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]

SAQ 2 (10 marks)

A 3-year-old girl presents with a two-hour history of high fever, looking unwell and toxic, drooling and sitting forward, with a muffled voice and soft stridor but no barking cough. Her parents report she is not fully immunised. [1] [5]

1. What is your leading diagnosis and differential, and what features drive it? (4) [1]
2. Describe your immediate management priorities. (3) [1]
3. Explain why this presentation differs from typical croup and the pitfalls to avoid. (3) [5]

Model answer — SAQ 2

(1) Diagnosis and differential (4). The leading diagnosis is epiglottitis: a toxic, febrile child who is drooling, sitting forward, with a muffled voice and — crucially — no barking cough, in the setting of incomplete immunisation (raising the possibility of unprotected Haemophilus influenzae type b). The differential for a toxic child with stridor also includes bacterial tracheitis, retropharyngeal abscess, an inhaled foreign body, and rarely membranous (diphtheritic) croup if diphtheria immunisation is incomplete. The absence of the barking cough and the toxic, drooling, forward-sitting posture are the features that move this away from viral croup. [1]

(2) Immediate priorities (3). Do not distress the child: no throat examination, no cannula, no lying flat, and let her stay with her parent. Call the airway team immediately — senior paediatrician, anaesthetics and ENT — and move toward a controlled airway assessment in a safe environment (theatre or a resuscitation area with difficult-airway equipment). Give gentle oxygen if tolerated, and give intravenous antibiotics and further airway management once the airway is secured or under expert control. [1]

(3) Difference and pitfalls (3). This differs from typical croup by its toxicity, the drooling and forward posture, the muffled rather than hoarse voice, the absence of a barking cough, and the rapid onset. The key pitfalls are anchoring on croup and treating with steroid and adrenaline while missing a bacterial airway emergency, and — most dangerously — examining the throat or agitating a child with possible epiglottitis, which can precipitate complete obstruction. The safe approach is calm handling and early involvement of the airway team. [5]

References

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