Parents bring their 22-month-old son to the urgent care clinic late at night because he su… — USMLE Step 2 CK

Parents bring their 22-month-old son to the urgent care clinic late at night because he suddenly developed a harsh, 'seal-like' cough and noisy breathing. For the past two days, he has experienced clear nasal discharge and a low-grade temperature. On evaluation, the child appears anxious. His temperature is $38.2^\circ\text{C}$ ( $100.8^\circ\text{F}$ ), heart rate is $145/\text{min}$ , respiratory rate is $42/\text{min}$ , and oxygen saturation is $95\%$ on ambient air. Physical examination reveals an audible, high-pitched noise during inspiration even when the child is calmed and resting on his mother's lap. This is accompanied by pronounced suprasternal and subcostal retractions. Auscultation of the lungs demonstrates equal air entry bilaterally without expiratory wheezing. Which of the following is the most appropriate next step in the management of this patient?

A
Transfer to the radiology suite for a lateral neck radiograph
B
Administration of nebulized albuterol and oral dexamethasone
Administration of nebulized epinephrine and oral dexamethasoneAnswer
D
Immediate endotracheal intubation and mechanical ventilation
E
Prescription for oral amoxicillin and supportive care at home

Answer

Administration of nebulized epinephrine and oral dexamethasone

This patient's presentation of a harsh, barking cough, preceding viral symptoms, and inspiratory stridor is classic for croup (laryngotracheitis), most commonly caused by the parainfluenza virus. The presence of audible stridor while the child is at rest, along with prominent suprasternal and subcostal retractions, classifies this presentation as moderate-to-severe croup. The most appropriate immediate management is the administration of nebulized epinephrine, which causes rapid mucosal vasoconstriction and decreases subglottic edema. This acute rescue therapy must be given in conjunction with a corticosteroid, such as oral or intramuscular dexamethasone, which provides a longer-lasting anti-inflammatory effect to prevent rebound symptoms after the transient effects of epinephrine wear off.

Step-by-Step Solution

Identify the clinical syndrome from the presentation.

The patient has a barking cough, inspiratory stridor, and preceding viral upper respiratory symptoms, which is characteristic of croup (laryngotracheitis).

Accurate diagnosis is required to determine the appropriate treatment pathway and avoid unnecessary testing.

Assess the severity of the disease.

The presence of inspiratory stridor at rest and significant retractions indicates moderate-to-severe croup.

Severity dictates the need for immediate acute interventions versus supportive care and observation.

Select the appropriate intervention based on severity.

Nebulized epinephrine is indicated to rapidly reduce airway edema, alongside dexamethasone for a prolonged anti-inflammatory effect.

Epinephrine provides rapid, temporary relief of critical upper airway narrowing while the steroids take hours to reach peak effect.

Key Concept

Patients with moderate-to-severe croup (indicated by stridor at rest or significant retractions) require immediate treatment with nebulized epinephrine and corticosteroids to rapidly reduce subglottic edema and prevent airway compromise.

Estimated Time:1m 0s

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic