Croup — branching viva

Opening

Examiner: A 2-year-old arrives at 1 a.m. with a barking cough, a hoarse cry and inspiratory stridor at rest after two days of a runny nose. He is alert and pink on his mother's lap. How do you approach him? ^[1]

Candidate: I would make a clinical diagnosis of viral croup and grade its severity by observation before touching him, keeping him calm on his mother's lap because agitation worsens the obstruction. He has stridor at rest, so this is at least moderate croup on the Westley score; I would note his retractions, air entry, colour and conscious level. My immediate plan is a corticosteroid for him as for every child with croup, calm handling, and nebulised adrenaline ready if he develops distress, with observation and reassessment. ^{[1] [2]}

Branch 1 — grading and steroid

Examiner: Why give a steroid if he might only be moderate? ^[2]

Candidate: Because the evidence supports a corticosteroid for every child with croup across the whole severity range. The Cochrane review of glucocorticoids for croup shows they reduce symptom severity, return visits, length of stay and the need for adrenaline, and the Bjornson NEJM trial showed benefit even in mild croup. I would give dexamethasone 0.15 mg/kg orally as a single dose, or nebulised budesonide 2 mg if he will not take it orally. ^{[2] [4]}

Examiner (probe): What score is the Westley score made of? ^[1]