Emergency Department Treatment for Croup
The initial treatment for croup in the emergency department should include oral corticosteroids for all cases regardless of severity, with nebulized epinephrine added for moderate to severe cases. 1, 2
Initial Assessment
- Assess for signs of respiratory distress: barking cough, stridor, hoarse voice, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 1
- Determine severity based on clinical presentation - mild (occasional barky cough, no stridor at rest), moderate (frequent barky cough, audible stridor at rest, some retractions), or severe (prominent stridor, marked retractions, agitation or lethargy) 2
- Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis such as foreign body aspiration or bacterial tracheitis 1, 2
Treatment Algorithm
For All Croup Cases (Regardless of Severity):
- Administer oral dexamethasone 0.6 mg/kg (maximum 10-12 mg) as first-line treatment 2, 3
- For patients unable to tolerate oral medication (vomiting or severe respiratory distress), use intramuscular dexamethasone at the same dose 3
For Moderate to Severe Cases (Stridor at Rest or Respiratory Distress):
- Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 2, 4
- If racemic epinephrine is not available, L-epinephrine (1:1000) can be substituted at the same dosage 4
- Recent evidence suggests that a lower dose of nebulized epinephrine (0.1 mg/kg) may be equally effective with potentially fewer side effects 5
- Provide oxygen therapy to maintain oxygen saturation ≥94% 2
Observation and Disposition
- Monitor the patient for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 6, 2
- Consider hospital admission when three or more doses of racemic epinephrine are required 1, 2
- Recent guidelines have shown that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 2
Important Considerations and Pitfalls
- Nebulized epinephrine should not be used in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 1, 2
- The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours, necessitating close observation 2
- Consider bacterial tracheitis if a patient fails to respond to standard croup treatment 1
- Ensure emergency equipment is readily available, including appropriate facemasks, airway adjuncts, and equipment for front-of-neck access if needed 1
- Cool mist/humidified air therapy, once commonly used, has not been shown to provide additional symptom improvement and is no longer recommended as a primary treatment 7
Alternative Corticosteroid Options
- Nebulized budesonide has been found to be effective and may be used as an alternative to oral dexamethasone, particularly when oral administration is difficult 3, 8
- Studies have shown that nebulized budesonide, oral dexamethasone, and intramuscular dexamethasone have similar effectiveness for treating croup 8