A 20-month-old girl is brought to the emergency department due to cough and fever. She had nasal congestion and a dry cough yesterday, but the symptoms are worse today. The patient developed a fever overnight and the cough is now more forceful. Her father says, "She was coughing so hard that it sounded like she couldn't breathe." Her appetite is mildly decreased, but she has been drinking water and juice frequently throughout the day. The patient's immunizations are up to date, and she takes no medications. Temperature is 38.1 C (100.6 F), pulse is 100/min, and respirations are 28/min. Physical examination demonstrates an awake, alert patient playing with a toy on her father's lap. When the examiner approaches her, she cries and has an episode of harsh, brassy coughing followed by mild inspiratory stridor. The nares are patent with clear rhinorrhea, the pharynx has no erythema or exudate, and the tympanic membranes are clear. S1 and S2 are present without murmurs. The lungs are clear to auscultation, but there are mild intercostal retractions. The abdomen is soft and nontender without organomegaly. There are no rashes or lesions. Which of the following is the most appropriate next step in management of this patient?

Question

A 20-month-old girl is brought to the emergency department due to cough and fever.  She had nasal congestion and a dry cough yesterday, but the symptoms are worse today.  The patient developed a fever overnight and the cough is now more forceful.  Her father says, "She was coughing so hard that it sounded like she couldn't breathe."  Her appetite is mildly decreased, but she has been drinking water and juice frequently throughout the day.  The patient's immunizations are up to date, and she takes no medications.  Temperature is 38.1 C (100.6 F), pulse is 100/min, and respirations are 28/min.  Physical examination demonstrates an awake, alert patient playing with a toy on her father's lap.  When the examiner approaches her, she cries and has an episode of harsh, brassy coughing followed by mild inspiratory stridor.  The nares are patent with clear rhinorrhea, the pharynx has no erythema or exudate, and the tympanic membranes are clear.  S1 and S2 are present without murmurs.  The lungs are clear to auscultation, but there are mild intercostal retractions.  The abdomen is soft and nontender without organomegaly.  There are no rashes or lesions.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c07f_6ec5_8f63_0dadd8e71a18_MD0005_00 Croup (laryngotracheitis) is a parainfluenza viral infection of the larynx and trachea that peaks in the fall and early winter. Croup usually affects children age <3. Clinical manifestations include rhinorrhea, cough, and fever, which progress to the sudden onset of a harsh, barking cough; inspiratory stridor; and hoarseness. Stridor in mild croup occurs with agitation and activity, whereas children with moderate/severe croup have stridor, retractions, and distress at rest.Croup is usually diagnosed clinically. Viral testing and x-rays are not indicated when the presentation and examination are characteristic. A posterior-anterior neck x-ray can be ordered for uncertain cases and may reveal the steeple sign due to subglottic narrowing (Choice D). x-ray Croup is generally a self-limited illness and usually resolves within a week. Treatment for mild croup consists of humidified air to soften secretions and decrease drying of inflamed mucosal surfaces. A single dose of corticosteroids (either as an oral liquid or intramuscular injection) can be given to reduce stridor, which often worsens at night. Corticosteroids plus nebulized epinephrine should be administered for moderate/severe croup to relieve upper airway obstruction. Moderate/severe croup often improves significantly after treatment. Patients who are hypoxic and whose condition worsens or does not improve should be hospitalized for repeated doses of nebulized epinephrine. (Choice B) Nebulized beta agonists, such as albuterol, are the first-line treatment for asthma exacerbations as they relax smooth muscle to relieve lower airway bronchoconstriction. Asthma presents with wheezing rather than stridor, and beta agonists are ineffective for croup as it is an upper airway disease. (Choice C) Intravenous antibiotics are the treatment for bacterial pneumonia, which also presents with fever, cough, and tachypnea. However, stridor is not characteristic, and rales or crackles would be expected on auscultation. Antibiotics have no role in the treatment of croup, as it is a viral illness. (Choice E) Endotracheal intubation is critical in a child with epiglottitis, which also presents with fever and stridor. However, cough is absent in epiglottitis, and patients appear toxic (high fever, drooling, leaning forward, severe respiratory distress). Educational objective: Croup is a parainfluenza viral infection characterized by a barking cough and stridor. Mild croup is treated with humidified air and corticosteroids; moderate/severe croup is treated with corticosteroids plus nebulized epinephrine. References: Viral croup: diagnosis and a treatment algorithm. (http://www.ncbi.nlm.nih.gov/pubmed/24596395) Nebulized epinephrine for croup in children. (http://www.ncbi.nlm.nih.gov/pubmed/24114291) Glucocorticoids for croup. (http://www.ncbi.nlm.nih.gov/pubmed/21249651)

A 20-Month-Old Girl Is Brought to the Emergency Department Due