Infectious Upper Airway Obstruction - Croup or Epiglottitis

Section 3 - RESPIRATORY

3.04 INFECTIOUS UPPER AIRWAY OBSTRUCTION CROUP/EPIGLOTTITIS

Croup

• Sudden onset dyspnea, barking cough, stridor in a previously well - afebrile child
• Stridor at night 1 AM – 5 AM
• Hoarse voice
• Fever is common
• Chest usually clear – may have mild wheezing
• Stridor may be both inspiratory and expiratory
• Intercostals retractions and nasal flaring may be present
• Severe lethargy and agitation
• Tachycardia and tachypnea
• Cyanosis is late and ominous sign

Viral-Bronchiolitis

• Wheezing in infants caused by infectious agents (i.e. Flu, RSV, CMV and others)

TREATMENT

INITIAL MEDICAL CARE (2.01)Administer humidified OXYGEN @ 100% via Pediatric mask or ‘blow-by’ technique. Significant attempts should be made to keep child calm at all times; including allowing parents close contact with patient during transport.

• Do not attempt aggressive airway intervention unless airway becomes obstructed.
• Initiate IV access ONLY after airway control is established and patient’s condition warrants this intervention.
• Obtain history and assess respiratory status.
• If wheezing present, ALBUTEROL (PROVENTIL) 2.5 mg via updraft. Monitor heart rate. (IPRATROPIUM BROMIDE (ATROVENT) is not indicated).
• For wheezing with viral illness or spasmodic croup not responding to ALBUTEROL.
  • Pulse oximetry
  • O2 and RACEMIC EPINEPHRINE (VAPONEFRINE) via blow-by updraft
  • 0.5 ml RACEMIC EPINEPHRINE (VAPONEFRINE) in 2 ml Saline, nebulized
  • Requires 4-6 hrs observation in the ER

NOTE: RACEMIC EPINEPHRINE is not the treatment of choice for Epiglotitis and should be limited to patients without stridor, who have a barking cough and are tachypneic.

• If the patient is not responding to the above interventions, contact on-line medical control of the receiving facility for order to administer: METHYLPREDNISOLONE (SOLU-MEDROL) 1-2 mg/kg IM OR IVP
• If breathing becomes labored, assist ventilations with OXYGEN @ 100% via BVM
• If patient becomes apneic, perform endotracheal intubation.
• If unable to ventilate and airway not patent, perform Cricothyrotomy, (use Needle Cricothyrotomy technique in children under age 12).

In the event of impending acute Airway Obstruction and Cardiac Arrest, EPINEPHRINE may be administered IV or SQ as per Broselow dosage.