Really bad croup - your management?

[pinipig523]

Hey guys, really bad croup... how do you guys manage it?

Other than the typical decadron and rac epi... what if the patient is still stridorous after a single rac epi neb? Do you do it back to back? Do you resort to heliox? What are the things to watch out for or pitfalls of heliox?

Thanks fellas.

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[RustedFox]

transfer to peds facility.


zzzing!

you get my package yet, homeboy?

 

[pinipig523]

LOL! Thanks redfox!

I have to check the mail... I think I haven't checked the mail in a few days... hopefully it's there bud! Thanks broman!

Man... the kid I had tonight was probably the worst crouper I've seen yet. I did rac epi q20min x 3... man... good thing he turned around at the end and the transfer team was here to bail me out. Yikes.

Do you guys give epi IM also?

 

[Tiger26]

Might not have been croup, although it seems like you did everything right. How old was the kid? All sorts of laryngotracheal abnormalities or vascular rings can look and sound like croup

 

[Stitch]

Might not have been croup, although it seems like you did everything right. How old was the kid? All sorts of laryngotracheal abnormalities or vascular rings can look and sound like croup

This. Plus I think you need to think of epiglotitis or tracheitis as well. Make sure to get a vaccination history.

I have no problem giving a few racemics close together and even going to heliox, but if you're doing that, bells should be going off that push you to investigate further. Have ENT take a look, and get them involved early. I'd rather call them and have it be 'just croup' than not call them and have an unmanageable airway.

 

[docB]

This. Plus I think you need to think of epiglotitis or tracheitis as well. Make sure to get a vaccination history.

I have no problem giving a few racemics close together and even going to heliox, but if you're doing that, bells should be going off that push you to investigate further. Have ENT take a look, and get them involved early. I'd rather call them and have it be 'just croup' than not call them and have an unmanageable airway.

Ok. Let's say, just for the sake of argument 🙄, that I'm at a community place without heliox or ENT or peds and I'll be needing to stabilize a crouper as well as I can to transfer. Any tips?

 

[Rendar5]

Ok. Let's say, just for the sake of argument 🙄, that I'm at a community place without heliox or ENT or peds and I'll be needing to stabilize a crouper as well as I can to transfer. Any tips?

If they're really that bad, Intubate with a tube a size smaller than expected for the age if they're no good for transport. Then change your pants.
Pitfalls of heliox: the more helium in the mixture, the less oxygen in the mixture. 80:20 is no more oxygne than room air, 70:30 is extra oxygen, but less helium.

 

[Stitch]

Ok. Let's say, just for the sake of argument 🙄, that I'm at a community place without heliox or ENT or peds and I'll be needing to stabilize a crouper as well as I can to transfer. Any tips?

Pray? 😉
If they're looking ok and oxygenating, I'd say you have time. If they hate you that's probably an good sign. I'm not a fan of getting gases in these instances because it might push you to do something you don't want to. Bolus them up, make sure you've got steroids on board.

If they look bad, mess with them as little as possible. The question of whether to secure an airway prior to transport is tough. Any chance you'd have anesthesia around? The couple I've seen we used ketamine and kept them spontaneously breathing with ENT right there. I've also seen anesthesia take them for an inhaled induction, which would be my preference.

How would others approach this one?

 

[Stitch]

If they're really that bad, Intubate with a tube a size smaller than expected for the age if they're no good for transport. Then change your pants.
Pitfalls of heliox: the more helium in the mixture, the less oxygen in the mixture. 80:20 is no more oxygne than room air, 70:30 is extra oxygen, but less helium.

Agree with the smaller tube. I might try half size smaller first. What would you use for induction?

We only use 80/20 here, and not often. I don't think there's great evidence behind it, but it's worth a try. Probably institution dependent. I'd be curious what others' experience with heliox is.

 

[pinipig523]

4 rac epis and the kid was doing better, still had retractions but no more inspiratory stridor. Was on 1.5L NC and was at 97%.

I didn't really want to intubate the 17 month old child because I knew the supraglottic region was going to be edematous and a mess.

I thought about bacterial tracheitis and pulled the trigger on ceftriaxone. Kid was up to date on vaccinations and ft at birth.

I was wondering about using heliox and whether I should've also given an IM shot of epi.

 

[pinipig523]

Seriously man... thinking back about that case just gives me the "I need to wet my pants" feeling. Geez.

 

[8654Marine]

Every shift I have at least one patient who tests my sphincter tone.

Keeps me humble.

Pinipig, this one was yours.

 

[Rendar5]

4 rac epis and the kid was doing better, still had retractions but no more inspiratory stridor. Was on 1.5L NC and was at 97%.

I didn't really want to intubate the 17 month old child because I knew the supraglottic region was going to be edematous and a mess.

I thought about bacterial tracheitis and pulled the trigger on ceftriaxone. Kid was up to date on vaccinations and ft at birth.

I was wondering about using heliox and whether I should've also given an IM shot of epi.

Once had a crouper so bad as a senior resident in my critical care area that I called my other senior resident to watch my patients so I could walk with the kid up to the PICU. Heliox worked instantly , and bought the picu several hours but checking on the kid a couple days later he ended up being intubated. neither I nor the PICU bothered with IM epi.

 

[pinipig523]

Every shift I have at least one patient who tests my sphincter tone.

Keeps me humble.

Pinipig, this one was yours.

Yes sir... this was the one.

Once had a crouper so bad as a senior resident in my critical care area that I called my other senior resident to watch my patients so I could walk with the kid up to the PICU. Heliox worked instantly , and bought the picu several hours but checking on the kid a couple days later he ended up being intubated. neither I nor the PICU bothered with IM epi.

Interesting... no im epi. I wonder about bipap...

 

[Rendar5]

Yes sir... this was the one.



Interesting... no im epi. I wonder about bipap...

I duobt bipap or cpap would have any effect. It's an upper airway issue after all, not a lower airway one.

 

[pinipig523]

I duobt bipap or cpap would have any effect. It's an upper airway issue after all, not a lower airway one.

Understood, but would it not help alleviate some of the breathing requirements? Just like osa is not a lower airway issue.

 

[ptarmigan]

Understood, but would it not help alleviate some of the breathing requirements? Just like osa is not a lower airway issue.

My thought are that they are 2 totaly different pathophysiologies.

OSA is due to the tongue andf other floppy supraglottic structures relaxing and pushing on the airway causing airway obstruction. CPAP stents this portion of the airway open and prevents the tongue from sliding back and collapsing the airway.

BiPap of course does the same but also provides additional positve inspiratory pressure with inspiration.

In laryngotrachiitis (croup), the narrowing is subglottic. If you are breathing through a straw already, then increasing the pressure of the air going into that hole is not going to help much. In fact, putting the mask on might agitate the kid which won't help. The flow of air will be more turbulent as well.

I think of BiPap as being most helpful for increasing ventilation in RAD (i.e. CO2 retention or just working really hard and want to assist them so they don't tire out) or in CHF to help decrease preload.

I don't have a PICU, so if they didn't improve after a few racemics and looked bad, then I would have to intubate prior to transfer. I would probably call anesthesia down and call ENT +/- the peds from home if I had 15 minutes to get set up because that is a really scary situation. I think I would do ketamine.

How small of a tube will fit over a fiberoptic bronchoscope?

 

[Rendar5]

Understood, but would it not help alleviate some of the breathing requirements? Just like osa is not a lower airway issue.

My thinking? don't reinvent the wheel by playing around with maybes in a sick kid. It's not like asthma where they may do worse with the tube. This is more like your angioedema case that you made the call to intubate. When the tube's in, you don't even need 30%FiO2 half the time.

 

[WilcoWorld]

Understood, but would it not help alleviate some of the breathing requirements? Just like osa is not a lower airway issue.

First of all, it sounds like you managed a sick kid excellently, pulling some triggers that were worth pulling, and holding off on others that were better off left alone at the time.

That being said, I heart BiPAP in adults, but I don't like it in kids. They just get freaked out by it and I end up taking off the mask before things go south from breath-stacking (usually).

A 14 yo obese kid who has sleep apnea? Heck yes I'll try some BiPAP if he's tiring out from a prolonged asthma exacerbation. But bad crouper (who is pretty much certain to be under 3) is highly unlikely to tollerate it. Also, do they even make the masks that size?

 

[cyclohexanol]

I actually just had this last night. 6 y/o severe stridor, SpO2 53% on arrival, lethargic. Immediately placed on racemic. Wasn't sure if it was bad croup or epiglottitis. Got him up to 85% within a minute or two. Given NS bolus, IV steroids. After 4 or 5 back to back racemics he didn't sound much better. Then he started vomiting into the mask which we removed to just give blow by until he stopped, but he was desatting to the 70s again without it. At that point we decided to tube (with some difficulty - big inflammed epiglottis, swollen cords) [so maybe not croup per se, although he may have aspirated too]. Ended up having to use an ETT 1.5 sizes smaller to get it through on the 4th attempt. Transferred to PICU facility after ceftiraxone, vanc. SpO2 up to 100% after intubation.

I had thought about Heliox and BiPAP but the vomiting into the mask sealed the deal to just tube and send.

 

[ptarmigan]

Cyclo - Wow, that is a great case. Kids that sick don't come along very often so that is great experience. Did you call anyone down to help (anesthesia, ENT, peds?) Did you use ketamine, or RSI? DL?

 

[cyclohexanol]

Cyclo - Wow, that is a great case. Kids that sick don't come along very often so that is great experience. Did you call anyone down to help (anesthesia, ENT, peds?) Did you use ketamine, or RSI? DL?

Called anesthesia after 2nd attempt. It was at like 2am so no in-house ENT backup and peds at our shop is less than useless (and also not in-house). I started with etomidate+succ, but the kid blew threw it like it was nothing, I was only able to get 1 attempt in per dosing. Great cord views each time, but the tube was just too big each time and I wasn't able to pass it, I probably should have just downsized tubes faster and would have been able to get it in. After the 3rd attempt I gave ketamine and a larger dose of succ and an ETT 1 size smaller but by that time anesthesia was there and placed it by DL and a tube 1.5 sizes smaller, but still had to twist it in through the swollen cords.

It was definitely a good learning case, and luckily the kid should have a good outcome.

I think next time I'd probably skip the etomidate and just use ketamine for its longevity, preservation of airway reflexes, bronchodilation, etc.. use a different method to calculate tube size (went off broselow, which had us starting with a way too big ETT).. and have a peds bougie. I carry an adult bougie and had it out to use it, but realized I had no way to railroad a 5.5 or 5 ETT over it.

 

[joeDO2]

I think next time I'd probably skip the etomidate and just use ketamine for its longevity, preservation of airway reflexes, bronchodilation, etc.. use a different method to calculate tube size (went off broselow, which had us starting with a way too big ETT).. and have a peds bougie. I carry an adult bougie and had it out to use it, but realized I had no way to railroad a 5.5 or 5 ETT over it.

yes, you rarely see a pediatric bougie for some reason. we had them where i last worked but you have to watch out because we found they can be difficult to move through the smaller tubes with the plastic on plastic. has anyone had good success with budesonide for croup? i've heard you can combine this with racemic epi in a neb and have it be quite effective but never actually seen it done.

 

[pinipig523]

Dang cyclo... that's a SICK kid.

 

[cyclohexanol]

Dang cyclo... that's a SICK kid.

Got an update today too. Kid was positive for parainfluenza. Today was the first day he had a cuff leak, and they plan on extubating in the AM. Otherwise doing well.

 

[BAM!]

I had a croup kid not too long ago. stridorous, moderate supra sternal and abdominal retractions. I gave IM epi. improved back to baseline, watched him till morning, dc home.

 

[CraftyMed]

Had bad crouper the other night. Gave 3 race epi's almost back to back while he got dex 10mg in a 50ml bag. He turned around a bit, and I left him on some humidified air while waiting for his transfer.

Some times it's hard to wait for the drugs to work, but they usually work well.

Pt also ended up having a pneumonia on xray, so he got abx (Amp) too.

 

[RustedFox]

Had bad crouper the other night. Gave 3 race epi's almost back to back while he got dex 10mg in a 50ml bag. He turned around a bit, and I left him on some humidified air while waiting for his transfer.

Some times it's hard to wait for the drugs to work, but they usually work well.

Pt also ended up having a pneumonia on xray, so he got abx (Amp) too.

Funny, had one last night. Stridorous and retracting. All abnormal breath sounds resolved after the first racemic epi - but she just wouldn't improve her sat to above 92-93%, no matter what. Normal rate, no stridor, able to recite the alphabet in a single breath and discuss her favorite Disney princesses at length. Steeple sign on AP soft tissue neck films. I transferred her, too.