UMEM Educational Pearls

The peak age for croup is 6 months to 3 years.  The cornerstone of treatment is corticosteroids, traditionally dexamethasone.  With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.

Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes.  There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given.  Previous studies have suggested both 2 and 4 hour observation.

299 patients were included in this study.  136 patients were observed for 3.1 to 4 hours.  In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours.  No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.

Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.


Smith S, Giordano K, Thompson A and DePiero A.  Failure of Outpatient Management With Different Observation Times After Racemic Epinephrine for Croup.  Clinical Pediatrics.  Epub ahead of print.  Accessed October 2017.