Of the vast number of children attending emergency departments, approximately 2–5% are classified as immediate emergencies (Australasian Triage Scale (ATS) 1 and 2) that require urgent assessment and management.¹ Importantly, children can present with a less urgent triage category, but may rapidly deteriorate from evolving sepsis or airway compromise. The majority of paediatric presentations consist of less emergent problems involving a wide spectrum of injuries and illness. Of this group of paediatric patients there is a subset where the diagnosis is not immediately apparent. Thus, paediatric patients can generally be divided into three broad groups: the obviously well, the obviously sick or the potentially sick child. One of the major tasks for the emergency physician is to identify the ‘sick child’ from a large undifferentiated group of children who may present as potentially sick. It is by a ‘filtering process’ via history, examination, observation, investigation and consultation that one identifies the potentially sick child (Fig. 1.1.1). This group of patients includes: those children who have progressed to a severe form of a usually benign illness; those with early, subtle signs of a serious disease; or those who on initial assessment appear unwell, but require investigation to help rule out serious disease. It is often through observation of a child, that one is able to more accurately assess each of these possibilities.² With experience, the ability to appreciate a ‘sick child’ improves; however, a good rule, particularly in the younger child, is, if in doubt, investigate, admit for a longer period of observation or seek the second opinion of a colleague.

Fig. 1.1.1 Algorithm of paediatric decision making.

Children with fever

The concept of ‘occult bacteraemia’ (OB) highlights the difficulties in detecting significant illness in febrile young children. With the recent advent of widespread vaccination to the common agents of occult bacteraemia (Hib, pneumococcus) the prevalence of paediatric sepsis has diminished significantly and the clinical experience of managing septic children has been diluted in developed countries. Hence, one needs to have a planned approach to the assessment of febrile children at various ages. Bacteraemia can in its most manifest form present as a febrile, pale, pasty, mottled child, centrally warm but with cool peripheries. Some young children with bacteraemia, however, can appear completely well apart from fever. Investigations may help identify them with a high white cell count or c-reactive protein (CRP), but these inflammatory markers are unfortunately often non-discriminatory between benign and serious causes. The problem is not so much that children with OB are sick at that moment of time, but the possibility of the later development of serious bacterial sequelae necessitates timely treatment. Conversely, many bacteraemic children will spontaneously clear the organism without therapy. Therefore, these children remain in the potentially sick category of patients and are obligated to have either admission for observation or discharge with frequent planned reviews for sequelae and a definitive action plan for their parents should the condition change. The evidence for the use of prophylactic antibiotics in these children is controversial. The age of a patient and height of the temperature are useful risk factors to consider in the approach to individual patients. In children less than one month, any fever is significant, whereas older children are more at risk of serious illness with higher temperatures. Likewise, hypothermia can occur in overwhelming sepsis, particularly in neonates and infants.

Evolving illness in children

Due to differences in anatomy, physiology, development and psychology, children’s diseases are age specific, with serious illness often taking time to evolve.³ Many children present to an emergency department in the early stage of an illness and making a definitive diagnosis may require time. The clinical status of paediatric patients may also change rapidly. This can occur in response to prior trauma, evolving sepsis, toxin absorption or a seizure, and necessitate a change in the initial priority to receive treatment. The younger the child, the greater the potential for rapid deterioration as the early manifestations of a serious illness may be subtle and non-specific. One must be vigilant for the early signs of compensated shock such as tachycardia, decreased capillary refill, mottled skin, cool peripheries, decreased urine output, or drowsiness. Early detection and fluid resuscitation at this point may prevent hypotension in a child with evolving sepsis. Children with severe and deteriorating respiratory illness will manifest fatigue. It is the early recognition of children with serious illness or the potential to deteriorate that is critical to the timely initiation of effective treatment.² An important principle in emergency paediatrics is to be proactive. One must be aware of the importance of regularly reviewing a child’s response to a given therapy, escalate treatment if required and be vigilant for subtle signs of deterioration.

The environment

The physical environment of the emergency department needs to reflect a paediatric milieu with appropriately equipped cubicles for the reception of children accompanied by their carers. Despite the noise inherent in a busy department of sick children, the environment should be as calm and relaxed as possible. Wall or ceiling posters, mobiles, a selection of toys and books are useful to distract younger children from the distress and threat of an unfamiliar hospital environment. Posters of current popular characters such as ‘Teletubbies’, Blues Clues, Shrek, Wiggles or Harry Potter are useful. Not only do these characters make kids feel happy, but their active recognition provides a useful CNS diagnostic tool. A few initial moments gaining a child’s confidence with a toy will usually reward the doctor with a more rapid and thorough assessment of the reluctant child. Supplies of stickers or bravery certificates are excellent rewards to have on hand for young frightened children who have undergone imaging or blood tests. If possible, in a mixed department, children should be completely separated from adult patients. Adult patients who are behaviourally disturbed will be distressing for a child and family to see or hear in a nearby cubicle.

Likewise if a child is to undergo a procedure during which he may become distressed, such as intravenous insertion or laceration repair, it is best performed in a closed dedicated procedure room. This will avoid visual or auditory distress to other children and parents. A mounted television/video monitor in this setting can be an excellent distraction during procedures, as an adjunct to analgesia and sedation. For neonates and small infants a radiant heater over the examination bed will aid temperature stability, examination and often the discovery of veins for cannulation.

The paediatric resuscitation area should include wall charts, which refer to emergency algorithms and drug dose guidelines, which can be rapidly referred to during the resuscitation of critically ill children. A white board is handy for pre-sizing and dosing for the imminent arrival of a sick child. Updated clinical guidelines in hard copy and electronic form in the management of common paediatric emergency conditions are a useful resource to be available within the department. Clinical pathways initiated in the emergency department can be useful in ensuring consistency of management from all levels of medical and nursing staff, as well as improving continuity of care in children who require admission to an inpatient unit.

Triage

Paediatric patients arriving in the emergency department should undergo triage according to standardised Australasian Triage Scale (ATS 1–5) so that they are seen in a prioritised fashion according to acuity. In mixed emergency departments where triage nurses may have had less paediatric experience, there has been a tendency to up-triage paediatric patients.¹ The use of scoring systems for specific conditions or a Triage Observation Tool may be helpful in improving the reliability of triage in young children, who may present with non-specific symptomatology.⁴ A secondary nursing assessment should occur when the child is admitted to a cubicle, with further observations performed at the bedside, so that any change in condition can be detected early and acted on promptly. The senior doctor in the department should immediately be informed of children triaged as ATS 1 or 2 to direct timely management. In times of high workload, children with an ATS 3 may not be definitively assessed within 30 minutes and should have a senior doctor rapidly assess status and initiate therapy, if required. It may be necessary to modify normal triage systems when emergency department numbers are affected by surges in demand when significant influenza outbreaks or the like occur.

Fast tracking

Some initiation of treatment is appropriate during the triage process, such as the provision of analgesia for pain or an antipyretic in a child symptomatic of fever. It is important that children with pain are given early and appropriate analgesia or have injuries splinted when required. This will facilitate a more comfortable, reliable and expeditious assessment. The use of opiates, when required, will only enhance, rather than detract from the subsequent physician’s physical examination.⁵ The use of visual analogue scales such as the Wong–Baker faces may assist the assessment of a child’s response to analgesia. A process of fast tracking appropriate children with single limb injuries for an X-ray prior to definitive medical review may improve efficiency through the department. Febrile children who present with a rash, not clearly due to a viral exanthema or benign phenomena, should be fast tracked to be seen by a senior doctor to consider the possibility of meningococcaemia. It is useful to have documented management plans for children who may recurrently present to the department. This includes conditions such as complex children, brittle asthma, cyclical vomiting or recalcitrant seizures where a clear plan of management can expedite care by ED staff.

The paediatric approach

The evaluation process of a child in the emergency department involves history, observation, examination and may include relevant investigations.

Each of these components needs to be considered in the formulation of a diagnosis and disposition plan. A child needs to be considered in the context of the family. The assessment of children in the emergency department setting can be both challenging and very rewarding. It is a challenge to modify the clinical approach according to the chronological and developmental level of the individual child. Likewise, treating paediatric patients is a rewarding area of emergency medicine, as children will often respond rapidly to management within the time frame of the emergency department attendance.

Gaining rapport

Endeavouring to gain initial rapport with a child and the confidence of the parents is the key to assessing children in the emergency department setting. An unrushed, gentle and caring manner will rapidly settle the fears and anxieties of most children and their parents. This usually allows the examination to proceed in a non-threatening fashion and improves the reliability of clinical signs. It will take time, experience and the observation of colleagues’ techniques for every emergency physician to develop their own individual approach to children. A thorough examination without causing distress to a child is very reassuring to a parent. Many children arrive at an emergency department miserable, in pain, fearful, or with some trepidation of what lies ahead. With a child-friendly approach by all staff, most will leave feeling much better and, hopefully, even having enjoyed the experience.

Age appropriate

The approach to any child in the emergency department is dictated by the child’s age and developmental level. It is useful to have a modified approach to suit newborns, infants, toddlers, preschoolers, school children and adolescents. An understanding of the concept of ‘the fourth trimester’ is useful in dealing with crying phenomena in the first months of life, which will often precipitate emergency department visits (see Chapter 1.2). A preverbal or developmentally delayed child won’t tell you of pain which has shifted to the right iliac fossa. An unwell 14-month-old clinging to mother may actively resist the initial attempts to be examined by a stranger. The absence of familiarity with a family or child that their family doctor may have may further impede the assessment of anxious children. When explaining procedures to children it is important to be age appropriate and above all honest. Never tell a child ‘you won’t feel a thing!’ prior to plunging a cannula through an EMLA anaesthetised cubital fossa. Rather, explain in age-appropriate terms what it may feel like and that it’s OK to cry.

Maintaining a child’s trust at all times is crucial and will positively influence any subsequent medical contacts the child may have. The demonstration of a procedure on a doll may decrease the anticipatory trepidation in a child.

The assessment of a child should always be carried out in the presence of the parent or carer, unless the child arrives by ambulance or other means without the parent/carer present, and the child’s medical needs warrant immediate attention. Otherwise, it is prudent in the non-urgent situation to provide a staff member to support the child and defer the assessment until carers are present.