Pharmacotherapy

Emergency Management

• Moderate-severe croup with stridor at rest
  • Racemic or L-epinephrine via nebulizer
    • Racemic epinephrine: 0.05 mL/kg (max 0.5 mL) of 2.25% solution diluted to 3 mL
    • L-epinephrine: 0.5 mL/kg (max 5 mL) of 1 mg/mL (1:1000) solution
    • Administer over 10-15 minutes
    • Provides temporary relief (1-2 hours) of stridor and work of breathing by reducing edema
    • May repeat every 20 minutes as needed
    • Cardiac monitoring if giving >2-3 doses over 2-3 hours

• Moderate-severe croup
  • Dexamethasone 0.6 mg/kg PO/IV/IM (max 16 mg)
    • Preferred glucocorticoid due to longer duration of action
    • Decreases airway inflammation and edema
    • Can take 2-6 hours for effect
    • Use lowest invasive route possible (PO preferred if child can tolerate)
    • Provides lasting improvement in symptoms and reduces return visits/admissions
    • Consider repeat dose if symptoms persist >48 hours

Additional Therapies

• Humidified oxygen for hypoxia
• IV fluids if unable to tolerate PO
• Antipyretics for fever
• Heliox temporarily decreases work of breathing but data limited
• Intubation if impending respiratory failure
  • Use smaller ETT size
  • Have anesthesia/ENT assist
  • Avoid paralysis if mask ventilation not proven

Key Monitoring

• Mental status, stridor, retractions, hypoxia
• Cardiac monitoring with >2-3 epinephrine doses in 2-3 hours