Determine the Cause

Chief Complaint: Stridor

a. History: Barking cough – A harsh, seal-like cough, Hoarseness – Due to swelling around the vocal cords

• Difficulty breathing – Can range from mild to severe
• Low-grade fever – Sometimes present
• Runny nose and congestion – Often precede the cough
• Worse symptoms at night – Symptoms often peak at night and improve during the day

Severe cases may include retractions (skin pulling in around the ribs or neck when breathing), lethargy, or bluish skin (cyanosis), indicating a medical emergency.

 

Next Pivotal Assessment	Finding

 

1. Croup (Most Common Cause) - Viral Laryngotracheitis

   • Mild (Barking cough, no stridor at rest):
     • Dexamethasone (0.15–0.6 mg/kg PO, single dose).
   • Moderate/Severe (Stridor at rest, retractions, distress):
     • Nebulized epinephrine (racemic or L-epinephrine) for airway swelling.
     • Dexamethasone (0.6 mg/kg PO/IM).
     • Observe for rebound symptoms.

2. Foreign Body Aspiration (Sudden Onset, No URI Symptoms)

   • If partial obstruction (child can cough/cry): Encourage coughing, avoid blind sweeps.
   • If complete obstruction (cannot cough, cyanotic, silent):
     • <1 year: Back blows + chest thrusts.
     • >1 year: Heimlich maneuver.
   • If stable: Get an urgent bronchoscopy for removal.

3. Bacterial Tracheitis (Toxic, High Fever, Thick Secretions, Rapid Deterioration)

   • ICU admission, airway management with intubation often needed.
   • Broad-spectrum IV antibiotics (vancomycin + ceftriaxone).
   • Suction thick secretions.

4. Epiglottitis (Rare but Life-Threatening, Drooling, Tripod Position, High Fever)

   • Do not attempt to examine the throat (risk of sudden obstruction).
   • Immediate anesthesia/ENT consult for intubation in controlled setting.
   • IV antibiotics (ceftriaxone + vancomycin).

5. Anaphylaxis (Stridor + Urticaria, Swelling, Hypotension Possible)

   • IM epinephrine (0.01 mg/kg, max 0.5 mg).
   • IV fluids, antihistamines, steroids.
   • Secure airway early if worsening.

6. Laryngomalacia (Chronic Congenital Stridor, Improves Prone/Exacerbates Supine)

   • Typically self-resolving by 12-18 months.
   • Severe cases with failure to thrive or respiratory distress: Consider supraglottoplasty.

Summary of Urgent Interventions:

• Croup: Dexamethasone ± nebulized epinephrine.
• Foreign body: Encourage coughing or Heimlich/back blows if choking.
• Epiglottitis: Avoid throat exam, urgent airway control.
• Bacterial tracheitis: Airway management + IV antibiotics.
• Anaphylaxis: IM epinephrine + airway management.

Would you like specific dosing guidance or further details on any of these?