1. Croup Matthew Stajcer PGY1 FM Community (Renfrew)

2. Case #1 - Hx 22 Month Old male infant Developed sudden onset ‘weird’ cough for 1/7 Slightly hoarse voice Fever 38.5 Funny breathing noise when breathing in Rhinorrhea

3. Case #1 - Exam Alert, Warm well perfused, mild WOB at rest HEENT - TM N, Tonsils mild swelling no lymphadenopathy, rhinorrhea + Chest - inspiratory wheeze, no creps, barking cough CVS = N, Abdo = N T 38.5, RR 44, Sa02 91%, HR 140

4. ?Stridor and Weird Cough Respiratory noise - inspiratory Weird Cough - Barking

5. Case #1 Differential Dx: Acute epiglottitis (Much more rare since H. Flu vaccine) ●Peritonsillar and retropharyngeal abscesses ●Foreign body aspiration or ingestion ●Allergic reaction ●Upper airway injury ●Congenital anomalies of the upper airway ●Laryngeal diphtheria ●Acute angioneurotic edema

6. Case #1 - Croup Etiology (Laryngotracheobronchitis) -Parainfluenza Virus - (1,2,3) -RSV -Adenovirus

7. Case #1 - Severity Scoring System - Westley Croup Score ●Level of consciousness: Normal, including sleep = 0; disoriented = 5 ●Cyanosis: None = 0; with agitation = 4; at rest = 5 ●Stridor: None = 0; with agitation = 1; at rest = 2 ●Air entry: Normal = 0; decreased = 1; markedly decreased = 2 ●Retractions: None = 0; mild = 1; moderate = 2; severe = 3 Mild ≤2, Mod 3-7, High ≥8 Our 22 month old = 4 or 5

8. Back to Case #1 Summary so far: 1/7 hx fever, barking cough, stridor tachypnea and stridor on exam looks like he is tiring

9. Croup - treatment Fast: Racemic Epinephrine neb (Beware rebound after ~2 hours) Slow: PO/IV steroid (Make sure they dont puke it up) if receiving multiple nebs - consider admission

10. Croup - Investigations? CXR - only if abnormal tx response/?other cause Labs - very rarely needed.

11. CXR Steeple Sign --> ← Subglottic Narrowing

12. Sequelae Pneumonia Repeated Symptoms (5%) Hypoxia/Respiratory Failure

13. Croup - Summary Stridor + barking cough = croup (most likely) If stridor at rest - likely needs treatment = Epi Neb (x1) and PO Steroid (one dose) No need for Labs/XR if patient responds to tx

14. References ● http://emedicine.medscape.com/article/962972-clinical http://emedicine.medscape.com/article/962972-clinical ● http://www.uptodate.com/contents/croup-clinical-features-evaluation-and- diagnosis?source=search_result&search=croup&selectedTitle=2~58 http://www.uptodate.com/contents/croup-clinical-features-evaluation-and- diagnosis?source=search_result&search=croup&selectedTitle=2~58 ● http://www.sickkids.ca/Nursing/Education-and-learning/Nursing-Student- Orientation/module-two-clinical-care/vitals/ http://www.sickkids.ca/Nursing/Education-and-learning/Nursing-Student- Orientation/module-two-clinical-care/vitals/ ● http://emedicine.medscape.com/article/763612-overview#a4 http://emedicine.medscape.com/article/763612-overview#a4 ● Toronto Notes 2014 ● CHEO Croup e-learning module