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History
Presenting features
Stridor and upper airway symptom history
Noisy breathing onset pattern
Sudden onset minutes to hours
Gradual onset hours to days
Symptom timing context
At rest
With agitation or crying
Audible quality
Inspiratory predominant
Biphasic
Voice and swallowing changes
Hoarseness
Muffled voice
Feeding and hydration impact
Poor oral intake
Drooling
OPQRST
OPQRST
Onset
Exact time last well
Preceding choking episode
Provocation and palliation
Worse supine
Better upright
Quality
Stridor
Barky cough
Region and radiation
Throat tightness localization
Chest involvement symptoms
Severity
Ability to speak or cry
Work of breathing severity
Timing
Intermittent episodes
Progressive worsening
Associated symptoms
Associated symptoms
Fever and infectious symptoms
Fever history
Coryza
Allergy symptoms
Urticaria
Facial or lip swelling
Aspiration features
Coughing with eating
Sudden wheeze after choking
Toxic ingestion or caustic exposure
Odynophagia
Oral burns
Pediatric specific
Pediatric history
Vaccination status
Hib immunization completeness
DTaP immunization completeness
Baseline airway history
Prior croup episodes
Known laryngomalacia
Foreign body risk context
Age under 4 years
Access to small objects
Traumatic and iatrogenic context
Trauma and procedures
Recent intubation or airway instrumentation
Post extubation timing
Known difficult airway
Neck trauma
Blunt neck injury
Strangulation mechanism
Recent head and neck surgery
Thyroid surgery
Tonsillectomy
Alarm Features
Immediate danger triggers
Immediate escalation triggers
Impending airway failure
Silent stridor or decreasing air movement
Fatigue with reduced work of breathing
Hypoxemia
SpO2 persistently under 92 percent on room air
Cyanosis
Altered mental status
Agitation with hypoxia concern
Lethargy
Inability to handle secretions
Drooling
Pooling secretions
Signs of anaphylaxis
Hypotension
Progressive facial or tongue swelling
High risk clinical patterns
High risk patterns
Suspected epiglottitis
Toxic appearance
Tripod positioning
Suspected bacterial tracheitis
High fever
Rapid progression despite typical croup care
Suspected deep neck space infection
Neck swelling
Trismus
Suspected foreign body
Sudden onset with choking
Unilateral wheeze or asymmetric breath sounds
Vital sign danger thresholds
Vital sign danger thresholds
Respiratory distress
Marked tachypnea for age
Use of accessory muscles
Circulatory compromise
Hypotension
Poor perfusion
Fever pattern concern
High fever with toxic appearance
Fever with neck stiffness
Medications
Current and recent exposures
Medication review
Respiratory meds
Recent beta agonist use
Recent inhaled steroid use
Allergy meds
Antihistamines
Epinephrine autoinjector availability
Recent antibiotics
Within last 7 days
Non adherence
Recent anesthesia or sedation agents
Opioids
Benzodiazepines
Contraindications and interaction traps
Medication risk considerations
Beta blocker therapy
Blunted response to epinephrine in anaphylaxis
Consider glucagon if refractory anaphylaxis local protocol dependent
ACE inhibitor therapy
Bradykinin mediated angioedema possibility
Poor response to antihistamines alone
Anticoagulants
Higher risk airway bleeding with trauma
Lower threshold for imaging if neck hematoma concern
Diet
Intake and exposure
Diet and exposure
Recent oral intake
Poor intake
Vomiting
Aspiration risks
Eating at symptom onset
Dysphagia history
Caustic exposure risk
Household cleaners access
Intentional ingestion concern
Review of Systems
Airway and respiratory
Respiratory ROS
Dyspnea
At rest
With exertion
Cough
Barky cough
Productive cough
Wheeze
Diffuse
Unilateral
Chest pain
Pleuritic
Non pleuritic
ENT and systemic
ENT and systemic ROS
Sore throat
Odynophagia
Globus
Voice change
Hoarseness
Muffled voice
Fever and chills
Measured fever
Rigors
Rash
Urticaria
Purpura
GI and neuro
GI and neuro ROS
Drooling
New onset
Progressive
Vomiting
Post tussive
Persistent
Headache or neck pain
Neck stiffness
Photophobia
Altered mental status
Confusion
Somnolence
Collateral History and Family History
Collateral and reliability
Collateral
Source
Parent or caregiver
EMS report
Reliability factors
Witnessed choking event
Baseline developmental status
Family history
Family history
Hereditary angioedema suspicion
Recurrent swelling episodes in family
Laryngeal edema history in relatives
Atopy
Asthma
Food allergy
Risk Factors
Infectious and exposure risks
Exposure risk
Sick contacts
Viral URI exposure
Influenza exposure
Immunization gaps
Hib incomplete
DTaP incomplete
Immunocompromised status
Chronic steroids
Chemotherapy
Airway and anatomic risks
Airway risk
Prior airway disease
Subglottic stenosis
Prior tracheostomy
Obstructive sleep apnea
Baseline airway collapsibility
Sedation sensitivity
GERD and aspiration
Recurrent aspiration pneumonia
Neuromuscular disease
Foreign body and trauma risks
Foreign body and trauma risk
Pediatric choking risk
Toddlers
Nuts and small toys
Facial or neck trauma
Sports injury
Assault
Differential Diagnosis
Life threatening
Life threatening causes
Anaphylaxis (T78.2)
Stridor with urticaria or hypotension
Rapid progression minutes
Angioedema (T78.3)
Tongue or oropharyngeal swelling
ACE inhibitor exposure
Epiglottitis (J05.1)
Drooling with toxic appearance
Tripod positioning
Bacterial tracheitis (J04.1)
High fever
Thick secretions with rapid deterioration
Foreign body upper airway (T17.2)
Sudden onset after choking
Unilateral findings
Deep neck space infection
Peritonsillar abscess (J36)
Retropharyngeal abscess (J39.0)
Airway burn or inhalation injury (T27)
Facial burns
Soot in mouth or nose
Post intubation airway edema or obstruction (J95.821)
Stridor after extubation
Rapid fatigue
Expanding neck hematoma
Anticoagulation use
Neck swelling and voice change
Common
Common causes
Viral croup (J05.0)
Barky cough
Worse at night
Laryngitis (J04.0)
Hoarseness
URI symptoms
Vocal cord dysfunction (J38.3)
Inspiratory noise with normal oxygenation
Triggered by anxiety or exercise
Laryngomalacia
Infant onset
Worse supine
Less common
Less common causes
Tracheomalacia
Expiratory and inspiratory noise
Recurrent symptoms
Subglottic stenosis (J38.6)
History of prolonged intubation
Recurrent croup like episodes
Neoplasm or mass effect
Thyroid mass
Laryngeal tumor (C32)
Diphtheria (A36)
Pseudomembrane concern
Incomplete vaccination
Mimics and pitfalls
Mimics and pitfalls
Wheezing misclassified as stridor
Expiratory predominant sound
Response to bronchodilator suggests lower airway
Anxiety and hyperventilation
Paresthesias
Normal exam between episodes
Stertor from nasal obstruction
Congestion
Improved with suction in infants
Past Medical History
Relevant conditions
Relevant PMH
Asthma history
Prior ICU admissions
Prior intubation
Prior croup
Frequency per year
Prior steroid response
Allergies
Food allergy
Medication allergy
Prior airway surgery
Tracheostomy history
Laryngeal surgery
Devices and prior care
Devices and prior care
Implanted devices
Tracheostomy tube type
Home ventilator
Prior hospitalizations
Recent admission within 30 days
Prior airway complications
Physical Exam
First look and vitals interpretation
Initial appearance
Work of breathing
Retractions
Nasal flaring
Posture and positioning
Tripod
Sniffing position
Ability to speak or cry
Full sentences
Single words or weak cry
Perfusion
Cap refill delay
Diaphoresis
Airway and ENT
Airway and ENT exam
Voice quality
Hoarse
Muffled
Drooling and secretions
Active drooling
Pooling secretions
Oropharynx
Tonsillar asymmetry
Uvular deviation
Neck
Tenderness
Swelling
Stridor characteristics
At rest
Only with agitation
Lungs and cardiopulmonary
Cardiopulmonary exam
Breath sounds
Symmetry
Unilateral decreased air entry
Wheeze
Diffuse expiratory wheeze
Focal wheeze
Air movement
Good
Poor
Cardiovascular
Tachycardia
Hypotension signs
Skin and systemic
Skin and systemic exam
Rash
Urticaria
Angioedema facial swelling
Fever pattern
Hot and flushed
Rigors
Neurologic status
Agitation
Lethargy
Lab Studies
Core labs when indicated
Lab strategy
CBC
Suspected bacterial process
Immunocompromised host
Electrolytes
Severe distress
Anticipated intubation
Venous blood gas
Rising CO2 concern
Fatigue and hypoventilation concern
Lactate
Sepsis concern
Shock concern
Infectious testing
Infectious testing
Viral testing local protocol dependent
Influenza
SARS CoV 2
Blood cultures
Toxic appearance
Suspected epiglottitis or bacterial tracheitis
Pitfalls and limitations
Lab limitations
Normal labs do not exclude epiglottitis
Diagnosis is clinical with airway risk
Imaging and visualization timing depends on stability
Early blood gas may be falsely reassuring
Hyperventilation phase
Decompensation can be rapid
Imaging
Scoring Systems
Severity scoring
Westley croup score
Components
Level of consciousness
Cyanosis
Stridor
Air entry
Retractions
Use case
Track response to therapy
Support disposition decisions
Pediatric early warning scores local protocol dependent
Use case
Deterioration monitoring
Escalation triggers
MRI
MRI role
Indications
Suspected deep neck space complication when CT contraindicated
Evaluation of soft tissue mass when stable
Contraindications and limits
Unstable airway
Time and sedation requirements
CT
CT role
Indications
Retropharyngeal abscess concern
Neck trauma with expanding swelling concern
Protocol considerations
Contrast enhanced CT neck for abscess evaluation
Radiation risk discussion in pediatrics
Contraindications and cautions
Contrast allergy history
Renal impairment risk assessment
Ultrasound
Ultrasound role
POCUS indications
Superficial neck swelling evaluation
Guidance for drainage when appropriate and stable
Limitations
Limited for deep spaces
Operator dependent
Special Tests
Bedside and procedural diagnostics
Special testing
Flexible nasolaryngoscopy
Indication
Stable patient with uncertain diagnosis
Suspected vocal cord dysfunction
Safety constraints
Avoid if epiglottitis suspected and unstable
Perform with airway backup available
Lateral neck radiograph
Indication
Stable patient when deep neck infection in differential
Consider when CT not immediately available
Pitfalls
False negatives early
Patient positioning and technique dependent
Direct laryngoscopy in OR
Indication
Suspected epiglottitis
Suspected airway foreign body
Operational note
Anesthesia and ENT coordination
Controlled environment preferred
ECG
When to obtain
ECG indications
Chest pain or syncope associated with distress
Rule out arrhythmia contribution
Baseline before epinephrine infusion when used
Anaphylaxis with hypotension
Ischemia screening in older adults
Tachyarrhythmia detection
High risk patterns
ECG red flags
Ischemia patterns
ST elevation
Diffuse ST depression with aVR elevation
Conduction abnormalities
High grade AV block
Wide complex tachycardia
Assessment
Problem representation and severity
Assessment
Working syndrome label
Upper airway obstruction concern
Lower airway obstruction mimic excluded or not excluded
Severity tier
Mild stridor only with agitation
Moderate stridor at rest with stable oxygenation
Severe stridor at rest with hypoxemia or fatigue
Most likely etiologic bucket
Viral inflammatory
Allergic edema
Foreign body
Bacterial infection
Complications to rule out
Complications
Impending respiratory failure
Rising CO2 concern
Fatigue
Sepsis
Hypotension
Altered mental status
Aspiration and pneumonitis
Persistent cough after choking
New focal findings
Plan
Immediate stabilization
First 5 minutes
Airway positioning and minimal agitation
Upright position of comfort
Avoid unnecessary oropharyngeal exam if epiglottitis concern
Monitoring and access
Continuous pulse oximetry
Cardiac monitor if severe distress or anaphylaxis concern
Oxygen strategy
Blow by oxygen for children if mask intolerance
High flow nasal cannula if hypoxemia and tolerated
Airway backup activation triggers
Severe distress with stridor at rest
Drooling with toxic appearance
Medication time critical actions
IM epinephrine for anaphylaxis suspicion without delay
Nebulized epinephrine for moderate to severe croup
Targeted therapies by etiology
Treatment pathways
Croup pathway
Dexamethasone PO or IM 0.6 mg per kg maximum 10 mg
Nebulized epinephrine 5 mg of 1 mg per mL solution or 0.5 mL per kg of 2.25 percent racemic maximum 0.5 mL local availability dependent
Reassessment at 15 to 30 minutes after nebulized epinephrine
Rebound monitoring at least 2 to 3 hours after last nebulized epinephrine local protocol dependent
Anaphylaxis pathway
Epinephrine IM 0.3 to 0.5 mg of 1 mg per mL in adults
Epinephrine IM pediatric 0.01 mg per kg of 1 mg per mL maximum 0.3 mg
IV fluids for hypotension
Crystalloid 20 mL per kg bolus in children
Crystalloid 1 L bolus in adults then reassess
Adjuncts
H1 antihistamine for hives
Steroid adjunct for biphasic risk reduction uncertain benefit
Angioedema pathway
Suggestive of histamine mediated
Epinephrine IM if airway involvement
H1 antihistamine
Steroid
Suggestive of bradykinin mediated
Airway first and early airway team activation
Consider targeted therapy per local protocol
Epiglottitis or bacterial tracheitis pathway
Early ENT and anesthesia coordination
Avoid agitation and avoid attempts at visualization in unstable patient
Antibiotics
Ceftriaxone IV adult 2 g daily
Ceftriaxone IV pediatric 50 mg per kg daily maximum 2 g
Add vancomycin if MRSA risk local protocol dependent
Diagnostics and sequencing
Diagnostic sequencing
Stable patient
CXR if foreign body lower airway concern
CT neck with contrast if deep neck infection concern and stable
Unstable patient
Prioritize airway control over imaging
Defer transport off unit until airway secured
Reassessment loop
Reassessment loop
Timing
Every 15 minutes until improving
After each therapy change
Reassessment domains
Work of breathing trend
Stridor at rest versus with agitation
Oxygen requirement trend
Escalation triggers
Increasing oxygen requirement
Fatigue or altered mental status
Disposition
Level of care criteria
Disposition criteria
ICU
Persistent stridor at rest with hypoxemia
Need for repeated nebulized epinephrine with deterioration risk
Suspected epiglottitis or bacterial tracheitis
Inpatient admission
Moderate symptoms requiring oxygen
Poor oral intake or dehydration requiring IV fluids
Significant comorbidity
Observation pathway
Post nebulized epinephrine monitoring window local protocol dependent
Improving work of breathing with stable oxygenation
Discharge criteria
No stridor at rest
Minimal work of breathing
Tolerating oral intake
Reliable caregiver and return access
Transfer and consult
Consult and transfer
ENT consult indications
Suspected deep neck infection
Suspected airway foreign body
Anesthesia consult indications
Anticipated difficult airway
Worsening airway edema
Transfer triggers
Need for pediatric ICU where unavailable
Need for OR airway intervention where unavailable
Discharge Instructions
Copy discharge instructions
Discharge instruction text
Diagnosis summary
Upper airway swelling causing noisy breathing
Current exam stable at time of discharge
Medications
Steroid dose given today
Any prescriptions provided and how to take them
Home care
Keep upright if symptoms return
Avoid smoke exposure
Follow up
Primary care within 24 to 48 hours
ENT follow up if recurrent episodes
Return to ED now if
Stridor at rest
Trouble breathing
Lips or face turning blue
Drooling or trouble swallowing
Worsening swelling of lips tongue or throat
Severe tiredness or confusion
References
Guidelines and key sources
References
American Academy of Pediatrics clinical practice guideline croup management updates as applicable
Pediatric croup severity assessment and steroid use
Nebulized epinephrine use and monitoring practices
Infectious Diseases Society recommendations for epiglottitis and deep neck infections updates as applicable
Empiric antibiotic coverage principles
Airway first management emphasis
World Allergy Organization anaphylaxis guidance 2020
Epinephrine as first line
Dosing principles for adults and pediatrics
American Academy of Allergy Asthma and Immunology practice parameter updates for anaphylaxis and angioedema as applicable
Differentiation of histamine versus bradykinin mediated angioedema
Airway escalation principles
Canadian Paediatric Society position statements on croup and epiglottitis updates as applicable
Canadian ED practice considerations
Local protocol dependent monitoring windows
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.