Download Croup - Nursing and midwifery in Western Australia

Child and Adolescent Health Service Princess Margaret Hospital for Children Nurse Practitioner
Clinical Protocol Emergency Department Croup Background and practice notes Scope Assessment and initial intervention Working diagnosis and investigations Management Patient education and discharge information Medications Management flowchart Associated documents Clinical audit Definition of terms Clinical protocol authorship and approval References Acknowledgement Disclaimer Background and practice notes Croup (also known as laryngotracheobronchitis) describes an acute clinical syndrome of hoarse voice, barking cough and stridor resulting from inflammation of the upper airway.3,7 Symptoms can fluctuate in severity depending on whether the child is distressed or calm.3 The loudness of the stridor is not a good guide to the severity of obstruction.15 Croup is caused by a variety of viruses, most commonly Parainfluenza. Others implicated include Influenza A and B, Adenovirus, Respiratory syncitial virus, Metapneumovirus and Mycoplasma pneumoniae.3 Croup is most common in children between the ages of six months and three years3 but can occur in children younger and older than this. The following conditions should be excluded as they may have similar features: Bacterial tracheitis, epiglottitis, inhalation of foreign body, laryngo/tracheomalacia, quinsy/severe tonsillitis and anaphylaxis. The benefits of steroids for children with croup are well established. Corticosteroids have been shown in randomised trials1,13 to improve symptoms and reduce hospital admissions, hospital stay duration and re‐
presentation.4,14 All children presenting with signs and symptoms suggestive of croup should be considered for steroid therapy, regardless of the severity.3,8,15 The management of children with symptoms suggestive of mild to moderate croup vary widely in the literature. It has been shown that a single oral dose of Dexamethasone 0.15mg/kg is as effective as Dexamethasone 0.6mg/kg or Prednisolone 1mg/kg (which is common practice throughout Australia) and is effective in reducing return to medical care in children with mild to moderate croup.7,8 Evidence has recently shown that for children with croup an oral dose of Dexamethasone 0.15mg/kg offers benefit by thirty minutes, much earlier than the four hours suggested by the Cochrane Collaboration.6 This might encourage clinicians to treat more children with all severities of croup and be less concerned about potential side effects and delayed benefit.6 It has also been suggested that Dexamethasone and Prednisolone are equally effective but relapse and representation to medical care is more common with Prednisolone, which may reflect its short half life.7 For the purpose of this clinical protocol, the following diagnostic criteria of mild and moderate croup will be used.3,11,15 Mild croup Moderate croup •
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Barking cough No stridor at rest No recession or tracheal tug •
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Frequent barking cough Audible stridor at rest Mild recession +/‐ tracheal tug •
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Use of accessory muscles Child able to be placated, interested in surroundings Nurse Practitioner Clinical Protocol Date Issued: September 2011 Croup Date Revised: September 2011 Emergency Department Review Date: September 2013 Princess Margaret Hospital Authorised by: PMH Emergency Department Perth, Western Australia Review Team: PMH Emergency Department This document should be read in conjunction with disclaimer in this clinical protocol
Page 1 of 9 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Croup Scope Outcomes Nurse Practitioner Inclusion criteria: • Child over 6 months and less than 6 years of age • Barking cough • +/‐ Inspiratory stridor / mild biphasic stridor • +/‐ Mild to moderate respiratory distress • Alert and shows interest in surroundings • No significant underlying medical condition • History not suggestive of foreign body aspiration • Not systemically unwell Identify patients suitable for Emergency Nurse Practitioner (ENP) clinical protocol Medical Practitioner +/‐
Nurse Practitioner • Child younger than 6 months and older than 6 years of age • History suggestive of foreign body aspiration or choking episode • Underlying relevant medical pathology eg: Down Syndrome, tracheo/laryngomalacia, subglottic stenosis, micrognathia related conditions • Severe respiratory distress • Marked stridor at rest • Moderate to marked biphasic stridor • Drooling • Cyanosis or pallor, mottling • Systemically unwell • Altered mental status • Adrenaline given in previous 4 hours • Oral steroid given in previous 12 hours Identify patients not suitable for ENP clinical protocol and refer to Senior Medical Practitioner (SMP) However, patient can be managed by ENP in consultation with SMP if appropriate Page 2 of 9 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Croup Assessment and initial intervention Outcomes Primary survey •
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History • Signs and symptoms of current illness – usually have recent preceding viral symptoms • Sudden onset of barking cough +/‐ respiratory distress is common • Treatment given pre hospital • Past medical history • Allergies • Immunisation status • Medications Identify patients not suitable for ENP clinical protocol and refer to SMP Examination •
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Abnormal examination outside defined scope ‐ refer to SMP •
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Abnormal primary survey identified – exit ENP clinical protocol and refer to SMP Airway Breathing Circulation Disability Exposure Vital signs General examination Barking cough, hoarse voice Varying levels of respiratory distress may be evident depending on severity Stridor may be present Drooling may be present Assess hydration status Assess conscious state Working diagnosis and investigations Meets inclusion criteria. History and examination findings support working diagnosis of croup. Imaging and pathology • No imaging or pathology is routinely required Page 3 of 9 Emergency Department Princess Margaret Hospital for Children Management Mild croup
Moderate croup Nurse Practitioner Clinical Protocol Croup Outcomes • ENP review with view to discharge home • Administer single dose of oral dexamethasone • Parent education, provide fact sheet Croup Health Facts • Discuss representation criteria Patient identified as suitable for ENP clinical protocol and discharged home • ENP review in view of observation for approximately 1 hour and consultation with SMP • Administer single dose of oral dexamethasone • If vomits or refuses corticosteroid exit clinical protocol and notify SMP • Monitor patient’s respiratory status during this time Improvement • Evidenced by no respiratory distress and no stridor at rest • Discharge after consultation with SMP • Consider time of day, distance from medical care, parental compliance • Provide fact sheet – Croup Health Facts • Discuss representation criteria Partial or no improvement • Possible need for nebulised adrenaline and admission until stridor and respiratory distress settles Patient identified as suitable for ENP clinical protocol and discharged home after consultation with SMP Patient referred to SMP if partial or no improvement Patient education and discharge information Discharge criteria Treatment instructions Medication instructions Follow up/ referral Outcomes • No respiratory distress, no stridor at rest • Systemically well • Consider time of day, distance from medical care, parent confidence and understanding • Discharge home or to usual residence • Identify likely progression of the illness, expected outcome, representation criteria and referrals • Verbal instructions given by ENP • Simple analgesia as required (over the counter medicine) • Not routinely required unless specific concerns • Seek further medical advice if condition deteriorates • Verbal and written instructions as appropriate Patient suitable for discharge Patient/parent understands instructions given Patient/parent understands instructions given Patient/parent understands follow up arrangement Page 4 of 9 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Croup Patient education and discharge information (continued) Outcomes Representation criteria Patient/parent understands • Increase in WOB criteria for representation • Stridor at rest • Signs or symptoms do not follow typical pattern or and is discharged home improvement and resolution • Systemically unwell • Condition deteriorates • Social circumstances are such that a responsible adult is not able to observe the child at home • Parental concern Documentation •
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Expected outcome Symptoms are typically worse at night, showing improvement during the day, but may recur the following evening. Croup symptoms are generally short lived with approximately 60% of children having resolution within 48 hours. A small proportion of children have symptoms which may continue for up to 1 week.3 The cough may persist for up to 2 weeks. Parent education – Croup Health Facts GP letter if applicable Medical certificate/ certificate of attendance Patient medical record Appropriate documentation completed Page 5 of 9 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Croup Medications Preparation • Suspension 1mg/ml (oral dexamethasone solution is only available in Australia as an extemporaneous preparation from specialised paediatric hospitals) • Tablet Route/administration
• Oral Dose • 0.15mg/kg single oral dose Pharmacology •
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Pharmacokinetics
• Rapidly absorbed following an oral dose, achieves peak plasma levels in 1 – 2 hours after oral administration • Well absorbed from the gastrointestinal tract • Quickly distributed into kidneys, intestines, skin, liver, muscle • Bound to plasma proteins • Metabolised by the liver • Excreted in the urine • Plasma elimination half life of dexamethasone is approximately 2 – 3 hours Indication • All levels of severity of croup Contraindications for ENP use • Treatment regimens of greater than a single oral dose • Co‐morbidities including cardiac failure, hypertension, diabetes, renal failure, liver disease, ulcerative disease, osteoporosis, psychiatric disease, ophthalmic infection or disease • Intercurrent varicella infection Interactions • Metabolism enhanced by medications which induce hepatic enzymes: carbamazepine, phenytoin • Effects on oral anticoagulants is variable • Corticosteroids and NSAIDs can be used concomitantly for short periods without sequelae • Other interactions: oral antihyperglycaemic agents and insulin, digoxin, diuretics, antacids, aspirin Paediatric considerations • Calculate lean body weight where child is overweight12 • Complications of treatment are dose and duration dependent Adverse effects • Short term use even at high doses unlikely to cause effects associated with long term use Patient education
• Follow administration directions provided Useful links • For full prescribing information refer to AMH online Dexamethasone Poison schedule 4 Predominantly glucocorticoid activity Mineralocorticoid activity Anti‐inflammatory actions Dexamethasone is 5 – 6 times as potent as prednisolone with regards to anti‐inflammatory potential6 Page 6 of 9 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Croup Management flowchart Croup management flowchart Barking cough Hoarse voice +/‐ Stridor Yes •
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Child < 6 months or > 6 years of age Hx of foreign body aspiration or choking Underlying relevant medical pathology Marked stridor at rest Drooling Cyanosis or pallor, mottling Systemically unwell Altered mental status Adrenaline given in previous 4hrs Oral steroid given in previous 12 hours Yes Refer to SMP No Yes Severe croup Refer to SMP No Yes Moderate croup Give single dose of oral steroid Observe child over next hour Discuss with SMP No Condition improved
Yes Partial or no improvement
Condition deteriorated
Discuss with SMP Admit to SSU until respiratory distress +/‐ stridor settles
Refer to SMP
Yes Mild croup with no signs of respiratory distress
Give single dose of oral steroid (if not already given)
Yes Yes
Meets discharge criteria Provide discharge advice Discharge home Page 7 of 9 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Croup Associated documents Croup, PMH Emergency Department Clinical Practice Guideline 2010 Clinical audit Unexpected representation Emergency Department Information System and ENP clinical log Definition of terms Emergency Nurse Practitioner Senior Medical Practitioner General Practitioner Work of breathing Australian Medicines Handbook Short Stay Unit ENP SMP GP WOB AMH SSU Date written September 2011 Date for review September 2013 Page 8 of 9 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Croup References 1.
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Ausejo M, Saenz A, Pham B, Kellner J, Johnson D, Moher D, Klassen T. The effectiveness of glucocorticoids in treating croup: meta‐analysis. British Medical Journal. 1999 Sept 4;319:595‐600. Australian Medicines Handbook (online). 2011 Jul. [cited 2011 Sept 6]. Available from: http://www.amh.net.au.pklibresources.health.wa.gov.au/online/view.php?page=chapter5/tablecommon‐
infections.tb.html#idxcrouptreatment(table)idx Bjornson C, Johnson D. Croup – treatment update. Pediatric Emergency Care. 2005;21(12):863‐73. Cherry J. Croup. The New England Journal of Medicine. 2008 Jan 24;358(4):384‐391. Clinical Pharmacology (online). 2011. [Cited 19 Aug 2011]. Available from: http://www.clinicalpharmacology‐
ip.com.pklibresources.health.wa.gov.au/Forms/Monograph/monograph.aspx?cpnum=174&sec=monphar Dobrovoljac M, Geelhoed G. How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double‐blinded clinical trial. Emergency Medicine Australasia (online). 2011. [cited 2011 Sept 6];1‐
7.doi:10.111/j.1742‐6723.2011.01475.x Geelhoed G, Sparrow A. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Archives of Disease in Childhood. 2006;91:580‐3. Geelhoed G, Turner J, Macdonald W. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled trial. British Medical Journal. 1996 Jul 20.313(7050):140‐2. Micromedex (online). [Cited 22 Aug 2011]. Available from: http://micromedex.hcn.net.au.pklibresources.health.wa.gov.au/mdx‐wah/ MIMS (online). Available from: https://www.mimsonline.com.au/Search/Search.aspx Princess Margaret Hospital for Children, Perth, Western Australia. 2010. Emergency Department Clinical Practice Guideline, Croup. Princess Margaret Hospital for Children, Perth, Western Australia. 2010. Guideline for dosing overweight and obese children 1 to 17 years of age. Child and Adolescent Health Service Intranet. Available from: http://cahs.hdwa.health.wa.gov.au/__data/assets/pdf_file/0009/72837/GUIDELINES_IBW_final21‐1‐09.pdf Russell K, Liang Y, O’Gorman K, Johnson D, Klassen T. Glucocorticoids for croup (Review). Cochrane Database. 2011 [Cited 19 Aug 2011]. Available from: http://onlinelibrary.wiley.com.pklibresources.health.wa.gov.au/doi/10.1002/14651858.CD001955.pub3/pdf The Royal Children’s Hospital, Melbourne, Australia. 2005. Nurse Practitioner Clinical Practice Guideline, Cough (barking). Therapeutic Guidelines online (eTG). 2011 Jul. [Cited 22 Aug 2011]. Available from: http://online.tg.org.au.pklibresources.health.wa.gov.au/ip/ Acknowledgement Princess Margaret Hospital wishes to acknowledge The Royal Children’s Hospital in Melbourne, Joondalup Health Campus and the Department of Health, Western Australia for their valued advice and support with regards to the creation of this clinical protocol. Disclaimer/ Statement of intent This clinical protocol is intended for use by Nurse Practitioners working in the Emergency Department (ED) at Princess Margaret Hospital for Children in the management of children presenting with signs and symptoms suggestive of mild to moderate croup. Standards of care are determined on the basis of clinical data available and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The clinical protocols detail diagnostic criteria and appropriate management options. Departmental clinical practice guidelines are available to guide clinical decision making. They form the foundation for the ENP clinical protocols which ensure that the practice of the ENP is consistent, safe and that the boundaries of ENP practice are well defined. It should be noted that clinical protocols provide a framework but do not attempt to take the place of sound clinical judgement. Nurse Practitioners may be responsible for clinical decisions not adequately defined by clinical protocols and under these circumstances collaboration with a Senior Medical Practitioner (SMP) will ensure that decisions are appropriate. A SMP will be the ED Consultant or a Senior Registrar delegated by the ED Consultant. Nurse Practitioner Clinical Protocol Date Issued: September 2011 Croup Date Revised: September 2011 Emergency Department Review Date: September 2013 Princess Margaret Hospital Authorised by: PMH Emergency Department Perth, Western Australia Review Team: PMH Emergency Department This document should be read in conjunction with disclaimer in this clinical protocol
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