Prehospital treatment for croup

DrParasite

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Yesterday, my son experienced a croup attack. Woke up from his nap screaming, crying, barking, etc, because he was having trouble breathing. With this not being his first bout (he's been in the ER at least 3 times for it, usually at 11pm), since it was 4pm, we took him to the pediatrician's office (to save on the ER bill).

long story short, they gave him 10 ML of Dexamethasone IM (which is exactly what he was given in the ER), which resulted decreased his work of breathing, resolved the barking, and made him feel a lot better. The only other thing they gave in the ER during his first croup attack was Racemic Epinephrine, after which he was admitted to the peds unit for observation.

Anyways, the reason I posted this to ask what is the prehospital treatment for a croup attack? not the home remedies, what can be done. We don't have many upper airway fixes, as the albuterol/atrovent/solumedrol is for asthma and lower airway issues.

So if someone calls 911, and you show up to find a 2 year old labored and barking like a seal, and your 45 min from the nearest ER, what's your treatment plan?
 

mgr22

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The last place I worked, it would have been nebulized epi -- not the racemic isomer, the other one, 1:1000.
 

DesertMedic66

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Going to depend on what you have available. Usually the treatment is keeping a calm environment and transport. You can consider doing nebulized water/NS. Aside from that the treatments you listed that were given in the ED are the prehospital treatments if you carry those medications.
 

DrParasite

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that was kind of my question.... does anyone carry Dexamethasone with the ability to administer it IM? Does anyone has a protocol they would be willing to share the allowed the administration of nebulized epi for croup?

Can you explain the mechanism behind how Nebulized water / NS would help the patient?
 

GMCmedic

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that was kind of my question.... does anyone carry Dexamethasone with the ability to administer it IM? Does anyone has a protocol they would be willing to share the allowed the administration of nebulized epi for croup?

Can you explain the mechanism behind how Nebulized water / NS would help the patient?
My previous job we gave IV dexamethasone orally.

Ive been told it has a fruity taste, most kids disagreed but took it without much issue. The reasoning behind the oral route is we've found medics are hesitant to poke kids, the earlier administration resuled in shorter hospital stays and lower admission rates.

We also carried racemic epi. I only ever gave it once. We carry both at my current job.
 

DesertMedic66

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that was kind of my question.... does anyone carry Dexamethasone with the ability to administer it IM? Does anyone has a protocol they would be willing to share the allowed the administration of nebulized epi for croup?

Can you explain the mechanism behind how Nebulized water / NS would help the patient?
15D016B5-325B-47DB-AC10-4345992A2D63.jpeg

The thought behind the nebulized NS/water is that it helps to add moisture into the airway making it a little more comfortable. One of the home treatments for croup is to go into the bathroom, shut the door, turn the shower on hot, and let the warm humidified air help sooth the throat. It somewhat replicates that.
 

FiremanMike

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It's interesting that you're seeing such quick results with decadron.. I've always been told the onset of action was ~1 hour and I don't know that I've ever personally seen it work in front of me..

For us, croup gets racemic and a trip to the hospital, but honestly the cool outside air during croup season usually does the trick..
 

Tigger

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Dex is a commonly carried prehospital steroid and could also be given PO. If you only had Solu-medrol that would be an option too though a couple of studies don't show it to be as effective.

We carry racemic epi at my of my places, those that don't do 0.5mg/kg of 1:1 Epi nebulized. Racemic is much easier to give logistically speaking as it's already mixed. For less severe cases I'll try cool air before giving racemic as its a nearly guaranteed admission at our local facilities. But if it's the scenario presented, racemic neb followed by saline. I have not had to ever repeat a racemic/epi treatment though we are able to.
 

DrParasite

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Unfortunately, yesterday was a hot and humid day in NC (90 degree day with 80% humidity), so the cool air was not an option. Our ambulances carry solu-medrol, but no dex and can give nebulized epi 1:1000 (1 mg in 2 ml NS) for stridor (as well as a 5mg albuterol treatment, which doesn't make sense to me since it's not a lower airway issue), followed by 2 mg of solumedrol if conditions worsen.

and @FiremanMike, in my anecdotal experience, the decadron starts working (once my son stops crying hysterically from one 5ML IM injection in each thigh) in 20-30 minutes, with the symptoms 90% resolved by the 1 hour mark.
 

Peak

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The current standard would be racemic epi if the patient has stridor at rest. Dex if indicated, not all kids who present will require it.

Dex should be given either PO or IV, IM administration has longer onset and causes the child to scream more worsening the edema present. Onset for IV or PO is about 5 minutes, however it acts more to prevent further swelling than reduce the current swelling hence the long time to see improvement.

If the kid is in respiratory failure you can bag in racemic if you have an inline neb setup. These are always nightmare intubations, so whatever you can do to avoid that until you get to a children's hospital is the key.

There is a study regarding giving budesonide in lieu of an oral steroid but it is more expensive and no more effective.

Saline mist does not provide any benefit, and often just angers the child. The same goes for steam showers, an old wives tale that doesn't have supporting evidence.

Motrin and tylenol also have a place in care for fever control and pain management. We generally prefer motrin for most kids for the anti-inflammatory aspect, although relative to steroids and epinephrine the benefit is minimal.

My previous job we gave IV dexamethasone orally.

Ive been told it has a fruity taste, most kids disagreed but took it without much issue.
Dex tastes awful. IV solution is better than crushed pills or PO elixir, but nasty none the less. We either mix ours with some apple juice or koolaid powder, but it still isn't great. If you are giving APAP or motrin I find this conceals the flavor better than most things.
 

DrParasite

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The current standard would be racemic epi if the patient has stridor at rest. Dex if indicated, not all kids who present will require it.
can you cite a source that you are basing that information on? my son received dex 3 times in the ER for croup, and only the first time did he get epi.
Dex should be given either PO or IV, IM administration has longer onset and causes the child to scream more worsening the edema present. Onset for IV or PO is about 5 minutes, however it acts more to prevent further swelling than reduce the current swelling hence the long time to see improvement.
again, going solely based on my experiences, giving any medication PO when my son is having a croup attack doesn't work, because he fights us whenever we do anything. so if we try to squirt the medication it his mouth, he spits it out. So if I squirt 5mg of dex in his mouth, he might swallow 1 or 2 mg of it; the rest ends up on his face, down his chin, on his shirt, etc.

from a practical standpoint, I understand IV is better and more effective, but the kid will scream when you stick the IV in, and is generally not in a great mood when he can't breath, and has strangers are now trying to assess and treat the toddler. At least with the IM, once it's in, it's in, even if it does have a longer onset.
Saline mist does not provide any benefit, and often just angers the child. The same goes for steam showers, an old wives tale that doesn't have supporting evidence.
That's what i thought too, but there are still plenty of medical professionals (nurses, paramedics, and doctors) who are continuing to tell patients these oldwives tales.
 

Peak

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can you cite a source that you are basing that information on? my son received dex 3 times in the ER for croup, and only the first time did he get epi.
Racemic epi (or 1:1000 L-epi if racemic is not available) is only indicated if the patient had stridor at rest. A barking cough or stridor after crying that quickly resolved at rest does not require epi. The majority of patients who present with croup will not need epi.

This is reflected in several recommendations including uptodate, our hospital's ED croup pathway, the CHOP pathway, and the ACEP recommendations.


again, going solely based on my experiences, giving any medication PO when my son is having a croup attack doesn't work, because he fights us whenever we do anything. so if we try to squirt the medication it his mouth, he spits it out. So if I squirt 5mg of dex in his mouth, he might swallow 1 or 2 mg of it; the rest ends up on his face, down his chin, on his shirt, etc.

from a practical standpoint, I understand IV is better and more effective, but the kid will scream when you stick the IV in, and is generally not in a great mood when he can't breath, and has strangers are now trying to assess and treat the toddler. At least with the IM, once it's in, it's in, even if it does have a longer onset.
I think that somewhat this is a matter of pediatric experience. I don't like using the old school pediatric nurse tricks (because most if them are not very nice) but there are ways to get kids to take PO meds, willing or not.

Most kids will take PO meds, it's just a matter of knowing how to give them. This isn't easy and is something that many general ED nurses and docs struggle with, but it certainly isn't impossible.

Also depending on the literature you look at an effective dose is as little as 0.15 mg/kg, so if we are dosing at 0.6 mg/kg and they get the majority of the drug they should still be getting an effective dose. By using IV solution of either 4mg/ml or 10mg/mg orally we also stand a much better chance than giving 1mg/ml elixir.
 

mgr22

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Saline mist does not provide any benefit, and often just angers the child. The same goes for steam showers, an old wives tale that doesn't have supporting evidence.
/QUOTE]

I'm not sure about saline specifically, but humidified air or O2 is listed among prehospital interventions for croup in the first three textbooks I pulled from my shelf: Mosby's Paramedic Text, 2nd Edition, p.1214; EMT Prehospital Care by Henry & Stapleton, 4th Edition, p.615; PALS 2016, p.133. The only anecdotal feedback I can add is that nebulized saline provided partial relief from upper airway irritation to several adult vocalists whom I treated within the last 10 years -- far from conclusive re croup in kids, but perhaps related.
 

Peak

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I'm not sure about saline specifically, but humidified air or O2 is listed among prehospital interventions for croup in the first three textbooks I pulled from my shelf: Mosby's Paramedic Text, 2nd Edition, p.1214; EMT Prehospital Care by Henry & Stapleton, 4th Edition, p.615; PALS 2016, p.133. The only anecdotal feedback I can add is that nebulized saline provided partial relief from upper airway irritation to several adult vocalists whom I treated within the last 10 years -- far from conclusive re croup in kids, but perhaps related.

A randomized controlled trial of mist in the acute treatment of moderate croup.

Neto GM, Kentab O, Klassen TP, Osmond MH

Acad Emerg Med. 2002;9(9):873.

OBJECTIVE: To determine whether the use of mist improves clinical symptoms in children presenting to the emergency department (ED) with moderate croup.
METHODS: Children 3 months to 6 years of age were eligible for the study if they presented to the ED with moderate croup. Moderate croup was defined as a croup score of 2-7. The patients were randomly assigned to receive either mist (humidified oxygen) via mist stick or no mist. The patients had croup scores measured at baseline and every 30 minutes for up to two hours. At these intervals the following parameters were also measured: heart rate, respiratory rate, oxygen saturation, and patient comfort score. The patients were treated until the croup score was less than 2 or until two hours had elapsed. All patients initially received a dose of oral dexamethasone (0.6 mg/kg). Other treatments, such as racemic epinephrine or inhaled budesonide, were given at the discretion of the treating physician. The research assistants were unaware of the assigned treatments.
RESULTS: There were 71 patients enrolled in the study; 35 received mist and 36 received no mist. The two treatment groups had similar characteristics at baseline. The median baseline croup score was 4 in both groups. The outcomes were measured as the change from baseline at 30, 60, 90, and 120 minutes. The change in the croup score from baseline in the mist group was not statistically different from the croup score change in the group that did not receive mist (p = 0.39). There was also no significant difference in improvement of oxygen saturation, heart rate, or respiratory rate at any of the assessment times. There was no adverse effect from the mist therapy.
CONCLUSIONS: Mist therapy is not effective in improving clinical symptoms in children presenting to the ED with moderate croup.

Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada. neto@cheo.on.ca
PMID 12208675


Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial.

Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S

JAMA. 2006;295(11):1274.

CONTEXT: Children with croup are often treated with humidity even though this is not scientifically based, consumes time, and can be harmful. Although humidity using the traditional blow-by technique is similar to room air and no water droplets reach the nasopharynx, particles sized for laryngeal deposition (5-10 microm) could be beneficial.
OBJECTIVE: To determine whether a significant difference in the clinical Westley croup score exists in children with moderate to severe croup who were admitted to the emergency department and who received either 100% humidity or 40% humidity via nebulizer or blow-by humidity.
DESIGN AND SETTING: A randomized, single-blind, controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department.
PARTICIPANTS: A convenience sample of 140 previously healthy children 3 months to 10 years of age with Westley croup score of more than 1 or 2 or higher (scoring system range, 0-17); 21 families refused participation.
INTERVENTION: Thirty-minute administration of humidity using traditional blow-by technique (commonly used placebo, n = 48), controlled delivery of 40% humidity (optimally delivered placebo, n = 46), or 100% humidity (n = 46) with water particles of mass median diameter 6.21 microm.
MAIN OUTCOME MEASURE: A priori defined change in the Westley croup score from baseline to 30 and 60 minutes in the 3 groups.
RESULTS: Groups were comparable before treatment. At 30 minutes the difference in the improvement in the croup score between the blow-by and low-humidity groups was 0.03 (95% confidence interval [CI], -0.72 to 0.66), between low- and high-humidity groups, 0.16 (95% CI, -0.86 to 0.53), and between blow-by and high-humidity groups, 0.19 (95% CI, -0.87 to 0.49). Results were similar at 60 minutes. Differences between groups in pulse and respiratory rates and oxygen saturation changes were insignificant, as were proportions of excellent responders; proportions with croup score of 0 at study conclusion; and proportions receiving dexamethasone, epinephrine, or requiring additional medical care or hospitalization.
CONCLUSIONS: One hundred percent humidity with particles specifically sized to deposit in the larynx failed to result in greater improvement than 40% humidity or humidity by blow-by technique. This study does not support the use of humidity for moderate croup for patients treated in the emergency department.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00230841.

Division of Pediatric Emergency Medicine, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario. dennis.scolnik@sickkids.ca
PMID 16537737
 

Bullets

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3mg Epi 1:1000 nebulized twice and 0.6mg decadron
 
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