What are the first-line treatments for croup in an emergency room setting?

Emergency Room First-Line Treatments for Croup

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to ALL children with croup regardless of severity, and add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) only for moderate to severe cases with stridor at rest or significant respiratory distress. 1, 2

Treatment Algorithm by Severity

Mild Croup

• Give oral dexamethasone alone (0.15-0.6 mg/kg, maximum 10-12 mg as a single dose) 1, 3
• The 0.15 mg/kg dose is as effective as higher doses for mild disease 4, 5
• Observe for 2-3 hours to ensure symptoms are improving 2
• No nebulized treatments are needed 2

Moderate to Severe Croup (stridor at rest, respiratory distress, accessory muscle use)

• Administer oral dexamethasone immediately (same dosing as above) 1, 3
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 6, 1, 2
• The effect of epinephrine is short-lived, lasting only 1-2 hours 6, 2, 3
• Observe for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 2, 3
• Administer oxygen to maintain saturation ≥94% via nasal cannula, head box, or face mask 1, 3

Alternative Corticosteroid Route

• Use nebulized budesonide 2 mg if the child cannot tolerate oral dexamethasone (vomiting or severe respiratory distress) 1, 7
• Intramuscular dexamethasone is another option when oral administration is not feasible 8

Critical Hospitalization Criteria

Admit to the hospital if any of the following are present:

• Need for ≥3 doses of nebulized epinephrine 1, 2, 3
• Oxygen saturation <92% 1, 3
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent difficulty breathing 1

The American Academy of Pediatrics now supports waiting until 3 doses of epinephrine are needed before admission (rather than the traditional 2 doses), which reduces hospitalization rates by 37% without increasing revisits or readmissions 1, 2

Common Pitfalls to Avoid

• Never discharge a patient within 2 hours of receiving nebulized epinephrine due to the risk of rebound symptoms after the medication wears off 6, 2, 3
• Do not use nebulized epinephrine in children who will be discharged shortly or on an outpatient basis 6, 2, 3
• Do not withhold corticosteroids in mild cases—all children with croup benefit from dexamethasone 1, 2
• Avoid humidified air or cold air treatments—these lack evidence of benefit 3, 5
• Do not use antibiotics routinely—croup is viral in etiology 1
• Do not perform chest physiotherapy—it provides no benefit 3

Discharge Criteria

Discharge is appropriate when ALL of the following are met:

• Resolution of stridor at rest 1, 2
• Minimal or no respiratory distress 1, 2
• Adequate oral intake 1, 2
• Parents can recognize worsening symptoms and know to return if needed 1, 2, 3
• At least 2 hours have passed since the last dose of nebulized epinephrine 2, 3

Additional Supportive Measures

• Use antipyretics to keep the child comfortable 1, 3
• Minimize handling to reduce metabolic and oxygen requirements 1, 3
• Provide clear return precautions to parents about signs of deterioration 1, 2
• Instruct families to follow up with their general practitioner if not improving after 48 hours 1, 3