Upper-airway obstruction and stridor — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in the emergency department. A two-year-old boy presents at 1 am with a two-day coryzal prodrome and an overnight barking, seal-like cough, a hoarse voice and inspiratory stridor when upset. Initially he is alert, pink and drinking with mild recession. Over the next 30 minutes he develops inspiratory stridor at rest, increasing intercostal and suprasternal recession and tracheal tug, and becomes more distressed. The team asks you to establish the diagnosis and severity, deliver the immediate management with doses, apply the do-not-distress principle, and set the escalation and safety-netting plan. You have 12 minutes with the team and 5 minutes for examiner discussion. [1]

Information available on request

• Previously well, fully immunised two-year-old; two-day coryzal prodrome. [1]
• Barking cough, hoarse voice, inspiratory stridor initially only when crying, now at rest. [1]
• Examination: pink, alert then increasingly distressed; stridor at rest, marked intercostal and suprasternal recession and tracheal tug; air entry reduced but present; no drooling, able to swallow; afebrile to low-grade fever; saturations 95 percent in air. [1]
• No history of choking; no urticaria or allergen exposure. [1]
• Westley score components deteriorate from mild to moderate-severe over the observation period. [1]

Tasks

1. Give the diagnosis and grade the severity, naming the score and how it has changed. [1]
2. Outline your immediate management with the specific drug and dose, and apply the do-not-distress principle. [3]
3. State what you would do if he deteriorated to severe obstruction, with the specific drug and dose. [4]
4. State two features that would move this out of the croup differential and toward a toxic airway emergency. [6]
5. State your disposition and the safety-netting advice to the family. [1]

Marking anchors

Must-hit

• Diagnoses croup (parainfluenza laryngotracheobronchitis); grades severity with the Westley score (consciousness, cyanosis, air entry, stridor, retractions), recognising progression from mild to moderate-severe as stridor moves to rest with increasing recession. [1]
• Gives a single dose of oral dexamethasone 0.15 to 0.6 mg/kg to a child of any croup severity; keeps the child calm on the carer's lap in the position of comfort, gives oxygen only if tolerated, and avoids distressing procedures. [3] [2]
• For severe obstruction, gives nebulised adrenaline 0.5 mL/kg of 1:1000 (maximum 5 mL) for rapid temporary relief, involves senior and anaesthetic help, and observes for rebound as it wanes at about two hours. [4]

Merit

• Names the Cochrane glucocorticoid review and the mild-croup dexamethasone trial as the evidence for treating all croup, and cites the Westley score as the validated severity tool. [2] [3]

Fail

• Distresses the child with throat examination or cannulation, or delays dexamethasone; or misreads a quietening chest and falling effort as improvement rather than exhaustion. [1]
• Fails to recognise the toxic, drooling, forward-sitting child as a supraglottic emergency needing a controlled airway rather than croup management. [6]