You are examining a 12-month-old boy who woke up early this morning with a sudden onset of noisy breathing and a barking cough. He has stridor on inspiration and tachypnea, as well as suprasternal and subcostal retractions. Optimal management for this patient is to give him:
An intramuscular dose of ceftriaxone.
+Intravenous fluids and admit him to the hospital.
+A beta-agonist medication by nebulization.
+Nebulized racemic epinephrine and oral dexamethasone.
+Saline mist therapy.
Croup or laryngotracheobronchitis, is the most common cause of upper airway obstruction in infants and children and is usually seen during the fall and winter months. Parainfluenza virus types 1 and 2 cause the majority of cases. Although stridor, barking cough, and respiratory distress are the most prominent symptoms, lower respiratory tract symptoms such as wheezing and rhonchi can also be noted. You have to consider the possibility of bacterial tracheitis, epiglottitis, or foreign body aspiration in any patient presenting with severe distress, toxicity, or a course not consistent with viral croup. The management of croup is supportive. Mild croup can be treated with oral dexamethasone at a dose of 0.15–0.6 mg/kg. Patients with moderate to severe croup may also be given nebulized racemic epinephrine in addition to dexamethasone. Antibiotics are not indicated for viral croup. Mist therapy and albuterol treatments are not definitive therapies. Most patients can be sent home after a period of observation in the ED. Indications for admission are dehydration, stridor at rest, moderate to severe respiratory distress, and presence of comorbid conditions.