Who sees paediatric emergencies?

It is essential that all doctors are familiar with the recognition and management of the seriously ill child. The majority of children presenting to emergency departments are either taken to tertiary paediatric centres or mixed departments that see both adults and children. A small number will arrive, due to close proximity in an emergency, at adult departments where staff may be less familiar with the management of children. Likewise, paediatric emergencies occur remote from emergency departments and may require stabilisation by general practitioners, paramedical staff or laypersons prior to subsequent referral. It is an important role of emergency departments to be an available resource to support the community in the management of paediatric emergencies. This function may occur through advisory, liaison and educative processes.

Some critically ill children will arrive in a more predictable fashion via ambulance and some preparation can occur to plan for their initial treatment. On the other hand, a child in extremis may well be rushed in from a family car, without any prior warning of their arrival. Systems of preparedness for these situations are critical for the immediate assessment and optimal early management of children by emergency department staff (see Chapter 2).

Evolution of paediatric emergency medicine

In Australia and New Zealand there are currently only nine stand-alone tertiary paediatric emergency departments. Hence, the majority of paediatric patients present initially to mixed departments where approximately 10–30% of attendances are paediatric. This is similar to the UK, Canada and USA. Some of these children will require subsequent referral to a paediatric tertiary centre for ongoing specialist care. The role and functioning of emergency departments has changed dramatically over the past three decades. Paediatric emergency medicine (PEM) has now developed as a speciality of paediatrics and emergency medicine. The initial assessment and stabilisation of paediatric patients, which in the past was often deferred to intensive care or anaesthetic colleagues, is now an important role of emergency physicians. In Australasia, the development of PEM as a subspecialty of the College of Paediatrics has seen the establishment of a supervised training scheme by the Paediatric Emergency Medicine Special Interest Group for advanced paediatric trainees. A joint training programme overseen by both the Australasian College for Emergency Medicine and the Royal Australian College of Physicians oversees the training qualifications of paediatric emergency physicians. It is paramount that physicians and trainees in both specialist and general emergency departments are well trained and the facilities are appropriate for the resuscitation of critically ill children. Hence, the education and training of emergency physicians in the management of common paediatric emergencies is an important role of both paediatric and emergency colleges. Whether a trainee is seeking a career in a paediatric or a mixed emergency department, experience gained in both environments with exposure to the teaching of both paediatricians and emergency physicians is advantageous. Likewise, a rotation in paediatric intensive care and paediatric anaesthesia provides additional skills in resuscitation, airway management, haemodynamic support and monitoring of critically ill children. The APLS (Advanced Paediatric Life Support) and ATLS (Advanced Trauma Life Support) or equivalent courses are invaluable additional resources and are requirements to satisfy fellowship qualifications in the training of physicians who will be managing paediatric emergencies.

Identifying the potentially sick child

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.

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.

Development appropriate

Infants particularly benefit from the constant presence of their parent in their visual field in order to avoid stranger distress and are often best examined in the parent’s arms. Neonates can be examined on the examination bed as long as they are kept warm. Toddlers, despite their evolving autonomy, will usually be less fretful if examined on a parent’s lap. It is a useful sign of illness or other cause to note when young children do not exhibit these normal stranger anxieties. The preschooler who enjoys a sense of play and imagination can usually be relaxed during an examination or procedure by storytelling or engaging in play with a toy. An anxious early school-aged child may respond to participation in the examination or being asked about school or other more favoured activities. Adolescents, on the other hand, need to be approached in a more adult fashion and should be offered confidentiality and the opportunity to choose whether their parents are present (see Chapter 30.1).

In the event of an unatonable child resisting any examination, one may have to modify the approach to gain essential clinical findings in a gentle but firm manner. It is unusual, however, for a child to remain ‘unexaminable’ if appropriate analgesia is given and the child is left for a period of time undisturbed.

Parental involvement

In order to provide emotional support, parents should be encouraged to remain close to their child during any procedures. Parents who appear at risk of vagal syncope are best seated away from the ‘viewing of action’ but still in their child’s earshot for verbal support. Children’s behaviour often mirrors that of their parents, so gaining the confidence of the parent will often make an anxious child relax prior to procedures. The use of a confident, calm, caring approach will be rewarded by a child who will allow a more reliable examination. It is very reassuring to the parents to see that the doctor is experienced in dealing with children and anticipates the expected anxieties and reluctance to examination that a child may have when unwell.

Critically ill child

Sometimes the normal routine of history, followed by examination will need to be altered in a child who arrives critically ill. The management will need to be expeditious and occur simultaneously with the gathering of pertinent information from the parents. Parents should be given the opportunity to remain at the bedside of their critically ill child undergoing resuscitation, with a dedicated support person.

Parental issues

The clarity of the history given by parents can be affected by parental distress, anxiety or sleep deprivation. One should begin the history in a focused manner according to the presenting complaint. Later it may be useful to explore individual parental anxieties. One of the most important questions to a parent is, ‘What is your biggest worry or fear?’ Some parents may have specific concerns such as a fear their febrile child has meningococcal disease when community alertness to this condition is heightened. Addressing this concern may occupy most of the doctor’s time. The parent of a child who has sustained an accidental scald or injury may be feeling distressed or guilty and sensitivity to this is required. Again, addressing guilt will involve much of the doctor’s time.

Children-specific issues

In younger children, certain symptoms are less specific. The report of vomiting in an infant may be due to meningitis, pneumonia, tonsillitis or urinary sepsis rather than gastroenteritis. The assessment of wellness or otherwise in infants can be more challenging due to their limited psychomotor activities. Indeed, their spectrum of normal behaviours involves sleeping, waking to cry or demand a feed, followed by a return to sleep. Hence, it is important to enquire into their feeding status and sleep/activity pattern as an indicator of compromise due to illness. One needs to carefully clarify what their current intake is compared to their normal breast- or bottle-feeding. An infant who is feeding less than 50% of normal has significant compromise. It is important to note the report of a young febrile child who remains lethargic and fails to smile or interact with parents. In the otherwise well-looking infant, who appears mottled, clarify with parents whether this may be usual for their child (i.e. physiological cutis marmoratum versus sepsis). In assessing young children with trauma, a thorough history of the timing and mechanism of injury, noting the child’s developmental capabilities, is paramount to detecting possible non-accidental injuries (see Chapter 18.2 on NAI).

Other useful information to cover in the paediatric patient history is shown in Tables 1.1.1 and 1.1.2.

Table 1.1.1 History warning bells

Age appropriate

The examination technique used in paediatric patients depends on the age and developmental level of the child. The key is to gain the confidence and then the co-operation of the child. Older children are generally examined in a systematic fashion similar to adult patients. However, younger children usually need to be examined in a less formalised manner, whilst maintaining a high degree of vigilance. The order of the examination may need to be adapted according to the individual child’s responses. In a reluctant examinee, clinical findings may be achieved by surreptitiously examining through play as the opportunity arises. Much can be ascertained in this situation by careful observation rather than a more threatening ‘hands on approach’. Entertaining a young child in a professional manner during examination will generally allow the confounding influence of anxiety to diminish.

Improvise

The examination of infants and young children is best done in the least threatening position. This is usually best whilst being held securely in the parent’s arms or on the knee. If a young child is sleeping, the opportunity should be taken to perform auscultation, palpation of a fontanelle/abdomen, which will be altered in the crying state, prior to disturbing the child to wakefulness. A neonate examined supine needs to be kept warm with a blanket or a radiant heater. Hands should be warm. The crying fractious baby may be settled by offering a feed or a pacifier before the examination. The symmetry of normal infant reflexes is a useful screen for any focal motor problem or as a localiser of a painful limb that will modify normal symmetry of response.

Index of suspicion

The routine methods of examination for signs of meningism in children are unreliable. Asking the child to look upwards at an object or down to their umbilicus is a more useful screen to detect nuchal irritation. The presence of photophobia is sensitivity to ambient light as most children will be offended by a torch light in the eyes. In children less than two years old, the early signs of meningism are often absent and threshold for cerebrospinal fluid (CSF) examination adapted accordingly. Other significant but subtle features that may be missed on examination include persistent tachycardia or tachypnoea that is not clearly related to fever. One needs to be alert to the spectrum of stigmata of non-accidental injuries that may present to the emergency department (see Chapter 18.2 on NAI).

Respiratory examination

Noisy breathing in children can sometimes be difficult to determine if it is due to airway obstruction of intra- (lower airway) or extrathoracic (upper airway) origin. The localisation of airway obstruction to a particular segment of airway can often be aided by successive auscultation over the nares, mouth, larynx and peripheral airways. Remember, young children may manifest both upper and lower airway involvement (‘crasthma, broup, cronchiolitis’) with inflammatory involvement of both segments of the respiratory tract. Younger children are often easier to auscultate by listening through clothes (avoiding the ‘stethoscope–cry reflex’) from behind whilst being held by the parent. Detection of ‘occult’ asthma in a child with suggestive symptoms but no wheeze, may be aided by comparing the diminished volume and rate of airflow in expiration compared to inspiration, or alternatively re-auscultation after exercising the child in the ED. Young children with throat discomfort will be reluctant to volunteer a cough, but a gentle tickle of the axilla or palpating the anterior larynx will usually produce a bark to clarify suspicion of croup. Recognising the pattern of respiratory distress in a child from the end of the bed will often differentiate upper and lower airway obstruction, prior to any auscultation. Children with upper airway obstruction have slower inspiration, whereas gas-trapped wheezers will have diminished flow and speed of expiration on observation.

Abdominal examination

The abdominal examination needs to always conclude with the nappy area for otherwise occult torsions, hernias, skin problems and for stool examination, if present. The rectal examination in children is not routine and only performed with clear indication. One needs to be cognisant to maintain privacy and dignity, particularly when examining older children and adolescents. The examination of a child with possible sexual abuse is outlined in Chapter 18.1.

ENT last

In preschool age and younger children examination of the ears and throat is best deferred to last. A gentle, but rapid approach is necessary to achieve an accurate assessment of the oropharynx, followed by a cuddle from the parent. Despite the potential difficulty, the source of fever will often be overlooked if the throat is inadequately visualised in children. In infants, the throat is best examined with the child lying supine with both arms abducted alongside the head to prevent movement. A young child who is fearful of throat examination needs to be held as still as possible for a rapid, ‘one gag, one look’ approach. This is best performed after explanation, positioning the patient upright on a parent’s knee, securing arms beside the trunk with the parent’s dominant arm and holding the head straight-ahead with the other. ‘Let’s count your teeth’ is a less threatening signal to most children to open the mouth, rather than mentioning ‘the tonsil or throat’ words, particularly if parents warn you that, ‘Nobody has been able to get a look at his throat’. Some children require gently inserting the spatula between clenched teeth to touch the tongue to initiate a gag. Most older children, fortunately, will happily volunteer a view of the pharynx.

Following any distressing procedure it is important to acknowledge bravery in a frightened child. Likewise, giving a child an honest, developmentally appropriate explanation of what to expect prior to any procedure, such as an IV insertion, is to be encouraged. This is best done immediately prior to the procedure so that an anxious child’s fears don’t escalate in the intervening period (Table 1.1.3).

Table 1.1.3 Examination warning bells

The pale, pasty child The floppy child The child who appears drowsy Alteration in vital signs, SaO₂ Early signs of compensated shock The tiring child with respiratory distress The child who never smiles despite appropriate prompting The child who looks sicker than the usual child with gastroenteritis/croup/bronchiolitis/URTI

Other specific signs
Non-blanching rash – petechiae/purpura-sepsis
Bulging or full fontanelle – raised intracranial pressure
Bilious vomiting – bowel obstruction
High pitched cry – meningitis
Grunting – respiratory distress

LOOK, prior to examination

Before the ‘laying on of hands’, much can be gleaned by initially observing a child and parent in the cubicle, from a distance. One’s first impressions of a child will often direct a subsequent approach. The child’s state of activity and interaction with the environment and parents will often change when a strange doctor approaches. The process of evaluating a child differs from that of an adult by the greater importance of observation. It is important to emphasise the observation of a child to aid diagnosis in the emergency department setting. This is particularly important in evaluating children during their first three years of life. The ‘end of bed’ observations can be an important indicator for differentiating the potentially sick child.

Observational variables

The general appearance of a child should include noting level of alertness, eye contact, activity, quality of cry, posture, interaction with the environment, irritability, colour, hydration, perfusion, general growth and nutrition, respiratory distress and presence of any unusual smell (e.g. ketotic). The lack of normal resistance to examination or a procedure expected of a child is an important observation to note. The sick child may make none of the resistance expected to examination or venepuncture. Observational variables have been shown to be more predictive of serious disease than historical information in young children.⁶ Likewise, clinical examination, considered alone, is a poor predictor of serious illness. Observation of a child needs to be performed as a separate process from the examination and may require a period of time for re-evaluation to detect disease progress. Researchers have used formalised scales such as the McCarthy Observation Scales to aid this assessment in febrile children.⁷ In the ED setting, discussion of a child with a colleague can be a rewarding aid to decision making.

A child’s posture, undisturbed, can be a useful clue to systemic illness, abnormal neuromuscular function or a painful limb or joint. Children with sepsis or meningitis may be floppy or flaccid. In other cases, the only sign of meningeal irritation may be a child who is holding his neck in a slightly extended position.

Observing breathing

When observing tachypnoea in a child, it is useful to determine whether a child has ‘quiet tachypnoea’ (breathing fast and quietly) with no evidence of increased work of breathing, such as may occur in conditions of fever, acidosis or cyanotic heart disease. Children with ‘noisy tachypnoea’ (breathing fast and hard) demonstrate increased work of breathing, due to conditions such as airway obstruction, pneumonia or heart failure.

Confounders

There are several observational confounders that can influence initial decision-making, when children can appear transiently sicker than they really are. There are many times when the initially sick-appearing child can pick up and appear well again over a short period of time. This situation usually occurs when the paediatric consultant is called and by the time he or she arrives the child is smiling and running around the department. The vomiting child will often look pale and ‘pasty’ for up to 20 minutes post vomiting. One-hour post antipyretic the symptomatic febrile child can look like a different child. Children initially emerging from a simple febrile convulsion can look well again in 20 to 30 minutes. A young child’s physiological sleep can mimic septic drowsiness or somnolence resulting from head trauma. A fearful child, during examination, can escalate the examiner’s perception of his illness.

Re-evaluate

This reinforces the power of observation. It allows time for a trial of fluids, reducing fever with an antipyretic, or seeing if a child responds to distraction. Subsequent re-evaluation of the child often allows one to differentiate whether a child is sick or well. The use of observation really allows one to identify the persistence of the initial abnormal examination findings. A child with intussusception may intermittently appear well and observation may be required to observe the clues to prompt the appropriate diagnostic investigation (Table 1.1.4).

Table 1.1.4 Observation warning bells

Decreased level of alertness, activity, eye contact Drowsiness or decreased interaction with the environment/parents Abnormal posture Abnormal quality of cry Prolonged irritability or inconsolability Ongoing pallor Decreased peripheral perfusion or hydration appearance Persistence of abnormal recorded vital signs Respiratory distress/tachypnoea (‘quiet’ or ‘noisy’)

Blood tests

Previous medical visits or advice may prompt a parent to feel that reassurance that their child is safe can only be confirmed by the ‘magic of blood tests’. This may be especially so with a young-looking doctor. However, with clinical experience and clear explanation, parents can usually be counselled out of this option, when it is clearly not warranted clinically, by explaining that blood taking is not always straightforward in a chubby toddler and that sometimes two, three or occasionally more attempts are required. The potential psychological stress to the child is not worth the information that will be obtained in this instance. However, on the positive side, blood tests such as a full blood count (FBC) or a CRP may provide reassurance in some uncertain situations. At other times they are useless, for example to exclude meningitis in a child with clinical tonsillitis, as inflammatory markers are already raised.

Investigations may provide extra time for observation (by clinically reviewing the child!) and reassurance; however, if an investigation is performed and is abnormal, action must follow! The screening of urine in febrile young children is vital to detect occult urinary infection. In children less than 2 years old, dipstick analysis is inaccurate to exclude infection and microscopy must be performed to exclude pyuria. The appropriate techniques for obtaining urine are discussed in Chapter 16.4.

Managing the parents

The emergency department visit may follow previous medical consultation(s) where their concerns may not have been addressed and it is important to explore these. Always acknowledge the parent’s fears and anxieties; however, medical judgement should allow an objective decision about whether a child is sick or not. An exception to this is the parents of children with a chronic illness or special needs. They are usually correct when they judge that their child is sick. Aggressive and unreasonable carers will usually respond to a professional, polite and courteous senior doctor. There is usually a reason behind their behaviour that needs to be explored. Even the most anxious parent will usually respond to a thorough assessment of their child followed by an explanation of diagnosis and management. In unplanned second presentations where parents demand admission, it is usually best to admit.

Communication issues

Explanations to parents as a general rule should be appropriate to their level of understanding and education. Provision of handouts (with accompanying verbal explanation) or written instructions is useful to reinforce diagnosis and management. Reviewing a parent’s understanding of instructions prior to discharge will allow clarification and avoid communication problems. Parents may have fears related to anecdotal advice from family/friends, misinterpretation of media reporting, or other sources, which need to be explored. Gaining the confidence of parents before they leave the department is an essential part of the therapeutic process and has a positive effect on compliance to therapy. It is useful to explain to parents the likely natural history of their child’s illness and encourage review should significant deviations from this occur.

Turning the corner

Managing children is often about understanding the natural history of the illness and predicting when the child will ‘turn the corner’. For example, one needs to be patient with a child who clearly has gastroenteritis who has been vomiting for two hours. Often a child will vomit hourly for eight hours, perhaps once or twice more and then improve. Advising the parents of the likely natural history of a condition and giving a clear action plan can be reassuring and prevent unnecessary re-presentation.

Decision making

Making decisions in paediatric emergency medicine is a balance of history, examination, intuition, knowing when to trust the parents and maintaining objectivity. If you feel uneasy with your diagnosis regarding a child, respect that feeling and gain support until you do feel comfortable with your decision. There are many strategies to do this:

When to admit

The decision to admit or discharge a child from the emergency department is easily made when the child requires medical care that is only available in the hospital setting. The receiving ward will need to have appropriate resources for the ongoing management of the child, which should be clarified by discussion with the receiving inpatient unit/paediatrician. Some children may need to be discussed with, and transferred to a tertiary paediatric environment when they require, or have the potential to require, paediatric intensive care facilities or paediatric subspecialty management.

Factors influencing disposition

However, many other factors need to be considered in the disposition decision (Table 1.1.5). The threshold to admit a child is influenced by the child’s age, availability of appropriate follow up, assessment of parent’s ability to provide care and ongoing monitoring, the natural history of the illness and likelihood to deteriorate, social factors, comorbidity, distance from hospital, time of day, parental anxiety levels, availability of an early paediatric opinion, and the possibility that a child may be at risk. One needs to assess in a non-judgemental fashion the ability of the parents to carry out any ongoing treatment, and consider admission if there appears to be a need for ongoing support. When in doubt regarding whether or not to discharge a child, err on the side of caution. It may be prudent to consult, consider a period of observation in the emergency department, or admit the child to hospital.

Table 1.1.5 Factors influencing admission threshold

Age of child Availability of appropriate follow up/review Parental ability to provide care and monitoring, social factors Comorbidity Distance from hospital Time of presentation Parental anxiety levels To enable a paediatrician opinion Possible child at risk outside hospital

Continuity of care

It is important for emergency department staff to liaise closely with the admitting paediatrician to provide continuity of care and to ensure ongoing care is expedited in the emergency department. Ongoing management and monitoring of the patient is an important role of medical and nursing staff after this decision has been made, particularly if there is a delay in the transfer process. Any significant change in a child’s previous status or treatment needs to be communicated to the appropriate receiving team.

Observation ward

Significant compromise from many childhood illnesses is often transient and will often respond rapidly to interventions commenced in the emergency department followed by a period of observation. Parents can often be reassured during this period of observation in hospital that their child has remained well and will respond to management strategies that subsequently can be continued at home. Studies have shown that many children admitted to hospital only require a limited period of subsequent in-patient therapy and are discharged in less than 24 hours.⁸ In a tertiary paediatric environment an effective way to manage these children is by admission to a short-stay observation ward. The emergency department needs to be appropriately resourced with staff to provide ongoing care and regular review of patients to expedite timely discharge. Conditions suitable for consideration of an observation ward admission will vary with local resources and may include asthma, croup, gastroenteritis, febrile convulsion, presumptive viral illnesses, non-surgical abdominal pain, minor trauma, post sedation recovery or ingestions.⁹ In mixed departments, without the facility of a short-stay ward, it is often appropriate to use the paediatric ward to admit patients who would benefit from a period of observation (see Table 1.1.5).

Making a diagnosis

Not every child leaving the emergency department will do so with a specific diagnosis. The unwell febrile child needs to have serious diagnoses such as meningitis considered, before making a diagnosis of viral illness. Many children without a clear diagnosis can be managed expectantly and safely discharged home with organised review by a local doctor, paediatrician, or return to the department. Giving the parents clear instructions to return should the state of their child not follow an expected course is essential. Children are often seen early in the natural history of their illness and a diagnosis will only become clear with time. It is important to communicate clearly, verbally or in writing, with the doctor who will be following up the child. Close liaison with a local doctor who has referred a patient to the emergency department is essential. One should always respect the concerns raised by a referring local doctor who usually has the advantage of familiarity with the child and family.

Introduction

General practitioners (GPs) are the cornerstone and often the child’s first contact within the Australian healthcare system. They are uniquely placed to have an intimate working knowledge of the biological, psychological and social dynamics that impact on a child’s illness.

GPs are involved in the long-term care of family members, often for many years and in some cases several generations. It is this continuity of care and ongoing relationship with a family that is invaluable in assessing and triaging presenting medical conditions in children and their subsequent management. This is particularly important when caring for the health of children, who are often seen in the early prodromal phase of serious illnesses. It is the skill of the GP to differentiate the possibility of a serious illness in a child, particularly during the seasonal peaks of febrile presentations. This child may be non-specifically ‘different’ to similarly febrile children, but the experienced GP may just have a ‘gut feeling’ that a second opinion may be warranted and refer to ED.

There are two distinct areas where the general practitioner plays a vital role in paediatric emergency management:-

Management prior to hospital care

The GP is more often than not the point of first contact for the potentially unwell child. The fundamental clinical medical tools of history taking and examination are used to make an initial assessment of whether the child can be treated in the community or requires referral to an emergency department for further opinion and management. This can be a challenging task as the GP is not afforded the luxury of observation over time, readily available ancillary testing such as pathology and imaging, nor an immediate further opinion from a specialist colleague. Particularly in the case of early or undifferentiated illness, the GP will need to make a judgement call on whether or not a child can be safely managed at home. Experienced GPs will not only use traditional methods of history and examination but will also listen to their ‘gut feeling’ when assessing children. This may involve attaching importance to red flag symptoms or signs or heeding the warning signs reported by an anxious, yet appropriately worried parent. This may depend not only on the medical status of the child but also the assessment of the social circumstances, education and competence of the parents/carers to detect their child is failing to ‘turn the corner’ or deteriorates. Often there is significant parental anxiety with an unwell child which cannot always be allayed by sound advice from an experienced GP when a child clearly has a self-limiting viral illness.

There may be parental demands for pathology testing to ensure ‘nothing is missed’ even though these may be deemed inappropriate by the family doctor. Parents may also report significant symptoms such as fever, an infant not feeding normally, cough or stridor which may no longer be present at the time of presentation to the GP. Some auscultatory chest findings are dynamic and therefore have a fluctuating presence, such as wheezing in bronchiolitis, so may vary greatly between the time of the GP and emergency department visit.

It is this complex interaction of both the medical and environmental factors which must be processed by the GP, often in the context of a 15-minute appointment. The outcome of this assessment may be the subsequent referral to hospital level care. Remember that the GP’s decision is carefully considered with all the aforementioned factors coming into play.

Some of the more common reasons for referral to the ED may include the following;

It is imperative once the decision has been made to refer the child on to the emergency department, that the clinical assessment and concerns of the GP are adequately communicated to the physician who will be the next link in the management chain. This is best done with a phone call to the emergency department outlining the reasons for referral. In potentially serious illnesses the emergency department clinician can instruct the GP in any necessary treatment prior to transfer (for example, antibiotics and blood cultures in suspected meningitis or sepsis). A referral letter which contains the child’s past medical history, allergies, immunisation status, list of current medications and any relevant investigations should accompany the child to the emergency department. This gives the treating doctor a head start in managing the child and avoids wasted time, effort and cost in repeating already established findings.

Management after hospital care

Once the child has been managed and discharged from the emergency department the circle of communication should include verbal and written feedback to the referring GP. This timely discharge communication contact has several benefits. First and foremost it ensures continuity of care for the child. If a treatment plan has been commenced by the hospital staff, the GP is then responsible for its implementation through continuing clinical assessment and adjustment of management according to progress. The natural history of illness and convalescence are dynamic processes which will vary from patient to patient and may require vigilant monitoring. This is most likely to be successful if the discharge plan is well communicated to the family doctor. It is vital that communication is not mislaid compromising patient care. The GP should receive information directly (fax or electronic) as well as via the patient or family as a back up if the usual communication systems fail.

Secondly, medical practitioners continue to accumulate knowledge and expertise throughout their careers so that reflective and sensitive feedback concerning outcomes of their referred patients is useful. This helps the GP to analyse and reflect upon their decision making processes and contribute to their evolving clinical acumen, which is a career long journey for all doctors. This is particularly so in the case of paediatrics as recognising the potentially unwell child can sometimes be as much art as science.

General practitioners can arrange further monitoring of the recovering child and is well placed to arrange further tests (for example chest X-ray following complicated pneumonia) or specialist follow-up if needed. Often the busy emergency department is not the easiest place, especially after hours, to arrange such important steps in the child’s follow up care. The GP is also able to assess any psychological impact of the child’s illness and offer ongoing support to the child and the family. These potential issues may not be evident at the time of the emergency department visit.

Integral to the communication process is a mutual respect between the GP and the emergency department physician with both having a respectful understanding and appreciation of the environment and challenges that each is working under. General practitioners have strong attachments to their patient and families and will appreciate a follow-up phone call and/or letter advising of the status of a referred child. The letter should be timely, with appropriate information including diagnosis, medication and results of investigations with an access phone number for any results pending. It should be presented in a clear concise form with a structured plan of management. Computer-generated letters are often more legible than hand written ones and reduce the chance of miscommunication in the discharge process. Some GP clinics now have secure email availability and may prefer to receive information this way.

If these strategies are implemented within a spirit of co-operation between GPs and emergency departments, this will ensure improved continuity of care and therefore better patient outcomes in the care of sick children.

Developmental milestones

It is important to have an understanding of the major developmental milestones throughout childhood for the provision of care to paediatric patients. These can be rapidly confirmed by examination or parental enquiry. This allows one to use an appropriate age-modified approach in the child’s evaluation. Some specific behaviours, such as stranger anxiety in a 12-month-old, may challenge the assessment, so it is important to adapt the approach to these expected behaviours. Significant deviations from normal warrant consideration of paediatric referral. Useful early milestones are shown in the Table 1.1.6.

Table 1.1.6 Normal milestones in first two years of life

Neonate Lift head, visually fix for period 6 weeks Smile, follow past midline 4 months Roll over 6 months Sit, transfer toy between hands 9 months Stand holding on, crawl, stranger anxiety 12 months Walking, single words 18 months Explorer (trauma/poisons), tantrums, several words 2 years Combine words, run, jump

Growth

It is essential to measure a child’s current weight on every emergency department visit in order to accurately dose any therapeutic drug and to quantify recent weight loss. Where a child is critically unwell and unable to be weighed, estimation can be made via Broselow or other charts. Between the age of one and ten years an estimation of weight is 2 × (age + 4) kg. Standardised percentile growth charts are useful to confirm suspicion of failure to thrive or discrepancy in linear or cranial growth. The trend of growth plotted on a growth chart over time is more important than a single measurement. As a general rule, birth weight doubles by five months, and triples by one year. Newborns are often discharged from hospital in the first few days of life and may present in the first week to an emergency department. Following the expected initial weight loss, term babies should normally regain their birth weight by the end of the first week. Appropriate neonatal weight gain is an important index of wellness. Head circumference increases by 2 cm in the first three months, 1 cm in the next three months, followed by 0.5 cm per month thereafter (Table 1.1.7).

The thoughts of a child during the emergency department experience

Thoughts on the emergency department through the eyes of a parent