EM Command Center / Pediatrics & Obstetrics • 3 min read • 3 sections

Pediatric Respiratory Emergencies

Comprehensive pediatric emergency management of acute upper and lower airway compromise. Details the Westley Croup Score and racemic epinephrine protocols, AAP bronchiolitis guidelines, continuous albuterol and IV magnesium dosing in pediatric asthma, epiglottitis avoidance traps, and foreign body localization.

Resuscitation Quick Ribbon (First 2 Minutes)

High-Acuity

Assess Pediatric Assessment Triangle (PAT):Appearance, Work of Breathing, Circulation to Skin.

Stridor at rest / Severe Croup:Dexamethasone 0.6 mg/kg PO/IV/IM (max 16 mg) + Nebulized Racemic Epinephrine (0.5 mL of 2.25% in 3 mL NS) or L-epinephrine 1:1000 (5 mL).

Suspected Epiglottitis:Do NOT agitate the child; DO NOT use a tongue blade; keep child upright on parent's lap; prepare for immediate airway management in the operating room with ENT and Anesthesia.

Pediatric Status Asthmaticus:Continuous nebulized Albuterol (10-20 mg/hr) + Ipratropium (0.5 mg x 3) + Dexamethasone (0.6 mg/kg) + IV Magnesium Sulfate 50 mg/kg (max 2 g) over 20 minutes.

Bronchiolitis (Infant < 12 months):Supportive care, nasal suctioning, heated humidified high-flow nasal cannula (HFNC 1-2 L/kg/min); do not administer routine albuterol or systemic steroids.

Bottom-Line Clinical Pearl

In severe croup treated with nebulized racemic epinephrine, observe the child for a minimum of 2 to 4 hours in the ED to monitor for rebound airway edema before considering discharge.

1. Upper Airway Emergencies: Croup vs. Epiglottitis vs. Bacterial Tracheitis

Condition	Etiology & Age Group	Clinical Presentation	Emergency Management
Croup (Laryngotracheobronchitis)	Parainfluenza virus; ages 6 months - 3 years	Barking 'seal-like' cough, inspiratory stridor, hoarseness, low-grade fever; steeple sign on neck X-ray	Dexamethasone 0.6 mg/kg PO/IM (max 16 mg). If stridor at rest: Racemic Epinephrine 0.5 mL in 3 mL NS nebulized. Observe 2-4 hours.
Acute Epiglottitis	Haemophilus influenzae type B, Strep, Staph; any age (unimmunized or adults)	Sudden onset high fever, drooling, dysphagia, muffled 'hot potato' voice, tripod posturing; thumbprint sign on lateral neck X-ray	Keep patient calm on parent's lap. Stat ENT and Anesthesia consult; transfer directly to OR for controlled endotracheal intubation. Broad-spectrum IV antibiotics (Ceftriaxone + Vancomycin).
Bacterial Tracheitis	Staph aureus, GAS; ages 3-8 years	Croup-like prodrome that acutely deteriorates with high fever, toxic appearance, thick purulent secretions refractory to epinephrine	Early intubation in ICU/OR; tracheal suctioning of pseudomembranes; IV Vancomycin + Cefepime.

2. Westley Croup Score & Disposition Algorithm

The Westley Croup Score stratifies severity based on 5 parameters: Stridor (0-2), Retractions (0-3), Air Entry (0-2), Cyanosis (0-5), and Level of Consciousness (0-5):

Score Range	Severity Classification	Emergency Interventions & Disposition
0 - 2 Points	Mild Croup	Single dose Dexamethasone 0.15 - 0.6 mg/kg PO; safe for discharge home with clear return precautions.
3 - 5 Points	Moderate Croup	Dexamethasone 0.6 mg/kg + Nebulized Racemic Epinephrine; observe for 2-4 hours. Discharge if stridor resolves at rest.
>= 6 Points	Severe Croup / Impending Failure	Dexamethasone + Repeated Racemic Epinephrine nebulization (q20-30 min) + Heliox / HFNC. Admit to PICU/step-down.

3. Pediatric Status Asthmaticus Escalation Pathway

First-Line (Minutes 0-15): Albuterol 2.5-5 mg nebulized back-to-back x 3 (or continuous 10-20 mg/hr) PLUS Ipratropium bromide 0.25-0.5 mg nebulized x 3 doses.
Early Corticosteroids: Dexamethasone 0.6 mg/kg PO/IV (max 16 mg) OR Methylprednisolone 2 mg/kg IV load (max 60-80 mg).
Second-Line (Minutes 15-30): IV Magnesium Sulfate 50 mg/kg (max 2 g) infused over 20-30 minutes. Monitor for hypotension and loss of deep tendon reflexes.
Refractory Adjuncts: Subcutaneous Epinephrine (1:1000) 0.01 mg/kg (max 0.3-0.5 mg) or Subcutaneous Terbutaline 0.01 mg/kg. High-Flow Nasal Cannula (HFNC) or BiPAP.
Rescue IV Beta-Agonist: IV Terbutaline load (2-10 mcg/kg over 10 min) followed by continuous infusion (0.1-4 mcg/kg/min) in PICU setting.

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