Croup-like illness

Any person, 4 weeks to 15 years, presenting with barking cough and/or stridor.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Allow the patient to adopt their own position of comfort Do not disturb unnecessarily Exhaustion and/or distress is a sign of serious illness Treat as per severity score

Airway

Assessment	Intervention
Severe or life-threatening croup Tripod or sniffing position Severe to complete obstruction Persistent stridor at rest, biphasic stridor (inspiratory and expiratory) Reduced air entry or no air movement Marked tachypnoea Severe work of breathing Agitated or drowsy	Immediately escalate as per local CERS protocol Minimise distress to the child Give nebulised adrenaline (epinephrine) 5 mg (equivalent to 5 mL or 5 ampoules of 1:1000) undiluted, with 8–10 L of oxygen via nebuliser. Repeat nebulised adrenaline dose every 15 minutes until improvement or airway support obtained And give one of: dexamethasone 0.6 mg/kg oral/IM/IV once only, maximum dose 12 mg (preferred option) or prednisolone 1 mg/kg orally once only, maximum dose 50 mg, if tolerated
Mild–moderate croup Nil to intermittent stridor when upset or active Nil to moderate work of breathing Barking cough Occasional stridor when upset or active	Minimise distress to the child If stable with mild–moderate symptoms, complete a full A to G assessment before further management Give corticosteroid following A to G assessment, see specific treatment section

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Oxygen saturation (SpO2)	Do not disturb the child unnecessarily Visually inspect work of breathing using a hands-off approach SpO2 monitoring is only required in life-threatening croup

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate	Assess circulation Note: children who have required adrenaline as first-line management may have pallor due to vasoconstriction

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities Do not disturb child unnecessarily

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses

Focused assessment

Complete a respiratory focused assessment.

Precautions and notes

• The loudness of stridor is a poor indicator of the severity of obstruction. Soft stridor in the context of worsening clinical indicators may be a sign of imminent airway obstruction.
• Less severe cases can be managed with corticosteroids alone.
• Oxygen saturations may be near normal in croup, hypoxia is a late sign of deterioration.
• Humidified air has not been proven to change the severity of croup.
• Supplemental oxygen is not usually required.
• Minimise handling, and reduce distress, to avoid worsening symptoms.
• Alternative diagnoses include, bacterial tracheitis, inhaled foreign body, anaphylaxis, epiglottis, peritonsillar abscess or retropharyngeal abscess.

Interventions and diagnostics

Specific treatment

Mild–moderate croup

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Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

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Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au