A barking cough at two in the morning

A 2-year-old woke his parents with a cough 'like a seal' and a noise when he breathes in. In the car he seemed better; in the waiting room it started again.

Age2 yearsWeight12.5 kgVitals read against the toddler band

Pediatrics

2 years old· toddler12.5 kgboy, Pediatric emergency, room 8Fictitious educational patient

Caregiver: Mother: 'He had a bit of a cold yesterday. At two he woke up barking and making this horrible noise breathing in. He was better in the cold air outside, then it started again in here.'
Immunizations: Up to date, including Haemophilus influenzae type b.

Previously well

Day 1 · 02:40

The noise

He sits on his mother's lap with a hoarse cry and a barking cough. Inspiratory stridor is audible from the doorway while he cries and settles to a faint noise when he is calm. Mild suprasternal retraction. He is drinking from a cup.

Vitals

HR 134RR 30SpO2 97Toddler band · HR 98 to 140 · RR 22 to 37

HR134BP92/58RR30SpO297%T38.0high for age

Read against the toddler band (1 to 3 years): HR 98 to 140 awake, RR 22 to 37, hypotension below 72 systolic at the youngest age in the band. Fever, crying and pain move these numbers.

Grade the croup, and name the one thing you must not do.

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