Management of Croup Patients After Decadron Administration in the Emergency Room
Patients with croup who have received dexamethasone (Decadron) in the emergency room should be discharged with additional oral steroids to complete a course of treatment, as this reduces return visits and improves outcomes. 1
Discharge Recommendations for Croup
Steroid Regimen
- Prescribe oral dexamethasone at 0.6 mg/kg (maximum 10-12 mg) for moderate-to-severe croup 1
- For mild croup, a lower dose of 0.15-0.3 mg/kg may be sufficient 1, 2
- A single dose of dexamethasone is often adequate, but additional doses may be needed for symptom management 3
Route of Administration
- Oral dexamethasone is preferred for discharge medication due to:
- Reserve intramuscular administration for patients who are vomiting or in severe respiratory distress 1
Monitoring and Follow-up
- Patients should be discharged only when symptoms have stabilized 4
- Parents should be instructed to return if:
- Stridor at rest returns or worsens
- Respiratory distress increases
- Child develops difficulty drinking fluids 5
- Follow-up with primary care provider within one week of discharge 4
Clinical Decision-Making Algorithm
Safe for Discharge When:
- Significant clinical improvement after dexamethasone administration 4
- No stridor at rest
- Minimal or no respiratory distress
- Adequate oral intake
- Parents understand home care instructions 5
Indications for Admission:
- Requiring two or more racemic epinephrine treatments 5
- Persistent moderate to severe respiratory distress despite treatment 4
- Inability of parents to recognize worsening symptoms 4
- Social concerns about adequate home monitoring 4
Home Care Instructions
- Maintain adequate hydration 5
- Use cool mist humidification 5
- Control fever with appropriate antipyretics 5
- Avoid antihistamines and decongestants (no proven benefit) 5
- Antibiotics are not indicated unless bacterial infection is present 4
Common Pitfalls to Avoid
- Discharging patients too early before adequate observation period after treatment 4
- Failing to provide clear return precautions to parents 4
- Underestimating the severity of croup in younger children (under 6 months) 5
- Not prescribing steroids for seemingly mild cases that may worsen at night 2
The evidence strongly supports that a single dose of dexamethasone (0.6 mg/kg) is highly effective for most croup cases, with oral administration being equally effective to intramuscular injection for discharge medication 3. This approach reduces return visits for ongoing croup symptoms and improves clinical outcomes 2.