CG26 VERSION 1.0 1/8 Guideline ID CG26 Version 1.0 Title Approved by Management of Croup Clinical Effectiveness Group Date Issued 01/10/2014 Review Date 31/09/2017 Directorate Authorised Staff Medical Ambulance Care Assistant Emergency Care Assistant Student Paramedic Advanced Technician Paramedic (non-ecp) Nurse (non-ecp) ECP Doctor Clinical Publication Category Guidance (Green) - Deviation permissible; Apply clinical judgement 1. Scope 1.1 This clinical guideline aims to provide clinicians with an evidence-based guide to the diagnosis and management of children presenting with croup. It includes advice on the clinical presentation and the assessment and management of mild, moderate and severe croup by ambulance clinicians. 2. Introduction 2.1 Croup is a viral respiratory tract illness commonly affecting children between the ages of 6 months and 3 years, with a peak incidence during the second year of life. However in some cases it can affect children up to 15 years of age. 2.2 Croup is categorised into four types; mild, moderate, severe and life-threatening. Whilst the vast majority of children with croup recover without consequence, in some cases it can be life-threatening. This guideline focuses on severe and lifethreatening croup as this is the severity of illness that most commonly presents to ambulance clinicians. 3. Clinical Presentation 3.1 Croup presents symptomatically in young children as a hoarse, barking cough with stridor (predominantly inspiratory), caused by obstructive oedema in the larynx and trachea. Symptoms may be worse at night and may be accompanied by a fever.
CG26 VERSION 1.0 2/8 3.2 Stridor is defined as an audible harsh, high pitched sound produced by turbulent airflow through a partially obstructed upper airway. This partial obstruction can be present at the level of the supraglottis, glottis, and/or trachea. 3.3 Table 1 - Croup Severity Categorisation: Mild Moderate Severe Life Threatening Airway/ Respirations Occasional barking cough Frequent barking cough Frequent barking cough Severe respiratory distress Respiratory Effort Normal Increase in work of breathing Significant increase in work of breathing Failing ventilations associated with croup Stridor None Audible at rest Prominent inspiratory and occasionally expiratory stridor at rest Audible stridor at rest Chest Examination No or mild Suprasternal and/or intercostal recession Suprasternal and sternal wall retraction at rest Marked sternal wall retractions Sternal wall retractions Cardiovascular Normal Mild tachycardia Tachycardia Tachycardia Colour Normal Normal Flushed Dusky in appearance Temperature Mild to moderate fever Mild to moderate fever Mild to moderate fever Activity Happy to eat, drink and play as normal Little or no distress / agitation Significant distress and agitation, or lethargy or restlessness (signs of hypoxaemia) Decreased level of consciousness
CG26 VERSION 1.0 3/8 3.4 Table 2 - Differential Diagnosis of Croup and Epiglotitis: Feature Epiglottitis Croup Organism H. influenzae Parainfluenza virus Age Generally 2-6 years old, may occur in older children and adults Generally less than 2 years old, may occur in children 6 months to 6 years Onset Rapid Gradual Temperature High fever Low grade fever Dysphagia Severe Absent (mild) Dyspnoea +++ Variable Drooling Present Not present (except in late stages) Stridor Inspiratory or expiratory Mainly inspiratory Lymph Nodes +++ + Cough Not common Barking cough Voice Muffled Hoarse Posture Sitting forward, tripod Lying down Behaviour Quiet, terrified Struggling Colour Grey Pink Previous Attack None May have had previous attack
CG26 VERSION 1.0 4/8 4. Assessment 4.1 It is essential to gain a history of the presenting complaint, past medical history and any known allergies. All clinical assessments should follow a CABCD approach, with any deficit considered time critical. The clinical assessment MUST include: Respiratory rate Level of consciousness Work of breathing Oxygen saturations Breath sounds Temperature Adequacy of breathing Pupil response Use of accessory muscles Glucose levels Skin colour Blood pressure if possible Heart rate 4.2 The assessment of severity can be determined using the Modified Taussig Croup Score (JRCALC 2013). 4.3 Table 3 - Modified Taussig Croup Score: Symptom Present Score None 0 Stridor Only crying, exertion 1 At rest 2 Severe (Biphasic) 3 None 0 Recession Only crying, exertion 1 At rest 2 Severe (Biphasic) 3 4.4 A score of 1-2 indicates a mild episode, 3-4 moderate and 5-6 severe/lifethreatening. Any signs of severe, or life-threatening croup identified using these parameters should be treated as time critical.
CG26 VERSION 1.0 5/8 5. Treatment 5.1 Severe and Life-threatening 5.1.1 Severe and life-threatening croup signs and symptoms should be treated as time critical. The child MUST be immediately transported to the nearest ED with paediatric facilities, providing an ATMIST pre-alert. 5.1.2 Registered Paramedics, Registered Nurses and ECPs are authorised to administer a single dose of nebulised adrenaline 1:1000 to patients aged one month to 12 years, suspected of suffering from severe, life threatening croup where ANY of the following are present: Signs of severe respiratory distress; Stridor at rest; Failing ventilations. 5.1.3 Whilst there are no contraindications for use in a life-threatening situation, use with caution for children with major congenital cardiac defects. 5.1.4 Dosage for administration should be calculated at 400 micrograms/kg, up to a maximum dose of 5mg using adrenaline 1:1000 (1mg/ml). Dilute dose with 5 millilitres of 0.9% sodium chloride. Single dose only. 5.1.5 Do not delay transfer - administer nebulised adrenaline 1:1000 en-route to hospital. All children treated with nebulised adrenaline MUST be conveyed to hospital. 5.1.6 Adrenaline stimulates bronchial beta-adrenergic receptors leading to bronchial smooth muscle relaxation and bronchodilation. Its effect is immediate (within 30 minutes) and lasts for 90-120 minutes (Defendi et al 2013). 5.1.7 Where a Doctor or an ECP, Registered Paramedic or Registered Nurse authorised by the Trust to administer dexamethasone is present on-scene and the medicine is available, it should be administered according to the Trust s medicines protocol.
CG26 VERSION 1.0 6/8 5.2 Moderate 5.2.1 If any signs of stridor at rest, sternal recession or agitation are present, the child must be conveyed to the nearest ED with paediatric facilities. If a Doctor, Registered Paramedic, Registered Nurse or ECP authorised by the Trust to administer dexamethasone is present on-scene, the medicine should be administered according to the Trust s medicines protocol. 5.2.2 Children who present with moderate croup without the warning signs detailed in 5.2.1, may be suitable to remain on-scene. All patients remaining onscene must receive dexamethasone as indicated. This may require referral to a Registered Paramedic, Registered Nurse, ECP or Doctor to ensure that it is received in a timely manner. Registered Paramedics and Registered Nurses should access senior clinical advice from an ECP, Doctor or the Senior Clinical Advisor On-call where required to support the decision making process; admit if at all unsure. 5.3 Mild 5.3.1 Mild croup with no signs of moderate, severe or life-threatening croup can usually be managed at home by administration of dexamethasone. Access senior clinical advice from an ECP, Doctor or the Senior Clinical Advisor On-call where required to support the decision making process; admit if at all unsure. Refer to Clinical Guideline CG16 - Paediatric Fever for further guidance on the the assessment and management of fever. 5.4 Dexamethasone 5.4.1 Dexamethasone is beneficial in all categories of croup. It is a long acting corticosteroid with a biological half life between 36 and 72 hours. The antiinflammatory action of the corticosteroid will assist in the reduction of the laryngeal mucosa. Studies have found a reduction in both hospital admission and symptoms of airway obstruction from as early as one hour post treatment with dexamethasone. Dexamethasone 2mg/5ml oral solution is carried in the paramedic and ECP drug bag, and on Urgent Care Services vehicles. It is stocked in Urgent Care Service Treatment Centres and the MIU, Tiverton. 6 Documentation 6.1 In line with Trust Policy, a Patient Clinical Record must be completed and annotated appropriately. Any deviation from this clinical guideline must be recorded, with any potential or actual adverse event reported through the incident reporting system.
CG26 VERSION 1.0 7/8 REFERENCES Advanced Life Support Group (2008). Paediatric and neonatal Safe Transfer and Retrieval; The Practical Approach. London: Wiley-Blackwell. 96-98. Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. (2013). Nebulised epinepherine for croup in children (Review). Available: www.ncbi.nlm.nih.gov/m/ pubmed/24114291/. Last accessed 27/11/13. Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. (2011). Nebulised epinephrine for croup in children. Available: http://www.ncbi.nlm.nih.gov/ pubmed/21328284. Last accessed 25/11/13. British National Formulary for Children. (2013). Adrenaline/epinephrine. Available: http://evidence.nhs.uk/formulary/bnfc/current/3-respiritory-system/34-antihistaminesimmunotherapy. Last accessed 25/11/13. Defendi GL. (2013). Croup. Available: http://emedicine.medscape.com/article/962972. Last accessed 14/1/14. Drug and Theraputics Bulletin. (1996). Inhaled budesonide and adrenaline for croup. Available: http://dtb.bmj.com/content/34/3/23.abstract?sid=608b44da-3dd7-41b4- a078-497cb5bc6cc9. Last accessed 25/11/13. Kavanagh S. (2012). Croup. Available: http://patient.co.uk/doctor/croup.htm#. Last accessed 25/11/13. Marin J. (2007). Pediatric upper airway infectious disease emergencies. Available: http://ebmedicine.net/topics.php?paction=showtopicsegtopic_id=128seg_id=2543. Last accessed 25/11/13. National Institute Clinical Excellence (2013) Feverish Illness in Children: Assessment and Initial Management in children younger than 5 years (CG160). NICE. Roberts K, Jewkes F, Whalley H, Hopkins D, Porter K. (2005). A review of emergency equiptment carried and procedures performed by UK frontline paramedics on paediatric patients. Emergency Medical Journal. 10 (22), 572-576.
CG26 VERSION 1.0 8/8 Russell KF, Liang Y, O Gorman K, Johnson DW, Klassen TP. (2011). Glucocorticoids for croup. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd001955. pub3/full. Last accessed 25/11/13. Turner, H, Sergent, N. (2013) The use of nebulised adrenaline 1in 1,000 (1mg in 1ml) in the management of severe croup. Paper presented to SWASFT Medicines Management Group 3rd December 2013 Acknowledgements The Trust would like to thank Paramedic Mentor Hannah Turner (Bristol Station) for developing the guideline for nebulised adrenaline.