Introduction: Croup is a common viral upper airway infection in children aged 6 months to 6 years. Although a single dose of dexamethasone decreases return visits, the prescribed dose varies from 0.15mg/kg to 0.6mg/kg. Our objective was to examine the effect of varied dexamethasone dosing on unplanned return ED visits for croup. Methods: This was a retrospective chart review of IWK ED patient treatment records from September 1, 2014 – August 31, 2016 of children aged 6 months to 6 years with an ICD-10 discharge diagnosis code of croup. Data were abstracted by trained research assistants using a structured data collection form in REDCap. A sample of 5% of charts had double data abstraction to test for agreement. Our primary outcome was return visits to the ED within 7 days. Secondary outcomes were ED length of stay (LOS), admission to hospital and admission to the pediatric intensive care unit (PICU). Data were analyzed using descriptive statistics and chi-square for between group comparisons. Results: The dataset included 1595 patient visits for croup. Data analysis is in progress. Triage acuity as per CTAS included: resuscitation n = 5; emergent n = 351; urgent n = 558; less urgent n = 605; and, non-urgent n = 2. Most patients had no co-morbid conditions (n = 1548). Dexamethasone dosing varied: 0.15 mg/kg n = 64; 0.3 mg/kg n = 838; and, 0.6 mg/kg n = 493. ED LOS was under 1 hour in 483 patients, 1-3 hours in 805, 3-6 hours in 225 and 6-12 hours in 9 patients. Few patients were admitted to hospital (n = 22) and no patients were admitted to PICU. Within 7 days of the index visit, 78 patients had an unplanned return visit to the ED for croup. Conclusion: The data analysis is in progress. This study will inform our future research on a practice change in our ED to comply with the dose of dexamethasone recommended by the Canadian Pediatric Society for the treatment of croup in 2017.

Introduction: Croup is one of the most common childhood respiratory illnesses, affecting more than 80,000 Canadian children per year. Early dexamethasone administration in croup can reduce admission rates and length of stay (LOS), as well as return visits to the emergency department (ED). Pre-hospital emergency medical services (EMS) teams in Edmonton administer dexamethasone to children with croup. The objectives of this study were to (a) assess the clinical impact of pre-hospital administration of dexamethasone to children with croup and (b) compare clinical outcomes of these patients to those who did not receive their first dose of dexamethasone via the EMS providers. Methods: This study was a retrospective medical record review that included children between 6 months and 6 years of age who were brought via EMS to the Stollery Children’s Hospital ED with a final diagnosis of croup, between January 1st 2010 and December 31st 2012. Data were collected regarding pre-hospital presentation and management, ED presentation and management, ED LOS and final disposition, and patient demographics. Results: 188 patients were enrolled, 35.1% (66/188) of whom received a pre-hospital diagnosis of croup. The mean age of the participants was 32.96 months (SD±17.18). Overall, 10.6% patients (20/188) were given dexamethasone in the pre-hospital setting, while 30.3% patients (57/188) were given nebulized epinephrine by EMS. Out of the 66 patients with a pre-hospital diagnosis of croup, 10.6% (n=7) were given dexamethasone by EMS. In the ED, dexamethasone was administered to 88.3% of patients (166/188) while 56/188 participants (29.8%) received nebulized epinephrine. There was no statistically significant difference in ED LOS stay between those who received pre-hospital dexamethasone (2.6 hours, SD±1.6, n=18) and those who did not (3.3 hours, SD±2.7, n=159). The number of in-hospital epinephrine doses per patient was influenced by the administration of pre-hospital dexamethasone (p=0.010). Conclusion: Pre-hospital administration of dexamethasone likely influences the severity and short-term persistence of croup symptoms, as evidenced by less epinephrine use in the ED. Contrary to current EMS guidelines, very few patients with a pre-hospital diagnosis of croup received dexamethasone by EMS personnel. This likely represents a missed opportunity to decrease the severity of the patients’ disease.

The management of paediatric airway emergencies is part of ENT practice. The most common conditions are acute viral laryngotracheobronchitis (croup), acute epiglottitis and bacterial tracheitis. Management of these conditions is significantly different and accurate diagnosis is crucial. We performed a retrospective analysis of all acute airway admissions to the paediatric intensive care unit (PICU) at the Royal Belfast Hospital for Sick Children from 1990 to 2003. The results showed a gradual decrease in the number of admissions due to croup. Acute epiglottitis admissions decreased markedly after 1992 but rose again in 2000, with a peak in 2002. Bacterial tracheitis is now the most common paediatric airway emergency requiring PICU admission and its incidence has been steadily increasing since 1990, peaking in 2003. The total number of admissions showed little change over the 14-year period audited. The significant shift in the nature of these conditions and these findings confirm the ongoing requirement for caution in dealing with a suspected airway emergency.

Croup is the most common infectious cause of acute airway obstruction in children between 1 and 6 years of age, accounting for 90% of cases of stridor. The majority of cases of croup are caused by parainfluenza and occur during the late fall and winter. Mist has been a mainstay for croup since the 19th century and, even today, many emergency departments (EDs) routinely begin cool mist therapy for patients with croup. Further therapy of croup typically includes nebulized racemic epinephrine and corticosteroids.

We report our experience with 199 patients requiring admission with a diagnosis of croup over an 18 month period. The value of using pulse oximetry to monitor these children was critically examined. Twenty-nine patients with clinically significant stridor were monitored for an average of 12 hours. There was poor correlation of clinical status and respiratory rate with hypoxia as shown by the technique, with frequent dips in oxygen saturation being caused by technical problems such as movement artefact. Pulse oximetry is a useful adjunct to the clinical assessment of croup, but cannot be relied upon solely for monitoring these labile patients.