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Humidified oxygen and dexamethasone; discharge if the patient improves
9%
1/11
Discharge from the emergency department without treatment
0%
0/11
Dexamethasome, racemic epinephrine and observation for 4 hours; discharge if stridor remits
64%
7/11
Broncoscopy to remove a foreign body in the upper airway then discharge
18%
2/11
Empiric intravenous (IV) antibiotics, intubate and admission
Select Answer to see Preferred Response
This patient has a severe case of viral croup. The best treatment for a severe case of viral croup is: dexamethasone, racemic epinephrine, and supplemental oxygen if needed. Croup is most commonly caused by parainfluenza virus infection, resulting in subglottic edema and inflammation. Symptoms may range from mild (barking cough, no stridor) to severe (barking cough, stridor, respiratory distress). Treatment regimens depend on the severity of the patients condition: mild cases require dexamethasone and severe cases require both dexamethasone and racemic epinephrine. Treatment with humidified oxygen is optional. Zoorob et al. give a descriptive overview of croup. Croup is very common, accounting for around 15 percent of pediatric hospital visits secondary to respiratory causes. The viral infection typically presents with an upper respiratory prodrome for a couple of days followed by the sudden onset of stridor. It is important to rule out foreign body obstruction, bacterial tracheitis and epiglottis before continuing with treatment. Only a very small percentage of cases of croup are determined to be severe, 1-8% of them requiring hospitalization. Bjornson et al. review the evidence surrounding the use of nebulized racemic epinephrine as part of treatment for severe croup. Epinephrine is useful as it decreases upper airway edema, causes bronchodilation and smooth muscle relaxation. The therapeutic benefit of racemic epinephrine is often within the first 30 minutes of administration but may last up to two hours. Further, patients whose stridor resolves after racemic epinephrine need to remain in the hospital for up to 4 hours due to the risk of bronchospasm. Illustration A shows a radiograph, with the classic steeple sign displayed. Incorrect Answers: Answer 1: This treatment would be an acceptable regimen in a child with mild croup Answer 2: Evidence supports treatment with a one-time dose of dexamethasone for any child with mild croup Answer 4: A foreign body obstruction of the airway is unlikely. This patient does not have access to any objects which could be used to obstruct his airway. Answer 5: IV antibiotics with possible intubation is the mainstay for the treatment of bacterial tracheitis. This condition is commonly caused by S. aureus and presents with an acute onset of high fever and upper airway congestion.
5.0
(6)
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