1 or more factors returned?
Repeat racemic epinephrine
Consider giving IV formulation PO as it tastes much better
Meets discharge critiera?
- Clinical symptoms consistent with croup
- Toxic appearance
- History of upper airway anatomical or functional abnormality
- Hypotonia or neuromuscular disorder
Meets discharge criteria?
Reassessment in 1 hour
Discharge with follow up within 24 hours
Meets discharge criteria?
Reassessment in 1 hour
1 or more clinical factors returned?
1 or more clinical factors present immediately after racemic epinephrine?
- Stridor at rest
- Sternal wall retractions
- Tachypnea
- Agitation / Restlessness / Lethargy
- Difficulty with talking or feeding
Discharge with follow up within 24 hours
Reassessment in 1 hour
1 or more factors returned OR > 2 nebs given total?
Stridor at rest AND one other clinical factor:
- Sternal wall retractions
- Tachypnea
- Agitation / Restlessness / Lethargy
- Difficulty with talking or feeding
Consider alternative diagnosis (foreign body, epiglottitis, bacterial tracheitis, etc.)
Consider pediatric or pulmonary consult
Chest and Neck X-rays
- No evidence that x-rays improve the treatment of croup.
Epiglottitis
- May mimic the signs of croup
Discharge criteria
- Minimal stridor at rest (stridor with activity expected)
- Minimal retractions
- 2 hours after racemic epinephrine dose
- Reassuring vital signs
- Tolerating PO
- Well-appearing
- No social/family concerns
- Reliable follow up in 24 hours
- Parents comfortable and understand discharge plan
- Provider comfortable with outpatient therapy
Cool Mist
- No evidence that cool mist improves the treatment of croup.
Spasmodic Croup
- Occurs only at night, rarely requires medications
Respiratory Viral PCR
- No evidence that laboratory tests improve the treatment of croup.
Bacterial Tracheitis
- May mimic the signs of croup
