›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
›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