Don’t let your intervention define the diagnosis #WILTW

This is the 174th #WILTW

Summer is over.

Winter is coming.

The waiting room of our emergency department has altered, from being a collection of broken bones and abrasions, to one of hot and coughing children.

In particular we have seen a spate of children with croup.

Croup, on the whole, is a satisfying condition to treat. It comes with a very clear set of reproducible symptoms (such as a barking or seal like cough) and signs (noisy inspiration and breathing difficulty).

Generally parents are very good at recognising key features, especially if siblings have had croup previously, although for some reason they also seem to like posting videos of their croupy children online.

The satisfying part of treatment is the prompt response to a single dose of steroid (although the dose itself is amazingly still a matter of debate).

The challenge comes at the more severe end of the spectrum where adrenaline is required to temporarily reverse impending respiratory collapse (although in no way treat the underlying cause which clinicians often forget to tell parents and carers).

I am very protective of my staff giving adrenaline to children with croup when I am in charge of the department. I want to vet the decision, regardless of who makes it, not because I am a control freak (although I am) but because the use of adrenaline defines the disease process.

The child who receives adrenaline is then labelled ‘severe’ rather than vice-versa.

Of course many children do need this urgent treatment (and the close observation that it subsequently requires). But in my experience some don’t. It’s not that the child isn’t unwell, it’s just that they are unlikely to get worse without treatment. Patience, combined with good communication to the parents, are the key elements of management.


Once a child has received adrenaline however it is very difficult to pull back. Adrenaline is a powerful drug. Whether they have had mild, moderate or severe croup the child is likely to look better.  It will be impossible to know what they were previously like so, as the benefit of the doubt must be given the professionals treating the child, it is assumed they were severe. The child will need a prolonged period of observation; the very fact they have been judged severe often creating anxieties about the most appropriate place to do this.

Interventions defining severity are not unusual. This effect could be applied to the use of intravenous salbutamol in asthma and fluid boluses in presumed sepsis.

While no assessment is entirely objective it is important patients are managed based on the acuity of their illness; not always the treatments they have received for that illness.

What have you learnt this week? #WILTW

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(Other winter respiratory conditions reviewed here)


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