← Diagnosis and Management Guides
Croup (Laryngotracheobronchitis)
Key considerations: Epiglottitis, Foreign body aspiration, Bacterial tracheitis
Cannot miss
- Epiglottitis
- Foreign body aspiration
- Bacterial tracheitis
- Retropharyngeal abscess
Likely diagnoses
- Viral croup (parainfluenza)
- Spasmodic croup
- URI with stridor
Red flags
- Severe stridor at rest
- Cyanosis
- Altered mental status
- Drooling (epiglottitis)
Workup
- history: Barky cough, stridor, preceding URI symptoms, age 6mo-3yr; exam: Inspiratory stridor, barky cough, retractions, assess severity; labs: Generally not needed; imaging: AP neck XR: steeple sign (not required for diagnosis); bedside: Westley croup score
Management
- immediate: Dexamethasone 0.6mg/kg PO/IM (single dose) — all severities; Racemic epinephrine 0.5mL of 2.25% nebulized for moderate-severe stridor at rest; general: Observe 2-4 hours after racemic epinephrine for rebound; Cool mist (limited evidence but not harmful); Minimize agitation
Disposition
- admit: Persistent stridor at rest after treatment, multiple epi nebs needed, hypoxia; discharge: After dexamethasone with resolution of stridor at rest, no need for repeat epi; consults: ENT if atypical presentation or concern for alternative diagnosis
Clinical pearls
- Dexamethasone is effective for ALL croup severities — even mild croup benefits from single dose
- If symptoms recur after racemic epi, observe in ED — rebound typically within 2 hours
Source and review
- AAP Croup Guidelines 2018. Last reviewed: 2024-11-01