# Severe Croup



## MrBrown (Dec 22, 2009)

You're sent to a childcare centre for a kid who is in extremis with known history of lfe threatning severe croup.


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## rhan101277 (Dec 22, 2009)

Ok, what is your general impression when you walk in?  Also a good set of vitals signs and any history you can elicit from the childcare center workers.


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## MrBrown (Dec 22, 2009)

Kid is in extremis, extremely short of breath with a variable barking horrace cough; very lethargic, cyanosed and marked increase of breathing.

The childcare centre staff state "I don't know, it just happened" 

BP 150/100
RR 45
PR 160
SPO2 89% RA


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## Melclin (Dec 22, 2009)

Bp 150? s**t...how old is this kid?

Any drooling?

Any history of being unwell lately?

Temp?

Expiratory effort/sounds on inspiration vs expiration?

Obviously I'm heading down the croup pathway from your heading and the barking cough. But I'd like to quickly 'rule out' epiglottis with the above information then have a quick look in his gob to make sure (as best I can, I can hardly scope him) he hasn't swallowed Sergeant Pepperpants (but I don't want to go poking around if he has epiglot). If croup still stands, I hit the kid up with 5mg nebulised adrenaline and some diesel.


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## MrBrown (Dec 22, 2009)

LMFAOOO @ Sergeant Pepperpants

No drooling 
No immeadiate hx of being unwell, does have prior hx of life threatning, severe croup
Finger sweep nil
High pitched seal like cough and stridor upon insp wheeze upon exp with poor air entry in all lobes

5mg of adrenaline nebules has no effect

Transport time to the nearest facility is 20 minutes, ALS are coming and can reach you in about 6 minutes.  Would you like to transport or do you want to try another hit of adrenaline and wait for ALS ..... or something else?


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## Melclin (Dec 22, 2009)

I would already be transporting once I decided on the adrenaline. 

Rendezvous with ALS sounds best, although in practice I hear that can be a pain in the arse. Short of any obvious meeting spot like the old town well. I don't really want to wait for them, because I'm not sure there's much they can do. I don't know that they are going to be intubating this patient, or even if they can, and there aren't any drugs they have approved under guidelines for croup that we don't have but there might be something that they do that isn't in the book. At least it would be good to have a consult from a more experienced medic. I say head for the hospital, with another 5mg en route. 

I think I heard something about IM adrenaline working a treat for severe croup, but I don't know much about it, so I wouldn't be going down that path.

The only other thing I can think of is to monitor the patient closely so that you can identify when the tidal volume becomes too low and start ventilating.


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## Scott33 (Dec 22, 2009)

MrBrown said:


> The childcare centre staff state "I don't know, it just happened"



Sounds like he could also have a foreign body in his airway. 

Either way, airway, breathing and diesel are the management of choice. Position of comfort, O2, rapid transport, and prepare for the possibility of resuscitation. I wouldn't wait for ALS but if your paths cross, all the better.

As much history as you can get on the way.


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## rhan101277 (Dec 22, 2009)

I would view the airway with direct laryngoscopy, if obstruction is present I would remove it with magill forceps.  This kid is de-sating fast 89% isn't good and putting him on 02 may help some, but it won't increase the amount of air he can move.  If I don't see any obvious obstruction this kid is getting intubated.  His airway has to be managed, and what if he goes down hill, then you are stuck worrying about aspiration and trying to handle stuff in the back of the truck.

Between obstruction removal attempts and intubation attempts I will hyperventilate with BVM 100% oxygen for 30 seconds then re-try.


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## MrBrown (Dec 22, 2009)

Good, good you guys are on the right track here.

This is a real job a guy I know went to, got sent out as a "severe croup with known history" and all the teacher kept saying was "he has a history of severe croup".

Crew gets sucked in and didn't think you know in the five minutes that this kid with no recent history of being sick was left alone that he could have swallowed something.

He infact DID swallow something and by the time ALS got there, the kid had arrested and he ended up dying.

When he put it to us you know, I didn't think "oh this kid has gobbled up some Lego" but now in retrospect its like wow, you know, in the FIVE minutes this otherwise healthy kid was left alone, what are the chances of him *snap* devloping life threatning severe croup? None.


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## 18G (Dec 23, 2009)

Great post!


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## WTEngel (Dec 23, 2009)

In general a presentation of sudden onset of stridorous breathing during the day when the child has not been asleep with no history of fever or other illness in the past few days makes me inclined to not look at croup as my first working diagnosis. I am not saying it doesn't happen, it is not on my list of top offenders.

Typical croup presentation is usually 2 hours or so after the child goes to bed for the night after one to two days of fever and _MILD_ breathing difficulty. Think general cold, flu, upper respiratory symptoms... This is why the parents do not usually bring these kids in during the day. If you have seen much croup, you know that many times if you leave the child alone as much as possible, allow them to calm down, the work of breathing will decrease. Also, that little ride on the stretcher between the house and the ambulance in the cold night air does wonders to ease those inflamed airways...

 Bottom line is stridor is not always croup, as most of you alluded to earlier. As far as direct laryngoscopy, finger sweeping, IV's and other forms of agitation, bad ideas unless ABSOLUTELY necessary. The agitation caused by these techniques will usually lead to you having to take much more drastic measures. Also, direct laryngoscopy on an already inflamed airway in a small child will cause further airway swelling and potentially vagal the child down, and next thing you know you are doing chest compressions...I have seen it before (medical residents, never a dull moment!)!

Foreign bodies are best left alone unless absolutely unavoidable, and keeping the child calm is key. Just like in BLS with a choking patient, unless the airway becomes completely obstructed, you do not typically take action. Cool humidified oxygen will usually help the cyanosis and ease the throat pain. 

Lastly, if treating croup with racemic epi, be careful when spacing your treatments. Usually one treatment, and if no improvement after 30 minutes another. Racemic epi is pretty hard on the heart, and there have been studies that show pediatric MIs are a potential side effect of aggressive use of racemic and SQ epinephrine.

Great scenario...croupers will scare the crap out of people who are not used to seeing it. Work in a children's hospital ER for one winter, and you hardly notice the seal bark anymore...


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## Melclin (Dec 23, 2009)

WTEngel said:


> In general a presentation of sudden onset of stridorous breathing during the day when the child has not been asleep with no history of fever or other illness in the past few days makes me inclined to not look at croup as my first working diagnosis. I am not saying it doesn't happen, it is not on my list of top offenders.
> 
> Typical croup presentation is usually 2 hours or so after the child goes to bed for the night after one to two days of fever and _MILD_ breathing difficulty. Think general cold, flu, upper respiratory symptoms... This is why the parents do not usually bring these kids in during the day. If you have seen much croup, you know that many times if you leave the child alone as much as possible, allow them to calm down, the work of breathing will decrease. Also, that little ride on the stretcher between the house and the ambulance in the cold night air does wonders to ease those inflamed airways...
> 
> ...



So without investigating the airway would you proceed on the assumption of foreign body inhalation on the lack of positive history for croup alone? 

Brown, how was the tidal volume? Do you reckon the kid could have survived on sup O2? It sounds like that's what was done, but the pts condition worsened. In that case WTEngel, do you think this kid might have been a candidate for airway inspection on scene?


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## WTEngel (Dec 23, 2009)

Using a laryngoscope to inspect the airway of a conscious child is a bad idea, regardless of whether it is croup, FBO, or whatever. You run the risk of increasing swelling and edema, aspiration, increasing vagal tone, the list goes on. In addition to that, unless the parent can tell you what they swallowed (in this case we aren't sure if anything was swallowed at all) you don't know what you are dealing with. It could be a marble (nearly impossible to retrieve as they are slippery and hard to grab) it could be a safety pin or other sharp impaled object, you just don't know. The only way I would stick a laryngoscope in this kids mouth is if it was in an attempt to intubate, and if at that time I saw a foreign body, I would remove it.

A child with sats of 89% and not on supplemental o2, I would not describe as in extremis. Apply supplemental o2 and see where the sats go... I am predicting up... Also, the blood pressure of 150/100, I am not buying, probably too small or too big of a cuff, poor technique, etc. I am telling you, I have worked with kids long enough to know...

If the first racemic did absolutely nothing, then my money is not on croup, that is just my opinion based on experience in the field. However, that is taking into account that my mental image of this child may be very different than yours...If the diagnosis if croup still lingered in my head, I would consider another racemic 30 minutes after the first. 

If supplemental 02 can keep the sats above 92 then I am happy to transport the child without further agitation. However, being the prepared individual that I typically find myself to be, the airway roll and EZ IO drill would not be far from reach, along with some magils, just in case the child decides to make that partial obstruction, a full obstruction... 

Even in the emergency room you will see that most physicians will attempt to stabilize the child and keep the sats at 92% or greater, and get the kid a surgical consult. This is of course, if x ray findings do in fact support a foreign body obstruction. There is a narrow set of guidelines that can be met to cause a physician to remove the FBO in the ER, based on location, size, and patient condition.

The fact of the matter is that further agitation and constant poking, prodding, etc might have caused this kiddo to fully obstruct the airway.

In regards to meeting ALS, absolutely I say do it. The kid needs a provider who is prepared to do advanced airway maneuvers should it become necessary.

I hate to Monday morning QB these situations, but it is how we learn. As always, my opinion is based on the mental image that I have of this kid, and your mental image may be different...


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## MrBrown (Dec 23, 2009)

From what I understand TV was pretty minimal, by the time ALS got there the kid has resp arrested coz he was totally obstructed on a couple of legos.

Just the thought of a job like this scares the absolute crap out of me; kids are small, get really sick really quick and they aren't able to tell you what is wrong so it's kind of like doing a jigsaw blindfolded.


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## Scott33 (Dec 23, 2009)

It is said that a common mistake among medical students when reading a chest x-ray, is to stop looking when they have found what they are suspecting. That is why x-rays should be approached with the same systematic approach every time, regardless of what is found. The common mistake in this scenario was to stop looking. A history of croup means...a history of croup. A more recent history of the events leading up to the present condition is often more pertinent, and would have yielded more useful information.

Good scenario!


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## Melclin (Dec 23, 2009)

WTEngel said:


> Using a laryngoscope to inspect the airway of a conscious child is a bad idea, regardless of whether it is croup, FBO, or whatever. You run the risk of increasing swelling and edema, aspiration, increasing vagal tone, the list goes on. In addition to that, unless the parent can tell you what they swallowed (in this case we aren't sure if anything was swallowed at all) you don't know what you are dealing with. It could be a marble (nearly impossible to retrieve as they are slippery and hard to grab) it could be a safety pin or other sharp impaled object, you just don't know. The only way I would stick a laryngoscope in this kids mouth is if it was in an attempt to intubate, and if at that time I saw a foreign body, I would remove it.
> 
> A child with sats of 89% and not on supplemental o2, I would not describe as in extremis. Apply supplemental o2 and see where the sats go... I am predicting up... Also, the blood pressure of 150/100, I am not buying, probably too small or too big of a cuff, poor technique, etc. I am telling you, I have worked with kids long enough to know...
> 
> ...



I love these kinds of threads. Cheers Brown.


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## Omaha (Jan 2, 2010)

Some very educational replies.  So from what I understand from the conventional wisdom of the post is to visualize the airway, if you see the obstruction try to remove it, if not then leave it be (with no deterioration) unless partial becomes a complete airway obstruction (deterioration), in which you place the appropriate airway adjunct per level of care?

I appreciate this post as my one year old daughter continues to explore the world through her taste buds.  Everything straight to the mouth. 

I'm afraid she may be _that kid that eats poop LOL. Already had two scares with her choking._


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## MrBrown (Jan 4, 2010)

Omaha said:


> Some very educational replies.  So from what I understand from the conventional wisdom of the post is to visualize the airway, if you see the obstruction try to remove it, if not then leave it be (with no deterioration) unless partial becomes a complete airway obstruction (deterioration), in which you place the appropriate airway adjunct per level of care?
> 
> I appreciate this post as my one year old daughter continues to explore the world through her taste buds.  Everything straight to the mouth.
> 
> I'm afraid she may be _that kid_ that eats poop LOL. Already had two scares with her choking.



The objective here was to teach that we must make our own independant diagonses and think critically.

Croup is often preceeded by several days of a child being sick/febrile and having a loud barking cough.  It it not something that has a sudden, acute onset like asthma or chest pain.

So let us consider that we go to this kiddy who has had no history of being unwell, was well enough to go to play centre, is afebrile and has no other symptoms of croup except trouble breating.

What are the chances in the five minutes this kid was left alone while the teacher whipped out back for a smoke or to text her boyfriend or go for a piss that this kid developed severe, life threatning croup? None! 

Everybody gets sucked in and starts spinning off the planet oh lets do this lets do laryngascopy lets do that lets give em midaz and knock em out so we can intubate how about this or that .... how about we try a couple chest thrusts or a back blow or two?


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## Aidey (Jan 4, 2010)

I have to admit that in this kid FBAO was my primary DD over croup, specifically because of the sudden onset. Granted, the daycare worker may have been busy and not have noticed the kid being sick, or is trying to cover her butt because she noticed and brushed it off.


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## Melclin (Jan 4, 2010)

Well yes, I think it was my first thought too.



Melclin said:


> ...then have a quick look in his gob to make sure (as best I can, I can hardly scope him) he hasn't swallowed Sergeant Pepperpants (but I don't want to go poking around if he has epiglot). If croup still stands, I hit the kid up with 5mg nebulised adrenaline and some diesel.



The enlightening thing about this scenario for me though was the complexity of airway management in a pt like this, that I had not really considered before. While I did think FBAO and epiglot first (simply because that's what we learn as the hierarchy of things that kill toddlers with SOB ), *I only payed lip service to the idea* and moved onto croup because I was thinking, well its obviously croup. In scenarios at uni we verbalize, "..and I'll have a look at his airway...any obstructions", without acknowledging the actual practical difficulty of how you observe an airway like this. But this scenario is good because it showed the importance of accurate event hx to identify the FBAO over necessarily observing the foreign body yourself, a good lesson in light of this business of it being a bad idea to poke around in a toddlers inflamed throat (a fact about which, I was not aware [baring in epiglot of course]). At the end of the day though, I'm glad I didn't sit around and wait for ALS, like the real crew did.

I've already written the scenario up for uni to present to classmates when we officially cover adrenaline for croup next ..._this_..year ("neeeeerdd"). I think its a brilliant scenario to point out the practical difficulties of managing an airway which are often not evident in the way we run scenarios, and a good lesson in accurate, thorough hx taking.

I think I learn more off these kinds of threads than I do at university.


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## Aidey (Jan 4, 2010)

Um...no to get off topic, but who on earth is Sergeant Pepperpants?


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## Melclin (Jan 4, 2010)

The ubiquitous airway shaped toy/object/creature that all toddlers have the uncontrollable urge to stuff down their throats.


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## Aidey (Jan 4, 2010)

Ah, so it's a methphor, not the name of some Australian version of Pee-Wee Herman wearing a military uniform.....


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