›Supportive measures
›Calm environment
›Parent presence
›Oxygen when needed
›Blow-by oxygen
›Nasal cannula if tolerated
›Oral hydration when mild
›Small frequent fluids
›Antipyretics for comfort
›Acetaminophen weight-based per local formulary
›Ibuprofen weight-based per local formulary
›Systemic corticosteroids for all severities
›Dexamethasone PO or IM 0.6 mg/kg once
›Maximum 10 mg
›Onset within several hours
›Reduced return visits and admission risk
›Dexamethasone lower-dose options
›0.15 mg/kg once
›0.3 mg/kg once
›Budesonide nebulized alternative when oral not possible
›2 mg nebulized once
›Similar efficacy to dexamethasone in many studies
›Evidence level framing
›High-quality evidence supports corticosteroids improving symptoms and reducing admissions
›ACEP Level A style evidence equivalent support for steroid use in croup pathways
›Nebulized epinephrine for moderate to severe croup
›Racemic epinephrine 2.25% nebulized 0.05 mL/kg
›Maximum 0.5 mL
›Dilution to 3 mL with normal saline
›Clinical effect within minutes
›L-epinephrine 1 mg/mL nebulized 0.5 mL/kg
›Maximum 5 mL
›Comparable efficacy to racemic formulations
›Observation after dose
›Minimum 2-3 hours after last dose
›Recurrence monitoring as effect wanes
›Repeat dosing logic
›If persistent severe symptoms at 10-20 minutes, repeat nebulized epinephrine
›If repeated doses required, admission or ICU consideration
Escalation therapies and airway management
›Escalation options
›Heliox for refractory moderate to severe symptoms
›Bridge while steroids take effect
›Most effective with high oxygen saturation and minimal oxygen requirement
›Noninvasive ventilation considerations
›Not routine
›Specialist-guided in monitored setting
›Intubation indications
›Exhaustion
›Persistent hypoxemia or hypercapnia concern
›Decreasing level of consciousness
›Intubation technique pearls
›Smaller endotracheal tube than age-predicted
›Experienced operator
›Prepare for difficult airway and rapid deterioration
Therapies to avoid or limit
›Low-value or harmful interventions
›Routine antibiotics
›Viral etiology typical
›Routine beta-agonists
›Upper airway obstruction primary issue
›Routine humidified mist therapy
›Limited evidence for meaningful benefit in ED setting
›Sedation without airway plan
›Increased obstruction risk
Coexisting bacterial disease pathway
›If bacterial tracheitis suspected
›Broad-spectrum IV antibiotics
›Local guideline regimen
›Staphylococcus aureus coverage
›Early airway consultation
›High intubation frequency
›Admission to ICU
›Airway toileting needs