 2) oxygenate until the airway edema is reduced.
While my nurses get medications ready, I have a parent hold a 100% non-rebreather as close to the child’s face as they will tolerate to provide supplemental oxygen.
Reducing the airway edema
Epinephrine is the key to immediate management
- The first step is to provide nebulized epinephrine. The dose is either 5ml of standard L-epinephrine (1:1000 concentration) or 0.5ml of 2.25% racemic epinephrine. Use whichever your hospital stocks
- In the case of severe croup, I would run this nebulizer continuously, or repeat the dose frequently, as needed
- In a child this sick, I would like to use systemic epinephrine (IM or IV). However, we still have the problem of needles causing distress. If an IV is in place, I would use IV epinephrine. My preference is a controlled drip (starting at 0.2mcg/kg/min), but that usually takes too long to set up. To start, I use push dose epinephrine 0.2-0.5mcg/kg (2-5mcg in a 10kg child) IV every 2-3 minutes
Steroids are the key to longer term management
- The standard dose is dexamethasone 0.6mg/kg. (Studies show that 0.15mg/kg has the same effect as 0.6mg/kg, but this is not the time to become an EBM nerd)
- In most croup patients, PO is the way to go. However, in severe croup, the child is very unlikely to be able to swallow. I would use IM, or IV if available. (Again EMLA and allowing time for epinephrine to work are the keys to avoiding deterioration)
- An alternative, if no IV is available, is to put 2mg of budesonide in the same nebulizer as the epinephrine
In the case that steroids and epinephrine don’t work, or you do not have time to let them work, you are going to have to intubate. As a temporizing measure, Heliox is an option to improve laminar air flow and get oxygen to the lungs.
In an ideal world, this intubation would be done with a gas induction (to avoid the distress of starting an IV) in the OR, with ENT scrubbed and ready to perform a tracheostomy. Unfortunately, that option will not always be available. Announce to the room that this is an anticipated difficult airway. Have the most experience personnel available present at the bedside. Have all the pediatric difficult airway equipment open and ready. You will definitely need a smaller sized tube than predicted for the child’s age and weight. Make sure to have multiple options immediately available. I would also have a needle set-up ready for a potential needle cricothyroidotomy and jet ventilation.
Isolated, reversible upper airway disease is a good indication for crash ECMO if that is an option to you (it isn’t for me) and you are unable to secure the airway.
Often, the case will not be as clear cut as the one presented. A foreign body should present with a much more sudden onset and without infectious symptoms, but kids are always snotty and the presentation of foreign body is not always sudden. Epiglottitis and bacterial tracheitis generally have toxic appearing children – but by the time they aren’t moving air, it will be difficult to be sure. Luckily, you won’t get too far off base if you are treating the wrong diagnosis. All of these conditions can benefit from medications to decrease airway edema and experts for definitive airway control.
Other FOAMed Resources
Gunn JD, III. Chapter 119. Stridor and Drooling. In: Tintinalli JE et al. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381591
Cukor J and Manno M. Chapter 168. Pediatric Respiratory Emergencies. In: Marx JA et al. eds. Rosen’s Emergency Medicine, 8e. Philadelphia: Elsevier Saunders; 2014.
Vissers RJ. Chapter 29. Pediatric Airway Management. In: Tintinalli JE et al. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381491
D’Agostino J. Pediatric airway nightmares. Emerg Med Clin North Am. 2010;28:(1)119-26. PMID: 19945602
Pfleger A, Eber E. Management of acute severe upper airway obstruction in children. Paediatr Respir Rev. 2013;14:(2)70-7. PMID: 23598067
Schuh, S. Croup. In: Lalani, L and Schneeweiss, S, eds. The Hospital for Sick Children Handbook of Pediatric Emergency Medicine. Mississauga, ON: Jones and Bartlett; 2007.
Morgenstern, J. Management of severe croup, First10EM, June 10, 2015. Available at: