Croup — formative SAQs

SAQ 1 (10 marks)

A 2-year-old boy is brought to the emergency department at 1 a.m. He had a runny nose and low-grade fever for two days and has now woken with a barking cough, a hoarse cry and a harsh noise on breathing in. On the carer's lap he has inspiratory stridor at rest and mild-to-moderate chest-wall retractions, but he is alert, pink and interacting. His temperature is 37.9 °C. ^{[1] [2]}

1. State your assessment of severity and how you graded it. (3) ^[1]
2. Outline your initial management, including any drug doses. (4) ^{[2] [3]}
3. Describe how you would decide on disposition and what advice you would give. (3) ^[1]

Model answer — SAQ 1

(1) Severity (3). This is moderate viral croup: there is inspiratory stridor at rest with mild-to-moderate retractions, but the child is alert, pink and interactive with normal air entry and no cyanosis, which places him in the moderate band of the Westley croup score (stridor at rest and retractions scoring, but normal conscious level, air entry and colour). I would grade severity by observation with the child kept calm on the carer's lap, and I would reassess serially because the trajectory matters more than a single score. ^[1]

(2) Initial management (4). Keep the child calm and undisturbed, because agitation worsens the obstruction, and give gentle oxygen only if needed (hypoxaemia is a late sign). Give a corticosteroid to this child as I would to every child with croup: dexamethasone 0.15 mg/kg orally as a single dose (up to 0.6 mg/kg, maximum ~12 mg), or nebulised budesonide 2 mg if oral is refused. Because he has stridor at rest, I would have nebulised adrenaline ready and give it (adrenaline 1:1000, 0.5 mL/kg, maximum 5 mL, nebulised) if his distress increases; adrenaline works within minutes but wanes over about two hours. Avoid throat examination, routine bloods, imaging and humidified air. ^{[2] [3]}

(3) Disposition and advice (3). Observe him after treatment; if he settles with no stridor at rest and the steroid has been given, he can go home. If he needs nebulised adrenaline, observe him for the two-hour rebound window and admit if he needs it repeated or fails to improve. Give concrete safety-net advice: return urgently if there is stridor at rest, harder breathing with chest in-drawing, pallor, drowsiness or a blue colour, or if the family is worried; warn that the illness can flare again the next night; and ensure they can get back to care given the hour. ^[1]

References5ShowHide

1. [1]Bjornson CL, Johnson DW. Croup Lancet, 2008.PMID 18295000
2. [2]Gates A, Gates M, Vandermeer B, et al. Glucocorticoids for croup in children Cochrane Database Syst Rev, 2018.PMID 30133690
3. [3]Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children Cochrane Database Syst Rev, 2013.PMID 24114291
4. [4]Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup N Engl J Med, 2004.PMID 15385657
5. [5]Petrocheilou A, Tanou K, Kalampouka E, et al. Viral croup: diagnosis and a treatment algorithm Pediatr Pulmonol, 2014.PMID 24596395