Pediatric Respiratory Illness Severity Scoring
Every fall, someone's parent brings in a kid with barking cough at 2 AM. You need to know whether to send them home or admit them. Here's how to score it.
Westley Croup Score
Run through the Westley checklist. Five components, maximum score of 17.
- Stridor: None (0), with agitation (1), at rest (2)
- Retractions: None (0), mild (1), moderate (2), severe (3)
- Air entry: Normal (0), decreased (1), markedly decreased (2)
- Cyanosis: None (0), with agitation (4), at rest (5)
- Level of consciousness: Normal (0), altered/disoriented (5)
Here's what the score means:
≤2 (Mild): Stridor only when upset, minimal or no retractions. Send home with dexamethasone 0.6 mg/kg by mouth (max 10 mg). Improvement expected within 24–48 hours.
3–7 (Moderate): Stridor at rest but breathing is adequate. Give dexamethasone 0.6 mg/kg by mouth (max 10 mg) plus nebulized epinephrine if stridor is persistent. Racemic epinephrine: 0.5 mL of 2.25% solution in 3 mL NS. L-epinephrine: 0.5 mL/kg of 1:1000 (max 5 mL) nebulized. May need admission depending on response and ability to observe for rebound.
8–15 (Severe): Significant stridor at rest, marked retractions, or cyanosis. Dexamethasone 0.6 mg/kg IV/IM (max 10 mg) plus nebulized epinephrine as above, which may be repeated every 15–20 minutes if needed. Admit. Intubation is rare (<1% of croup cases).
L-epinephrine is equally effective to racemic epinephrine and is more widely available. Onset is within 10–30 minutes, with effects lasting approximately 2 hours. Observe for at least 2–4 hours after nebulized epinephrine for rebound symptoms.
Use Westley Croup Score.
HASS Asthma Score: Is This Kid Going to Hospital?
Look at five things:
Respiratory rate: Under 30 (mild), 31–40 (moderate), over 40 (severe)
Working harder?: No retractions (mild), retractions without flaring (moderate), retractions with flaring (severe)
Can they talk?: Full sentences (mild), short phrases (moderate), can't speak at all (severe)
Wheezing: End-expiratory only (mild), all through expiration (moderate), silent chest, no air moving (severe, bad sign)
SpO₂: Above 95 room air (mild), 90–95 (moderate), below 90 (severe)
Now scale your treatment to severity.
Mild exacerbation: Albuterol inhaler 2 puffs every 4–6 hours. Prednisone 0.5–1 mg/kg (max 50 mg) or dexamethasone 0.6 mg/kg (max 10 mg) for 3–5 days. Send home.
Moderate: Albuterol 0.15 mg/kg nebulized every 1–2 hours plus ipratropium 250 mcg. Steroids (IV or oral). Many of these kids get better in the ED and go home, but you might keep them.
Severe: Albuterol continuous (10–15 mg/hour) plus terbutaline 0.01 mg/kg (max 0.25 mg) subcutaneously every 15–30 minutes. Or IV epinephrine 1:10,000 if that's not working. IV methylprednisolone 1–2 mg/kg every 6 hours or IM/IV dexamethasone 0.6 mg/kg. These kids get admitted. PaO₂ <50 or PaCO₂ >50? ICU.
Use HASS Asthma.
Broselow Tape: When You Don't Know the Weight
The Broselow tape is laid alongside the kid (supine). Pick the color that matches their length. That color tells you the weight range, and you've got the drug doses right there on a card.
Color zones correspond to length-based weight estimates (varies by edition):
- Grey: 6–7 kg
- Pink: 8–9 kg
- Red: 10–11 kg
- Purple: 12–14 kg
- Yellow: 15–18 kg
- White: 19–23 kg
- Blue: 24–29 kg
- Orange: 30–36 kg
Always verify your institution's current Broselow edition, as weight ranges have been updated over time.
Common drugs pre-loaded:
- Epinephrine (1:10,000): 0.01 mg/kg IV/IO
- Atropine: 0.02 mg/kg (min 0.1 mg, max 0.5 mg)
- Amiodarone: 5 mg/kg IV/IO bolus, may repeat 5 mg/kg (up to 2 additional doses)
- Naloxone: 0.1 mg/kg (max 2 mg)
- Calcium gluconate: 0.6 mL/kg of 10%
- Dextrose: 0.5 g/kg (use 2 mL/kg of 25%)
- Sodium bicarbonate: 1 mEq/kg
Use Broselow Tape and Emergency Drugs to verify.
How to Actually Use These Scores
Westley croup: Score it (0–17), then dose dexamethasone and decide if they need epinephrine and/or admission based on where the score lands.
HASS asthma: Mild = inhaler and steroids at home. Moderate = nebulizers and watch them. Severe = admit or ICU.
Response matters more than perfection: A kid who's improving after 30–60 minutes might go home. One who's still struggling after an hour needs a bed. Watch the trend, not just one number.