November Week 2

Malhotra A and Krilov LR, Viral croup. Pediatr. Rev., Jan 2001; 22: 5 – 12. (272.495 Kb)

1. You are on night float at Arlington on a cold misty night in February. Dr. Griswell calls to says, “There’s a kiddo down here in the waiting room who doesn’t look so good.” You summon the energy and wander down to room 5, where you see a sweetly slumbering angel of about two years in his mother’s arms. His mom describes a terrifying sound that came from the nursery, like a monster breathing, and a seal barking. By the time they got to the hospital, he was fine. She swears he was different before, and she’s scared to go home. “Do you think he’s allergic to the new carpet in his room doctor?” All you see is an afebrile toddler breathing 25, satting 99% on room air, with a runny nose, no retractions, no adventitious sounds, no hives. Lucky for you, he screams and you get a stellar view of his pale, boggy pharynx, without a spec of erythema or exudate.

You tell her he likely has,
A) spasmodic croup, and there’s a chance it could return for the next few nights 
B) epiglotitis, and you are calling ENT & anesthesia stat
C) viral laryngotracheitis, and he needs racemic epi & dexamethasome
D) acute angioneurotic edema, and he needs sub-cutaneous epi stat.

2. You’re the Sick Resident, and a 9 month old girl comes in with difficulty breathing. Mom says she has had a runny nose and fever up to 100.5 for the last couple days, but the cough started at three o’clock in this morning. She sat with her in the bathroom with the shower running which seemed to help. She is breathing 45 times a minute, with inspiratory stridor, mild intercostal retractions and nasal flaring, but has no wheezing, and is satting 97% on room air. You suspect viral croup, and order a racemic epi neb & some dexamethasone. It’s almost time for noon conference, so you say,

A) Stay here so we can observe her for a few hours, if the stridor is still gone, you can go home.
B) Come back tomorrow if it’s worse.
C) I’m going to call the SAR so we can admit her for observation overnight.
D) We need to get an X-ray of her neck to make the diagnosis.