› ! Anaphylaxis → › ! Angioedema → › Epiglottitis → › Croup (laryngotracheobronchitis) → › 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
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