Management of severe croup
For a child with severe croup (see Severity assessment of croup), arrange immediate transfer to hospital (if not already in hospital) because severe croup can rapidly progress to life-threatening croup.
For initial treatment of severe croup (in hospital or in the community while awaiting transfer to hospital) use:
adrenaline (epinephrine) 0.1% (1:1000, 1 mg/mL) solution 5 mL by inhalation via nebuliser, repeated after 30 minutes if no improvement12 croup, severe adrenaline (epinephrine)
PLUS ONE OF THE FOLLOWING
1 prednisolone (or prednisone) 2 mg/kg (up to 50 mg) orally, then 1 to 2 mg/kg (up to 50 mg) orally 24 hours later croup, severe prednis ol one
OR
1 dexamethasone 0.6 mg/kg (up to 12 mg) orally, as a single dose3 croup, severe dexamethasone
OR if the child is vomiting
1 dexamethasone 0.6 mg/kg (up to 12 mg) intramuscularly or intravenously, as a single dose. dexamethasone
Hydrocortisone should not be used because evidence of efficacy is lacking and it has a short duration of action.
Nondrug strategies should be used in the treatment of severe croup.
The decision to admit or discharge is made after initial assessment, treatment and observation. It should take into account the time of day, social circumstances, parents' or carers' comprehension and adherence, and access to rapid review.
Observe the child for at least 4 hours after giving initial treatment of severe croup.
If there is no stridor at rest, the child may be safe for discharge. Follow up all children who have had severe croup within 24 hours of discharge.
If there is no response (eg ongoing stridor at rest) or deterioration occurs, escalate to senior or intensive care team involvement, and arrange hospital admission. Differential diagnoses include bacterial tracheitis and conditions associated with airway obstruction or deep neck space infection (see Causes of sore throat); antibiotics may be indicated.
More details on hospital management of croup is given in The Royal Children's Hospital (Melbourne) clinical practice guidelines.