Croup

Written By The Administrator

ED/PICU Transfers Learning Points

Case 1.

6-month-old with no PMH presented to the ED for evaluation of cough and congestion. The patient’s exam was significant for wheezing and subcostal/supraclavicular retractions. The patient was pale and lethargic appearing with accessory muscle use. The patient’s bronchiolitis score was noted to be 11. They were treated with suctioning, racemic epinephrine, Decadron. They were later transferred to the North ED with delays secondary to bed availability. The patient required high flow nasal canula on arrival to North ED with O2 saturation that dropped to 80% on room air. The patient was given a DuoNeb with some improvement and was admitted to the PICU on HFNC.

Learning points:

  • Whenever a patient is determined to require admission, please call for transfer arrangements as soon as possible.

  • If there are any delays in PICU acceptance, please call admin on call to escalate the process immediately. They will reach out to pediatric leadership to ensure transfer disposition in a timely manner.

  • Activate lights and sirens and transfer ED to ED. The patient can be managed in North until definitive disposition location is determined. 

  • Pediatric floor or PICU bed availability should not affect transfer.

Case 2. 

1-year-old female with no PMH presented with fevers/cough for 2 days with T-max of 103 °F.  The patient was assessed in the North ED and was safe for discharge. The patient returned the following day to PB with respiratory distress. The patient was noted to have subcostal and intercostal retractions with audible wheezing. She was diagnosed with COVID using an at home test. The patient was still making wet diapers at home and received antipyretics in the ED. IV access was attempted multiple times with success in the left foot.  Patient was placed on nonrebreather for 4 minutes prior to transfer with O2 saturation in the mid 90s. The patient was thus deemed stable for transfer.   Patient was placed on high flow on arrival to the North ED and then admitted to the PICU.

Learning points:

  • The decision to obtain IV access should be at the discretion of the examining physician.

  • Not all patients require IV access prior to transfer and establishment of IV access should not delay transfer.

  • If the patient is clinically dehydrated or in shock, consider all forms of access including IO for emergent access until definitive peripheral or central access is obtained.

  • Documentation of clinical stability on non-rebreather prior to transfer is an excellent way to demonstrate safety of transfer.

  • Please review the pediatric croup guidelines to assist in admission. 

Case 3.

12-year-old female with PMH of asthma presented with syncope.  The patient had multiple episodes of syncope at home. The patient did not remember the events. The patient endorsed having dizziness and visual disturbances prior to the syncopal event. The family attributed the patient to being dehydrated and thus delayed evaluation.  The patient’s EKG was significant for a QTC of 496. Pediatric cardiology was consulted who recommended PICU admission for telemetry monitoring for suspicion of prolonged QT.  

Learning points

  • Long QT and other significant EKG disturbances warrants consultation with pediatric cardiology and potentially admission.

  • Magnesium is not necessarily given for prolonged QT in pediatric patients unless instructed by the cardiologist.

Link to Learn more about Croup

- Arsalan Shawl, D.O

The Administrator
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