Paediatrics in the ED

​The key to managing children is to remain calm & confident, ensure sensitive & thorough communication at all times and to maintain a systematic assessment. Always consider the possibility of child maltreatment & document that you have done so.
 
The following section is written to assist you with one of the most common paediatric presentations you may see in the ED.

Febrile child < 5 yrs

Defined as above 38ºC. It is a common presentation usually indicating an underlying infection which may not be obvious. Use standard ABCDE approach & check for life threatening features as per APLS guidelines.
 
Emergency treatment:
  • Maintain airway
  • Give O2 if sats <92%, child shocked or other clinical indication
  • Obtain IV access & if shocked administer fluid bolus at 20mls/kg 0.9% NaCl
  • Consider need for urgent IV antibiotics (Unwell/sepsis Ceftriaxone 80mg/kg).
  • Consider IV Aciclovir if reduced conscious level or focal seizures.
 
Otherwise measure & record
  • Heart rate
  • Respiratory rate
  • Capillary refill time (CRT)
  • Oxygen saturations
  • BP if signs of shock
  • Blood glucose in unwell children
 
Assess for signs of dehydration
  • Prolonged CRT
  • Reduced skin turgor
  • Abnormal respiratory pattern
  • Weak pulse
  • Cool extremities
 
Manage as per NICE guidance on feverish illness in children.
Antipyretics
  • Consider paracetamol OR ibuprofen if a child is distressed or appears unwell. They should not solely be given to reduce body temperature if the child is otherwise well.
  • Do not give simultaneously but consider the alternative agent if the child does not respond to the first.
  • Do not rely on the response of a fever to antipyretics to differentiate between serious & non-serious illness. An afebrile child who continues to look unwell is a concern.
 
Admit
  • Child < 3 months with any reported fever
  • Child < 6 months with fever > 39ºC
  • A child with any RED features
  • A child with AMBER features should be reviewed by a senior doctor (ST4 +) & admission considered.

When considering admission consider both clinical condition AND:
  • Social circumstances
  • Other illnesses the child or family may have
  • Parent/carer anxiety/instinct
  • Contact with other people with serious infectious illnesses
  • Parent/carer concern causing repeated attendances
  • Recent travel abroad
  • Previous family experience of death through febrile illness
  • Child with a fever of no obvious cause but lasting longer than would be expected for self-limiting illness.
 
If a child > 3 months is being discharged from ED provide the parent/carer with written advice regarding the management of fever in children which can be found amongst the ED patient advice section on the intranet. Advise parents/carers of:
  • Antipyretic use
  • To offer their child regular fluids/continue breastfeeding
  • The signs of dehydration & to offer more fluids & consider seeking further advice if signs of dehydration occur.
  • How to identify a non-blanching rash
  • To check on the child during the night
  • To keep the child away from school/nursery while unwell
 
Advise parents/carers to seek help if their child:
  • Has a seizure
  • Develops a non-blanching rash
  • is getting worse
  • Fever lasts more than 5 days
  • Shows signs of dehydration
  • They are concerned they cannot look after their child.
  

Guidelines

Guidelines for managing specific conditions can be found on the ED intranet. The update or creation of new guidelines for managing paediatric conditions is strongly encouraged for your CT3 year. Promote their use within the department especially amongst the juniors as they make life/decisions much easier (and safer) for them. Currently covered are:
 
  • Life support algorithms
  • Asthma - including discharge advice leaflet
  • Paediatric antibiotic guidelines
  • Paediatric fast track clinic referrals
  • Ketamine sedation in Children
  • Intranasal diamorphine & chart
  • Quick assessment of the sick child
  • Management of critically ill infants aged < 3 months
  • Meningococcal septicaemia & meningitis
  • Cardiac arrhythmias
  • Anaphylaxis
  • Stridor, Croup, Epiglottitis & foreign bodies in the airway/oesophagus
  • Bronchiolitis (with advice leaflet) & pneumonia
  • Urinary tract infections
  • Assessing febrile children (NICE traffic light system) - including fever advice leaflet
  • Febrile convulsion - including advice leaflet
  • Seizures
  • Coma including paediatric coma score
  • Head injury
  • The limping child
  • Oncological emergencies in children
  • DKA
  • Hypoglycaemia in diabetic & non-diabetic children
  • UTI in childhood - including advice leaflet
  • Foreign body ingestion including button battery ingestion & metal detector use
  • ENT foreign body ear/nose
  • ED summary & level 12 guidance on diarrhoea (with or without vomiting) - including advice leaflet
  • Imaging head injuries & c-spine in trauma
  • Burns including referral criteria & charts
  • Toddlers fractures
  • Buckle (Torus) fractures - including advice leaflet
  • Fractured clavicle - including advice leaflet
  • Oro-nasal haemorrhage in infants
  • Hyperbaric oxygen in children
  • Paediatric plastics dressings clinic
  • Sexual assault in children
  • Self-harm & intoxication in children (including CAHMs information)
  • PEP risk assessment for children
There are also guides to practical procedures in children:
  • Guide to paediatric blood bottles
  • Plasters in children
  • LMA sizing
  • Needle & surgical cricothyroidotomy
  • Gaining IO access (EZ-IO)
  • Umbilical venous catheterisation
  • Saphenous vein cutdown
  • Femoral nerve block & femoral fracture protocol
 
And links to advice on:
  • Where to admit children & who to call for help, including contacting a paediatric anaesthetist
  • Child protection & death in childhood
  • Derriford ED Paediatric drug calculator
  • WATCH (Wales & West Acute Transport for Children) paediatric emergency drug calculator
  • Analgesia dosing charts & use of LAT gel.
  • Normal values, estimating weight, fluids & equipment sizing in children

Additional advice leaflets on:
  • Unlicensed medications in paediatrics (for parents)
  • Information for parents going to BRCH
  • The NHS SAM leaflet on spotting sepsis & getting help for children

Paediatric ED Clinics

Currently run on a Thursday morning.
​Complete a clinic referral form and send with the patient and the notes to reception to make an appointment.

Notifiable Diseases

A doctor attending a patient suspected of suffering from any of the notifiable conditions must report it to the Consultant for Communicable Disease Control. This can be done by contacting the Health Protection Agency (HPA) via switchboard. Out of hours make a clinical judgment on the urgency of the need to contact the HPA.