What is the recommended treatment for croup in the emergency room (ER)?

Treatment of Croup in the Emergency Room

For all patients with croup presenting to the emergency room, a single dose of dexamethasone (0.15-0.60 mg/kg orally) is recommended, regardless of disease severity, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) added for moderate to severe cases. 1

Assessment of Croup Severity

The Westley Croup Score should be used to assess severity:

Parameter	0 points	1 point	2 points	3 points	4 points	5 points
Stridor	None	When agitated	At rest	-	-	-
Retractions	None	Mild	Moderate	Severe	-	-
Air entry	Normal	Decreased	Markedly decreased	-	-	-
Cyanosis	None	-	-	With agitation	At rest	-
Level of consciousness	Normal	-	-	-	-	Altered

Severity classification:

• Mild: Score 0-2
• Moderate: Score 3-5
• Severe: Score 6-11
• Impending respiratory failure: Score ≥12

Treatment Algorithm

For All Patients with Croup

• Dexamethasone 0.15-0.60 mg/kg orally as a single dose (maximum 10-12 mg) 1, 2
  • This is supported by high-quality evidence from the American Academy of Pediatrics and American Thoracic Society
  • Lower doses (0.15 mg/kg) have been shown to be as effective as higher doses (0.6 mg/kg) for moderate to severe croup 3
  • For patients unable to tolerate oral medication due to vomiting or severe respiratory distress, use intramuscular dexamethasone at the same dosage 4, 5

For Moderate to Severe Croup (Score ≥3)

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1
• Monitor for at least 2-3 hours after nebulized epinephrine administration to observe for potential rebound symptoms
• Continuous oxygen saturation monitoring is required
• Reassess croup score 15-30 minutes after initial treatment and regularly thereafter

Supportive Care

• Maintain a calm environment
• Position the child in a comfortable position (often upright or in parent's arms)
• Ensure adequate hydration
• Provide supplemental oxygen if saturation is <92%
• Closely monitor respiratory rate, work of breathing, and oxygen saturation

Admission Criteria

Consider hospital admission if any of the following are present:

• Oxygen saturation <92% or cyanosis
• Persistent significant respiratory distress after treatment
• Stridor at rest that persists after treatment
• Need for more than one dose of nebulized epinephrine
• Inability to tolerate oral fluids
• Toxic appearance

Discharge Criteria

Patients can be discharged if:

• Significant improvement in symptoms
• Able to tolerate oral fluids
• No repeated doses of epinephrine required
• Follow-up should be arranged within 48 hours if symptoms persist

Important Caveats and Pitfalls

1. Avoid routine imaging unless there is suspicion of an alternative diagnosis or failure to respond to standard therapy 1

2. Avoid nebulized epinephrine for children who will be discharged shortly, as the effect is short-lived (1-2 hours) and rebound symptoms may occur 1

3. Consider alternative diagnoses if not responding to standard therapy, including:

   • Bacterial tracheitis
   • Epiglottitis
   • Foreign body aspiration
   • Peritonsillar abscess
   • Retropharyngeal abscess
   • Angioedema 2

4. Humidification therapy has not been proven beneficial in the treatment of croup 2

5. Risk of corticosteroid complications is rare, making dexamethasone a safe and effective treatment option 4, 6

6. Be vigilant for signs of deterioration including increased work of breathing, lethargy, or cyanosis, which may indicate need for escalation of care 1