Joan Choi

MS3
October 17, 2016
To Admit or Not to Admit is the Question
Viral croup is a common self-limiting airway obstruction disease in children 6
months to 3 years. A single dose of oral dexamethasone 0.15-0.6 mg/kg with
nebulized racemic epinephrine is used in moderate to severe coup.
After administration of corticosteroid and an inhaled dose of racemic epinephrine,
the patient may be discharged with improvement after an observation of 2-4
hours. However, if the patient requires greater than or equal to two doses of
racemic epinephrine, regardless of clinical status or response to therapy, the
common recommended practice is to admit the patient. This practice is
recommended in pediatric emergency medicine textbooks, review articles, and
published clinical guidelines.
Rudinsky et al conducted a retrospective chart review at an urban tertiary care
childrens hospital (annual ED census of 70,000) from June 2007-February 2011.
200 cases were reviewed, and of the 200, 96% presented to the ED with
moderate-severe croup. 56% (112) of asymptomatic patients were admitted
based on the number of racemic epinephrine doses. 36% (72) of the admitted
patients received additional intervention of additional racemic epinephrine
administration (34%; n=68), heliox therapy (5%; n=9), and supplemental oxygen
(2%); n=4. Of the 34% of patients that received inpatient racemic epinephrine,
the 1st dose was given after 4 hours and 53% only received 1 dose.
No patient admitted to the general pediatric service required intubation or higher
level of care. Most had <24 hr hospital stay with low readmission rates. The
symptomatic group had greater number of adverse events and longer hospital
stay compared to the asymptomatic group. 86% of the asymptomatic group did
not receive additional racemic epinephrine administration and 11% received 1
dose.
In summary, this study demonstrates that multiple ED doses of racemic
epinephrine for coup resulting in admission results in low rate of additional clinical
intervention for croup. The study also demonstrated that a longer period of
observation in the ED after a second racemic epinephrine dose could reduce the
number of admissions. In conclusion, management of croup should be guided by
clinical assessment of symptom resolution or sustainment after an appropriate
amount of time rather than the number of racemic epinephrine doses.

Rudinsky SL, Sharieff GQ, Law W et al. Inpatient Treatment After Multi-Dose Racemic Epinephrine
For Croup in the Emergency Department. The Journal of Emergency Medicine, Vol. 49, No. 4, pp.
408414, 2015