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History
Presenting pattern
Croup and stridor history anchors
Barky cough
Stridor
Hoarse voice
Viral prodrome
Fever pattern
Nighttime worsening
Prior croup episodes
Prior intubation
Baseline airway anomalies
Immunization status
Hib vaccine status
Sudden onset choking episode
Possible foreign body exposure
Drooling
Dysphagia
Muffled voice
Neck pain
Neck stiffness
Toxic appearance timeline
Recent airway instrumentation
Recent ENT procedure
Known allergy exposure
Angioedema history
History of asthma
History of anaphylaxis
OPQRST
Onset
Time of onset
Sudden onset
Gradual onset
Provocation and palliation
Worse with agitation
Worse when supine
Better when upright
Response to cool air
Response to prior dexamethasone
Response to prior nebulized epinephrine
Quality
Barky cough quality
Inspiratory stridor quality
Biphasic stridor quality
Voice change quality
Region and radiation
Upper airway localization symptoms
Chest symptoms suggesting lower airway
Severity
Stridor at rest
Retractions severity
Feeding difficulty severity
Sleep disruption
Ability to speak
Timing
Intermittent stridor
Persistent stridor
Progressive course
Associated symptoms
Associated symptoms set
Rhinorrhea
Sore throat
Cough
Wheeze
Increased work of breathing
Apnea
Cyanosis
Vomiting
Dehydration symptoms
Rash
Urticaria
Facial swelling
Chest pain
Hemoptysis
Prior episodes and baseline
Recurrent stridor framework
Episodes before age 6 months
Frequent episodes
Poor response to standard therapy
History of GERD symptoms
History of noisy breathing at baseline
Alarm Features
Airway and breathing red flags
Immediate danger features
Stridor at rest with fatigue
Silent chest
Minimal air movement
Cyanosis
Apnea
Altered level of consciousness
Severe retractions
Tripod position
Drooling
Unable to swallow secretions
Muffled voice
Rapid progression over minutes
Suspected foreign body
Suspected epiglottitis
Suspected anaphylaxis
Neck swelling
Floor of mouth swelling
Vital sign danger thresholds
High risk vitals patterns
SpO2 below 92 percent on room air
Severe tachypnea for age
Marked tachycardia out of proportion to fever
Hypotension
Escalation triggers
Escalate immediately if
Poor response to nebulized epinephrine within 10 to 20 minutes
Recurrent stridor after initial improvement
Need for repeated nebulized epinephrine
Persistent stridor at rest after dexamethasone
Concern for alternate diagnosis
Any impending respiratory failure signs
Medications
Current and recent exposures
Medication and exposure inventory
Recent dexamethasone
Recent nebulized epinephrine
Recent bronchodilator trial
Recent antibiotics
Recent sedation
Recent opioids
Recent antihistamines
ACE inhibitor exposure in household
Beta blocker exposure in household
ED therapies and dosing
Croup medication core
Dexamethasone
0.6 mg per kg PO
0.6 mg per kg IM
0.6 mg per kg IV
Maximum 10 mg
Lower dose options local protocol dependent
0.15 mg per kg
0.3 mg per kg
Nebulized epinephrine for moderate to severe
Racemic epinephrine 2.25 percent
0.05 mL per kg nebulized
Maximum 0.5 mL
L epinephrine 1 mg per mL
0.5 mL per kg nebulized
Maximum 5 mL
Onset expected within 10 to 30 minutes
Duration about 2 hours
Rebound monitoring required
Nebulized budesonide alternative or adjunct
2 mg nebulized once
Use when unable to take systemic steroid
Oxygen
Titrate to SpO2 at least 94 percent
Blow by oxygen to minimize agitation
Heliox adjunct for severe distress
70 percent helium 30 percent oxygen if available
Bridge while preparing definitive airway plan
Contraindications and do not do
Safety cautions
Avoid agitating procedures in suspected epiglottitis
Avoid routine throat exam with tongue depressor in suspected epiglottitis
Avoid sedatives unless airway plan and monitoring in place
Avoid beta agonists as primary therapy for isolated stridor without wheeze
Avoid antibiotics for uncomplicated viral croup
Diet
Intake and hydration
Hydration and intake status
Oral intake tolerance
Wet diapers count
Vomiting limiting intake
Signs of dehydration
Triggering exposures
Dietary and inhalational exposures
Honey ingestion in infants
Caustic ingestion risk
Smoke exposure
Vaping exposure
Allergen exposure
Review of Systems
Respiratory
Respiratory symptoms
Stridor
Wheeze
Cough
Shortness of breath
Apnea
Cyanosis
ENT
Upper airway symptoms
Sore throat
Drooling
Dysphonia
Dysphagia
Neck swelling
Infectious and systemic
Systemic symptoms
Fever
Lethargy
Poor feeding
Rash
Allergy
Allergy symptoms
Urticaria
Facial swelling
Lip swelling
Vomiting after exposure
Collateral History and Family History
Collateral source and reliability
Source context
Caregiver present
EMS report
Daycare report
Witnessed choking history
Family history
Relevant family conditions
Atopy history
Asthma history
Hereditary angioedema history
Risk Factors
Host and anatomic risks
High risk patient features
Age under 6 months
Prematurity
Known airway anomaly
Subglottic stenosis history
Neuromuscular weakness
Immunocompromised state
Incomplete immunizations
Exposure risks
Environmental and infectious exposures
Sick contacts
Daycare attendance
Secondhand smoke
Recent travel
Procedure and device risks
Iatrogenic risks
Recent intubation
Recent airway surgery
Recent endoscopy
Differential Diagnosis
Life threatening
Life threatening causes of stridor
Epiglottitis (J05.1)
Drooling
Toxic appearance
Tripod position
Minimal cough
Bacterial tracheitis
Toxic appearance
High fever
Poor response to nebulized epinephrine
Foreign body aspiration (T17)
Sudden onset
Witnessed choking
Focal wheeze
Unilateral decreased breath sounds
Anaphylaxis (T78.2)
Urticaria
Angioedema
Hypotension
Retropharyngeal abscess
Neck stiffness
Limited neck extension
Drooling
Peritonsillar abscess
Muffled voice
Trismus
Uvular deviation
Airway burn or inhalation injury
Soot
Facial burns
Hoarseness
Common
Common causes
Viral croup (acute laryngotracheitis) (J05.0)
Barky cough
Hoarseness
Inspiratory stridor
Viral URI with laryngitis
Hoarseness predominant
Minimal stridor
Asthma with upper airway noise mimic
Expiratory wheeze
Response to bronchodilator
Less common
Less common causes
Laryngomalacia
Chronic since infancy
Worse supine
Subglottic hemangioma
Progressive stridor
Poor response to croup therapy
Vocal cord paralysis
Weak cry
Aspiration
Diphtheria
Pseudomembrane
Unvaccinated
Mimics and pitfalls
Mimics and pitfalls
Bronchiolitis with transmitted upper airway sounds
Diffuse crackles
Wheeze
Psychogenic stridor
Normal oxygenation
Variable symptoms with distraction
Past Medical History
Relevant conditions
Key PMH for stridor
Prior croup admissions
Prior ICU admission
Prior intubation history
Known congenital airway disorder
Chronic lung disease of prematurity
Congenital heart disease
GERD history
Neuromuscular disease
Surgical and procedural history
Airway related procedures
Prior ENT surgery
Prior endoscopy
Recent dental procedure
Baseline status
Baseline functional status
Feeding baseline
Sleep baseline
Home oxygen use
Physical Exam
General appearance
Toxicity and work of breathing
Level of consciousness
Ability to console
Hydration status
Color
Posture
Vitals interpretation
Vitals patterns
Fever severity
Tachycardia severity
Tachypnea severity
SpO2 trend
Airway and ENT
Upper airway focused exam
Stridor at rest
Stridor with agitation
Voice quality
Drooling
Trismus
Neck tenderness
Neck range of motion
Oropharynx inspection only if safe
Respiratory
Lung and breathing exam
Retractions location
Nasal flaring
Air entry
Wheeze
Crackles
Prolonged expiratory phase
Cardiovascular
Perfusion and hemodynamics
Capillary refill
Pulses
Heart rate rhythm
Neurologic
Neuro status
Agitation
Lethargy
Tone
Skin
Skin and allergy signs
Urticaria
Angioedema
Rash
Lab Studies
When labs help
Lab strategy
No routine labs for typical mild to moderate croup
Labs if toxic appearance
Labs if severe respiratory distress
Targeted labs for severe or alternate diagnosis
Targeted labs
Venous blood gas if impending failure
Rising CO2 concern
Worsening acidosis concern
CBC if suspected bacterial tracheitis
Leukocytosis support
Not diagnostic alone
Blood culture if septic appearance
Before antibiotics if feasible
Do not delay airway stabilization
Respiratory viral testing local protocol dependent
Cohorting utility
Does not change acute management in most cases
Imaging
Scoring Systems
Westley croup score use
When to use
Standardize severity description
Track response over time
When not to use
Suspected epiglottitis
Suspected foreign body
Components
Stridor
Retractions
Air entry
Cyanosis
Level of consciousness
Interpretation
Mild typical outpatient pathway
Moderate consider nebulized epinephrine
Severe high risk airway deterioration
MRI
MRI role
Not first line in acute stridor
Consider for structural lesion workup after stabilization
Requires sedation risk assessment
CT
CT indications after stabilization
Suspected deep neck space infection
Suspected abscess with airway symptoms
Persistent stridor with atypical course
Contrast allergy considerations
Radiation risk considerations
Ultrasound
Ultrasound role
Neck soft tissue evaluation adjunct
Lymph node and abscess screening adjunct
Limited role for subglottic assessment
Plain radiography
X ray indications
Atypical presentation
Poor response to standard therapy
Suspected foreign body
Suspected epiglottitis only if stable and escorted
Suspected bacterial tracheitis
Neck radiograph pearls
Steeple sign supports croup but not required
Thumb sign supports epiglottitis
Normal film does not exclude dangerous causes
Chest radiograph pearls
Unilateral hyperinflation suggests foreign body
Atelectasis is nonspecific
Special Tests
Airway evaluation
Airway tests and procedures
Flexible nasolaryngoscopy
ENT setting after stabilization
Not for unstable child in ED without airway plan
Direct laryngoscopy
OR setting if suspected epiglottitis
Coordinate anesthesia and ENT
Bronchoscopy
Suspected foreign body
Persistent unexplained stridor
Bedside response tests
Treatment response as diagnostic support
Improvement after nebulized epinephrine supports croup physiology
Lack of improvement raises alternate diagnosis concern
ECG
When ECG is relevant
ECG considerations
Severe tachycardia after epinephrine
Known congenital heart disease
Electrolyte abnormality concern
High risk patterns
ECG red flags
Supraventricular tachycardia
Wide complex tachycardia
Ischemic changes rare in children
Assessment
Working diagnosis and severity
Viral croup (J05.0) assessment frame
Severity by stridor
None at rest
Present at rest
Severity by work of breathing
Mild retractions
Moderate retractions
Severe retractions
Air entry
Normal
Decreased
Oxygenation
Normal on room air
Hypoxemia present
Complications and alternate diagnoses
Alternate diagnosis screen
Epiglottitis concern features present
Foreign body concern features present
Bacterial tracheitis concern features present
Anaphylaxis concern features present
Deep neck infection concern features present
Plan
Approach to the critical patient first 5 minutes
First 5 minutes workflow
Minimize agitation
Caregiver presence if calming
Position of comfort
Continuous pulse oximetry
Cardiorespiratory monitor if moderate to severe
Oxygen blow by if needed
Nebulized epinephrine if stridor at rest
Dexamethasone as early as possible
IV access if severe distress
Airway team activation triggers
Fatigue
Altered mental status
Poor air entry
Cyanosis
Drooling with toxic appearance
Therapeutics by severity
Mild
Single dose dexamethasone
Supportive care
Moderate
Dexamethasone
Nebulized epinephrine
Observation for recurrence
Severe
Dexamethasone
Repeated nebulized epinephrine as needed
Heliox if available
Prepare advanced airway pathway
Reassessment loop
Reassessment loop timing
Recheck within 15 to 30 minutes after nebulized epinephrine
Recheck within 30 to 60 minutes after dexamethasone if initial mild
Repeat vitals each reassessment
Repeat work of breathing assessment each reassessment
Repeat stridor at rest assessment each reassessment
Reassessment triggers for escalation
Worsening retractions
New hypoxemia
Diminished air entry
Exhaustion signs
Consultation plan
Consult triggers
ENT for suspected epiglottitis
ENT for suspected foreign body airway
PICU for severe or recurrent epinephrine need
Anesthesia for high risk airway
Special populations and nuances
Recurrent or atypical croup
Consider anatomic lesion evaluation after stabilization
Consider reflux contribution evaluation after stabilization
Suspected epiglottitis pathway
Keep child calm
Avoid throat instrumentation
Controlled airway in OR plan
Suspected anaphylaxis pathway
IM epinephrine 0.01 mg per kg of 1 mg per mL
Maximum 0.5 mg per dose
Repeat every 5 to 15 minutes if needed
Disposition
Level of care criteria
ICU criteria
Persistent severe distress after therapy
Repeated nebulized epinephrine requirement
Hypoxemia requiring high flow oxygen
Hypercapnia concern
Impending respiratory failure signs
Inpatient admission criteria
Persistent stridor at rest after observation
Need for ongoing oxygen
Dehydration requiring IV fluids
Suspicion of bacterial tracheitis
Unreliable follow up
Observation pathway criteria
Received nebulized epinephrine
Monitor at least 2 to 3 hours after last dose
Discharge only if no recurrence
Discharge criteria
Safe discharge features
No stridor at rest
Minimal or no retractions
Normal oxygenation on room air
Adequate oral intake
Caregivers understand return precautions
Access to follow up
Transfer criteria
Transfer triggers
No pediatric airway capability locally
Suspected epiglottitis
Suspected foreign body requiring bronchoscopy
Need for PICU not available
Discharge Instructions
Copy discharge instructions
Diagnosis and expectations
Croup causes swelling in the upper airway and can cause a barking cough and noisy breathing
Symptoms often worsen at night and usually improve over a few days
Medications given today
Steroid dose given to reduce airway swelling
If a breathing treatment was given it may wear off in a few hours
Home care
Keep your child calm and sitting upright
Offer frequent fluids
Use cool or humidified air if it helps
Return to the emergency department now if
Noisy breathing at rest
Breathing is getting harder
Skin looks blue or gray
Pauses in breathing
Drooling or trouble swallowing
Very sleepy or hard to wake
Signs of dehydration
Follow up
Primary care follow up within 1 to 2 days
Earlier follow up if symptoms worsen
References
Guidelines and key sources
Evidence based sources
American Academy of Pediatrics clinical guidance on croup and upper airway obstruction local protocol dependent
Canadian Paediatric Society practice point on croup year local protocol dependent
Cochrane review on glucocorticoids for croup updated year local protocol dependent
Cochrane review on nebulized epinephrine for croup updated year local protocol dependent
Infectious Diseases Society guidance relevant to epiglottitis and deep neck infections local protocol dependent
Source file
Project instructions followed for formatting
Point of care checklist structure
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.