Croup (Laryngotracheal Bronchitis)
Most common URI in children
Parainfluenza type 1 is most common, but also type 2, 3 or RSV, influenza, mycoplasma (only after the toddler age)
Classically children aged 1-3
1-3 day history of URI, symptoms wax and wane over a weeks time. Barking seal-like cough. Usually low grade fever, but it can be high grade
Do not need labs, ABG or x-ray
Start with cool mist does nothing but reassure parents and perhaps placebo (Acad Emerg Med 9(9):873 September 2002)
Then steroids 0.6 mg/kg of decadron (.15-.3 mg/kg have been shown to be as effective) IM or PO. Also can use inhaled budesonide, which also might be helpful in addition to decadron. (Ann Emerg Med 30(3):353, September 2002)
Epinephrine L or racemic should be given if still in distress. Dose of racemic is .5 cc in 3 cc of NS or dose of L-epi, 5 cc of 1:1000 nebulized. Observe for three hours after epi for rebound. Five R/C studies show efficacy and no rebound after 3 hours. L and racemic have same effect.
Stridor at rest after steroids, epi, and 3 hrs observation. Patients requiring O2 to maintain, resp failure, tachypnea >60 after therapy. Pt looks toxic. If patient appears to require intubation, can try heliox as last ditch attempt to avoid.
Pseudomembranous croup. Consider in patients who appear to have croup, but do not improve with treatment. Patients also have profuse secretions and severe toxicity.
Sloughing of epithelial lining causes problems with airway management. May see ragged trachea on x-ray. 85% of patients will require endotracheal intubation. Usually occurs with superinfection of staph aureus, strep pneumoniae, moxarella, or H. Flu (now rare)
Supraglottic cellulitis from Group A B-Hemolytic Strep, but also S. Pneumo or Staph Aureus, though traditionally, H. Flu was the culprit.
Can involve the pharynx as well as the supraglottic tissues
Sick and toxic with dysphagia. Drooling, tripod position, muffled voice, and no coughing. Portable lateral neck x-ray only if Dx is unclear. Give Cefotaxime (50 mg/kg Q6) and oxacillin.
uncommon after five years old
can track to mediastinum or carotid or jugular vein
Life threatening infection of the space between buccopharyngeal and prevertebral fascia; this potential space extends from base of skull to T1 in mediastinum. Peak incidence is in children < 6 y/o. Caused by staph aureus, group A beta-hemolytic strep, or gram negative rods. Present with URI symptoms and pharyngitis. X-Ray shows space at C2 twice diameter of vertebral body. May also see air fluid levels or gas. Give antibiotics and get consult with head and neck surgeon, provide airway management, and admit to the PICU.
quinsy, abscess pushes uvula to other side of mouth. red, bulging soft palette.
Usually seen in children >8 y/o. Complications of bacterial tonsillitis or superinfection of Epstein-Barr.
Patients will have a hot potato voice, dysphagia, ipsilateral ear pain, trismus, dysarthria, and drooling. Pharynx exam will reveal an erythematous swollen tonsil which may displace the uvula to the opposite side. Manage with throat cx, and an ENT consult for needle drainage. If successfully drained, the patient can be give out-patient antibiotics.
Balloons cause the highest number of deaths.
Many authors note a predilection for foreign bodies to lodge in the right main stem bronchus. However, several pediatric studies have noted a similar frequency in the distribution of foreign bodies between the right and left bronchial tree. Of note, hyperinflation maybe a subtle finding in the child suspected of having aspirated a foreign body. Bilateral decubitus chest radiographs can be obtained to facilitate demonstration of hyperinflation. Normally on a decubitus view, the dependent lung will have a loss of volume, as compared to the overlying lung. When an obstructing foreign body is present on the dependent side, air trapping is demonstrated by the absence of volume loss in the dependent lung.
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