CROUP

Prepared by:

South West Education Committee

South West Education Committee

Croup Protocol

OBJECTIVES Identify the anatomical differences in

pediatrics which impact croup patients. Review of pediatric assessment Identify common presentations for

croup. Distinguish croup from Epliglottitis. Describe the treatment for croup. Explain the indications for treatment.

ANATOMICAL DIFFERENCES

Anatomy is smaller and proportioned differently.

Head proportionately larger on a weak neck.

Obligatory nose breathers. (Infants)

AIRWAY - Pediatric vs. Adult

Narrower at all levels The mandible is

proportionally smaller in young children

The tongue is proportionally larger than adults

Larynx is more anterior and superior than an adults’ (C3-C4)

AIRWAY - Pediatric vs. Adult

AIRWAY

Cricoid ring is the narrowest part of the airway in young children

Tracheal cartilage is softer

Trachea is smaller in both length and diameter

A Picture is Worth…..

Small, hypotonic jaw, large tongue, tonsils, adenoids, arytenoids, uvula, long floppy epiglottis. (prone to swelling)

Excessive secretions. (requires suctioning) Gums are more delicate, bleed easily, softer

teeth which dislodge easily

Anatomical Differences Why is this

difficult? The larynx:

– 3-3-2– More anterior.– More superior.

thyromental distance

– Big teeth or no teeth.

– Cone shaped.

BLS first– Open & maintain a/w– Ensure patency

• Suction & insert oral &/or nasal a/w

– ORAL or NASAL ETT?– Assist/prep for intubation

AIRWAY

HUMAN ERROR

Most preventable deaths that happen in the pre-hospital care setting are STILL attributed to poor airway management practices.

It has been found that upwards of 86% of preventable deaths of inhospital patients with airway complications were attributed to human error.

PEDIATRIC REVIEWCHEST AND LUNGS

Ribs are positioned horizontally Ribs are more pliable and offer less

protection to organs Chest muscles are immature and fatigue

easily Lung tissue is more fragile Mediastinum is more mobile Thin chest wall allows for easily transmitted

breath sounds

PEDIATRIC REVIEW ABDOMEN

Immature abdominal muscles offer less protection

Abdominal organs are closer together Liver and spleen are proportionally

larger and more vascular

PEDIATRIC REVIEW RESPIRATORY SYSTEM

Tidal volume is proportionally smaller to that of adolescents and adults

Metabolic oxygen requirements of infants and children are about double those of adolescents and adults

Children have proportionally smaller functional residual capacity, and therefore proportionally smaller oxygen reserves

PEDIATRIC REVIEW CARDIOVASCULAR SYSTEM

Cardiac output is rate dependent in infants and small children

Vigorous but limited cardiovascular reserve Bradycardia is a response to hypoxia Children can maintain blood pressure longer

than adults Circulating blood volume is proportionally

larger than adults Absolute blood volume is smaller than adults

WRAP UP! Smaller chest and respiratory reserve, belly

breathers. Poorly developed accessory and abdominal

muscles. ( prone to fatigue / injury) Poorly developed rib cage. (prone injury) Excessive air swallowing. (large stomach) Poor gastric emptying. (vomit) Immature temperature regulatory system. Higher metabolic rate requires a higher

respiratory and circulatory rate. Conversely they have a much lower blood pressure due to the lack of plaque, arteriosclerosis and muscle development in arteries.

ASSESSMENT - PEDIATRICS

SCENE ASSESSMENT Observe the scene for hazards or potential

hazards Observe the scene for mechanism of

injury/illness– Ingestion

• Pills, medicine bottles, household chemicals, etc.

– Child abuse• Injury and history do not coincide, bruises not

where they should be for mechanism of injury, etc.

– Position patient found

INITIAL ASSESSMENT General impression

– General impression of environment– General impression of parent/guardian and

child interaction– General impression of the patient/pediatric

assessment triangle• A structure for assessing the pediatric

patient• Focuses on the most valuable

information for pediatric patients• Used to ascertain if any life-threatening

condition exists • Components

GCS / LOA Determine level of consciousness

– AVPU scale • Alert• Responds to verbal stimuli• Responds to painful stimuli• Unresponsive

– Modified Glasgow Coma Scale – Signs of inadequate oxygenation

Pediatric Glasgow Coma Scale

0-1 year old >1 year old Score

Eye Opening Spontaneous spontaneous 4To shout To command 3To pain To pain 2No response No response 1

Verbal Cry, smiles, coos Appropriate words 5Cries Disorientated 4Inappropriate cry Cries/screams or inappropriate 3Grunts Grunts or incomprehensible 2No response No response 1

Motor Obeys Command 6Localizes pain Localizes pain 5Withdraws Withdraws 4Flexion Flexion 3 Extension Extension 2 None None 1

AIRWAY AND BREATHING Airway – determine patency Breathing should proceed with adequate chest

rise and fall. Visualize/Expose chest. Signs of respiratory distress

– Tachypnea– Use of accessory muscles– Nasal flaring– Grunting– Bradypnea– Irregular breathing pattern– Head bobbing– Absent breath sounds– Abnormal breath sounds

CIRCULATION Pulse

– Central – Peripheral– Quality of pulse

Blood pressure– 2 x Age + 80 = systolic– 2/3 the systolic = diastolic

Skin color Active hemorrhage

TRANSITION PHASE

Used to allow the infant or child to become familiar with you and your equipment

Use depends on the seriousness of the patient's condition– For the conscious, non-acutely ill child– For the unconscious, acutely ill child do not

perform the transition phase but proceed directly to treatment and transport

APPROACH TO PEDIATRICS Always remember there are 2 patients. Stay CALM, reassure parents and child.

– remain calm but be attentive and willing to act aggressively to reduce morbidity and mortality.

Handle child gently & explain before doing. Try to examine small children on parents lap when

appropriate. If child or parents are extremis to the point they

endanger resuscitation efforts, separate. Prevent heat stress and preserve Child’s body

heat.

PATIENT COMMUNICATION

Try to never be alone with a pediatric patient.

Sit close, eye level, but do not overcrowd. Use toys to aid your exam. Demonstrate on parents. Offer rewards. Be direct, do not lie!!!!!!! Parents sometimes feel guilty even if they

did nothing wrong.

HISTORY TAKING Parents of chronically ill children know the

disease better than most care givers - ask them. Ask if child has had a fever / are they hot. Hx of laboured breathing or excessive drooling. Lethargy. (A very quiet child is a scary thing) Blank staring, twitching other bizarre behavior. Poor appetite, refusal to eat, vomiting or

diarrhea recently. Increase or decrease in wet diapers. Inconsolable crying / screaming does not

recognize parents.

FOCUSED HISTORY–CONTENT

Chief complaint– Nature of

illness/injury– How long has the

patient been sick/injured

– Presence of fever– Effects on behavior– Bowel/urine habits– Vomiting/diarrhea– Frequency of

urination

Past medical history– Infant or child under

the care of a physician

– Chronic illnesses– Medications– Allergies

DETAILED PHYSICAL EXAMINATION

Should proceed from head-to-toe in older children Should proceed from toe-to-head in younger

children (less than 2 years of age) Depending on the patient’s condition, some or all

of the following assessments may be appropriate:– Pupils - Hydration– Capillary refill - Pulse oximetry– ECG monitoring

Is patient hypoglycemic?

ON-GOING ASSESSMENT

Appropriate for all patients Should be continued throughout the patient care

encounter Purpose is to monitor the patient for changes in:

– Respiratory effort– Skin color and temperature– Mental status– Vital signs (including pulse oximetry measurements)

Measurement tools should be appropriate for size of child

RESPIRATORY COMPROMISE

Several conditions manifest chiefly as respiratory distress in children including:– Upper and lower foreign body airway obstruction– Upper airway disease (croup, bacterial tracheitis, and

epiglottitis)– Lower airway disease (asthma, bronchiolitis, and

pneumonia) Most cardiac arrests in children are secondary to

respiratory insufficiency thus, respiratory emergencies require rapid prehospital assessment and management

CROUP Laryngotracheobronchitis Common inflammatory respiratory illness

in children– Viral infection of the upper airway

Differentiation between croup and epiglottitis in the prehospital setting may be difficult

Upper Respiratory Distress CROUP

– upper airway infection with “barking” cough.– mild to moderate respiratory distress with predominant

stridor.– may be relieved by cold air. (mist)– usually 2 - 7 years of age, Rapid onset.

Epiglottitis DEADLY EMERGENCY!!!!!• Rarely have Stridor. (inspiratory when they do)• Excessive drooling.• Absence of a “barking seal cough.”.• Preference for sitting in “sniffing position.”• Very “eerie”, quiet & obtunded look.• High grade fever.

Upper Respiratory DistressPRESENTATION CROUP EPIGLOTTITIS

Onset Sudden Gradual Fever Slight/absent High

Sore Throat Variable Prominent Fear, Anxiety Variable Prominent Pale/Cyanosis Variable Usually

Drooling Not usual YES Cough “Barking” No Barking cough Stridor Inspiration Rare Voice Very hoarse Muffled

Pref. Position Variable “Sniffing position”

CROUP PROTOCOLINDICATIONS

Any patient who is <8 years old .

A current Hx of upper respiratory infection.

Barking cough (seal-like)

Stridor at rest and/or Altered level of

consciousness and/or Cyanosis.

PROCEDURE

Monitor heart rate Attach cardiac

monitor Assess pulse rate. Pulse rate must be

<200 bpm.

PROCEDURE

Nebulized Epinephrine will not exceed 2 doses.

WHY EPINEPHRINE?

Epi. acts on the subglottic swollen area to vasoconstrict blood vessels and reduce the swelling with the alpha 1 effects.

Salbutamol has no vasoconstrictive effects and only acts on the smooth muscles of the bronchioles with its beta 2 effects.

PROCEDURE

Allow patient to assume position of comfort.

Reassure the patient and parents.

Administer 100% oxygen, via blow-by if needed, while preparing equipment

PROCEDURE

Nebulize Epinephrine 1:1000 based on patients weight and age.

EPINEPHRINE DOSING

<1y/o and <5kg 0.5 mg(0.5 ml) in 2 ml of

normal saline.

<1y/o and >5kg 2.5 mg(2.5 ml) 2 ml of

normal saline may be

added.

Age and Weight Dose

>1y/o and <8y/o 5.0 mg (5.0 ml)

REPEAT

Repeat treatment if no improvement is observed.

Max Epinephrine treatments is 2!

No exceptions.

TRANSPORT

ALL PATIENTS MUST BE TRANSPORTED WITHOUT DELAY.

REASSESS - ENROUTE

Reassess every 5 minutes.

Airway Breathing Circulation Vitals And document it all.

QUESTIONS?