Paediatric Emergencies 353STRIDOR2 It is characterized by a barking cough, harsh inspiratory stridor and hoarse
voice. Symptoms often develop during the night and may follow a mild upper
respiratory tract infection.
3 The child is febrile, irritable and tired, but lacks the drooling, dysphagia and
toxic appearance of epiglottitis. Feeding and general activity is usually
norma l. In most cases of mild to moderate croup sy mptoms pea k at 2–3 days
and completely resolve within 1 week.
4 Severe disease is indicated by:
(i) Hypoxia.
(ii) Harsh inspiratory and expiratory stridor.
(iii) Marked tachypnoea.
(iv) Sternal recession.
(v) Accessory muscle use.
(vi) Increasing agitation and restlessness.
(vii) Altered level of consciousness
5 Only attempt to examine the pharynx if the diagnosis remains unclear, and
epiglottitis or bacterial tracheitis are not suspected.
6 Croup is a clinical diagnosis and investigations are largely unhelpful.
MANAGEMENT1 Nurse in an upright position with parents present and avoid distress.
2 Give nebulized 1 in 1000 adrenaline (epinephrine) 0.5 mL/kg to a
maximum of 4 mL (4 mg) with oxygen in severe cases and call the senior ED
doctor.
3 Give dexamethasone 0.15–0.3 mg/kg orally or i.m., or nebulized budesonide
2 mg or prednisolone 1 mg/kg orally, according to local policy.
4 Admit for observation patients with significant respiratory compromise,
stridor at rest, patients who received adrenaline (epinephrine) and a patient
presenting late at night.
5 Otherwise discharge milder cases with a letter for follow-up the next day by
the general practitioner (GP).
Epiglottitis (supraglottitis)
DIAGNOSIS
1 This is a life-threatening infection of the supraglottic tissues which usually
affects children aged between 3 and 7 years in the winter months. The causa-
tive agent was classically Haemophilus inf luenzae type B (HiB); however, its
prevalence has markedly declined with immunization.
(i) Streptococci, staphylococci and viruses are now as likely to be the
cause of the infection, more so in adults.