A 3 year old male who presents to the emergency department with a chief complaint of cough. Two days ago he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh, "barky," cough. Today he developed a "whistling" sound when he breathes, so his parents brought him to the emergency department. His past medical history is unremarkable. His 6 year old brother also has cold symptoms.
VS: T 37.5, P 140, R 36, BP 90/64, oxygen saturation 96% RA
Physical Exam: He is alert, with good eye contact, in mild respiratory distress. He has a dry barking cough and a hoarse cry. He has some clear mucus rhinorrhea but no nasal flaring. His pharynx is slightly injected, but there is no enlargement or asymmetry. His heart is regular without murmurs. His lung exam shows good aeration and moderate inspiratory stridor at rest. He has moderate subcostal retractions. No wheeze or rhonchi are noted. His abdomen is flat, soft, and non-tender. His extremities are warm and pink with good perfusion.
Sound familiar?
What is different about this presentation?
Warren, what is your differential diagnosis and is it different than that of the average physician?
Would anyone manage this case differently than the last one? If so, how?
Are there any TOOLS to help you estimate the clinical severity of this presentation?
Can I get a HOLLA???!!!
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For me, there are many "key words" in this case. The phrases that caught my attention were: "barky cough", "whistling sound", and "inspiratory stridor at rest." The differential diagnosis for stridor includes Croup, bacterial tracheitis, epiglottitis, and foreign body. Bacterial tracheitis and epiglottitis are (fortunately) rare due to immunization. (In my opionion: The greatest high yield/low cost medical invention ever created.)
Yes, bacterial tracheitis typically includes fever and a "toxic appearance" with little response to epinephrine. The classic presentation for epiglottitis includes high fevers, drooling, and the sniffing position. If you see this, prepare to establish an airway...call for help ie ENT, Anesthesia, and Pediatric Surgery.
Tests: Croup is a clinical
diagnosis and does not require additional testing. However, if foreign
body or epiglottis is considered, then PA and Lateral neck films may be
helpful.
The classic radiographic finding in croup is a narrowed subglottic region of the trachea, referred to as the, "steeple sign."
The classic radiographic finding in croup is a narrowed subglottic region of the trachea, referred to as the, "steeple sign."
Radiographic findings can be absent
in as many as 50% of patients with croup.
Laboratory studies are not necessary.
Treatment: I would treat with nebulized epinephrine and steriods (similar to the last case.) The epinephrine dose was 0.9 mg/kg racemic or 0.03 mL/kg of the 2.25% solution (in 3 ml NS.) It is important to not that most experts recommend that patients who receive nebulized racemic epinephrine should be observed for at least 3-4 hours after the final treatment because of concerns for a rebound phenomenon of bronchospasm, worsening respiratory distress, and/or persistent tachycardia.
A single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup, if administered within the first 4-24 hours after the onset of illness. The long half-life of dexamethasone (36-54 h) often allows for a single injection or dose. Studies have shown that dexamethasone dosed at 0.15 mg/kg is as effective as 0.3 mg/kg or 0.6 mg/kg (with a maximum daily dose of 10 mg) in relieving the symptoms of mild-to-moderate croup. Despite this knowledge, clinicians still tend to favor the dose of 0.6 mg/kg for initial treatment of croup. Dexamethasone has shown the same efficacy if administered intravenously, intramuscularly, or orally.
Amir L, Hubermann H, Halevi A, Mor M, Mimouni M, Waisman Y. Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: a prospective, randomized trial. Pediatr Emerg Care. Aug 2006;22(8):541-4
The NNT website has a nice breakdown of the statistics associated with steroid treatment. Check it out:
http://www.thennt.com/nnt/steroids-for-croup/
Disposition: The Westley Score was intended to be used only for research, but I think it helps trigger some important considerations when evaluating the severity of disease and determining disposition.
Ultimately you will need to make a clinical decision based on severity, clinical response to treatment, ability to take po, and social indicators such as parental reliability. Here is a reasonable algorithm from the AAFP that might also help. It is based primarily on absence and or resolution of stridor.
http://www.thennt.com/nnt/steroids-for-croup/
Disposition: The Westley Score was intended to be used only for research, but I think it helps trigger some important considerations when evaluating the severity of disease and determining disposition.
Ultimately you will need to make a clinical decision based on severity, clinical response to treatment, ability to take po, and social indicators such as parental reliability. Here is a reasonable algorithm from the AAFP that might also help. It is based primarily on absence and or resolution of stridor.
barky cough and ins stridor sounds like croup.
ReplyDeletestridor vs wheezing = croup vs bronciolitis = parainfluenza vs RSV
(epiglottitis in ddx: the pic of the kid with tongue out makes me think of this)
Epiglottitis is relatively rare nowadays, so less likely, and should be febrile, hot potato voice, less likely to bark when coughing. I would manage this as croup, but the vitals aren't that bad, so I doubt he'll crash. That said, I might want to have him monitored overnight.
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