Case 3 - stridor

Question 1

What happens in croup?

Answer 1

• Upper respiratory tract infection by parainfluenza virus
• Causes oedema and inflamamtion of larynx and airway
• Typically aged 6 months to 6 yrs

Question 2

Symptoms/signs of croup

Answer 2

• Rapid onset
• Seal like barking cough
• Stridor
• Increased work of breathing
• Hoarse voice
• Low grade fever

Sometimes preceeded by coryzal symptoms

Question 3

Differentials for rapid onset strifor

Answer 3

• Epiglottitis
• Laryngeal foreign body
• Angioedema/anaphylaxis

Question 4

Management of croup

Answer 4

• PO dexamethasone - even for mild, single dose but can be repeated after 12hrs if needed
  If moderate/severe:
• Oxygen
• Nebulised budesonide (steroid)
• Nebulised adrenaline
• Intubation and ventilation

Question 5

Symptoms/signs of epiglottitis

Answer 5

• Drooling - intensely painful throat
• Stridor - soft inspiratory
• Hot potato voice/muffled
• High fever
• Very ill toxic looking child
• Tripod position - sat forward with hand on each knee
• Extending neck and chin
• Scared and quiet

Question 6

Management of epiglottitis

Answer 6

• Admit
• Call senior anaesthetist and ENT on call- to intubate using GA (tracheostomy needed if not possible), then do bloods and IV access

Question 7

Investigations for child with acute stridor

Answer 7

None - need to minimise distress

Question 8

Why is epiglottitis rarer now?

Answer 8

• Vaccination against causative organism Haemophilus influenzae is given at 2, 3 and 4 months as part of the 6 in 1 vaccine and as booster with MenC at 12 months
• HiB

Question 9

Scoring croup

Answer 9

• Westley croup score
• Based on sats, stridor, retractions, air entry and conscious level

Question 10

Advice for parents for child with croup

Answer 10

• Symptoms should resolve <48hrs
• Viral illness, abx not needed
• Paracetamol and ibuprofen can control pain and fever
• Ensure good fluid intake
• Seek urgent medical advice if symptoms worsen - stridor at rest, high fever or heart rate
• Call ambulance if signs of respiratory failure

Question 11

Complications of croup

Answer 11

• Lymphadenitis
• Otitis media
• Dehydration
• Rare - bacterial superfindection –> pneumonia or bacterial traceitis
• Extremely rare - pulmonary oedema, pneumothorax