This document provides guidance on approaching and managing common pediatric emergencies. It emphasizes taking an age-appropriate approach, thorough history and examination, involving pediatric nurses and specialists as needed, following guidelines like NICE, and considering rare or serious diagnoses. Common presentations like fever, wheezing, injuries and seizures are discussed. The importance of senior review, ongoing assessment, and team-based care for sick children is stressed.

1. PAEDIATRIC
EMERGENCIES
MISBAH MOHAMMAD
EM/PEM CONSULTANT
PED CLINICAL LEAD

2. APPROACHING CHILDREN WHEN
VULNERABLE
• Strangers
• Strange environment
• Rapport building
• Play
• Distraction
• Check with PED Nurses
• Listen to parent/carer concerns

3. HISTORY TAKING
• Source of history
• Witness of the story – nursery/school notes
• Delayed or timely presentation – timeline – reattendance
• Professional curiosity – exploring – non-judgemental
• Birth History
• Vaccination History
• Social History including safeguarding history

4. EXAMINATION
• Top-to-Toe exam without clothes
in infants & toddlers with injuries
• HEENT
• Chest – including WOB & noise like
grunting
• CVS – Cap refill time – peripheral
vs central – cold vs warm
• Innovative exam techniques

5. COMMON PRESENTATIONS
• Fever including Croup
• Wheeze, DIB
• Injuries
• ***NEEDLE in a HAYSTACK – SEPSIS & SAFEGUARDING CONCERN

6. FEVER
• URTI (including Tonsillitis) &/or EAR INFECTION – Abx or no
Abx
• Chest Infection – CXR or no CXR
• UTI – Culture or no Culture; Abx or no Abx
• Meningitis/Meningococcal Sepsis/Encephalitis
• Septic arthritis, discitis
• ***KAWASAKI DISEASE
• ***PIMS-TS
Fever in under 5s: assessment and initial management
NICE guideline [NG143] Published: 07 November 2019

7. NICE TRAFFIC
LIGHT
• THINK SEPSIS
– Escalation vs De-escalation
– Consider Resus based care
– Senior Review
– Team based care
– Early involvement of Paeds
team in sick patient’s care

8. MENINGOCOCCAL
SEPSIS/MENINGITIS
High Risk
Pale / mottled / ashen / blue
No response to social cues
Unable to rouse or unable to stay awake
Weak / high pitched / continuous cry
Appears ill
Grunting
RR > 60
Moderate to severe recession
Skin turgor 1 sec or more
Non-blanching rash
Bulging fontanelle or neck stiffness
Focal neurology or seizures
Status epilepticus
Atypical febrile convulsion
Temp 38 or more if 0 - 3 months
Bile-stained vomiting
or swollen
y
No below
PETECHIAE IN CHILDREN – THE PIC STUDY LANCET APRIL 2020

9. NON-BLANCHING RASH

10. HENOCH-SCHONLEIN
PURPURA

11. KAWASAKI DISEASE

13. PIMS – TS
• Paediatric Multisystem Inflammatory
Syndrome temporally associated with
SARS-CoV-2
• severe inflammation & shock
• some clinical similarities to Kawasaki
shock & toxic shock
• Cardiac Manifestations: Pancarditis may
include bi-ventricular impairment, mitral/
tricuspid valve regurgitation, diastolic
dysfunction, pericardial effusion, coronary
artery dilatation / aneurysm
• Clinical course unpredictable with rapid
deterioration observed in some
Clinical features
May include one or more of the following:
Persistent Fever > 39 C
Lethargy and Myalgia
Abdominal Symptoms: Pain, Diarrhoea and Vomiting
Rash/Conjunctivitis
Hypotension (Wide pulse pressure), tachycardia +/- Shock
Initial management
Examination:
Exclude potential septic foci and careful cardiac assessme
(liver, JVP, cardiac / thoracic ratio on CXR)
Resuscitation:
If signs of shock – fluid resuscitation (10ml/kg aliquots) wit
shock. This syndrome has some clinical similarities to Kawas
illness. In the majority of patients, coronavirus has not been d
SARS-CoV-2 infection is present in some. The likeliest mechan
Significant similarity in presen
Septic shock - may require higher volume fluid resuscitat
Peritonitis -negative laparotomy reported in some cases:
ediatric Critical Care
ediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2
Clinical features
include one or more of the following:
ersistent Fever > 39 C
thargy and Myalgia
bdominal Symptoms: Pain, Diarrhoea and Vomiting
ash/Conjunctivitis
ypotension (Wide pulse pressure), tachycardia +/- Shock
Covid-19 pandemic has been temporally associated with the emergence of a paediatric presentation of severe inflammatio
k. This syndrome has some clinical similarities to Kawasaki shock and toxic shock. Patients have presented with mild to s
ss. In the majority of patients, coronavirus has not been detected by PCR on throat/nasal swabs, however serological eviden
S-CoV-2 infection is present in some. The likeliest mechanism is a delayed antibody-mediated dysregulated host immune resp
Laboratory features
Hyponatraemia Raised CRP
Raised Ferritin (>500) Raised Troponin and B-NP
Raised Fibrinogen Lymphopenia / neutrophilia
Raised D-Dimer Platelets initially low or normal
Renal dysfunction
Significant similarity in presentation with other paediatric conditions
ic shock - may require higher volume fluid resuscitation and source control: senior clinical review

14. FEBRILE SEIZURE
• Aged 6 months to 6 years
• Simple FS - isolated, generalized, tonic-clonic seizures lasting
< 15 mins, do not recur within 24 hrs or within the same
febrile illness, with complete recovery within 1 hour
• Complex febrile seizures have one or more of:
partial (focal) seizure; duration > 15 mins; recurrence within
24 hrs or within the same febrile illness; or incomplete recovery
within 1 hour

15. BRONCHIOLITIS – RSV
• Wheeze vs Stridor vs Grunting
• Inhaler vs Nebs
• Salbutamol vs Atrovent
• Symptomatic & feeding support
• Nasal saline +/- suction
• +/- Oxygen –
• Consider HFNO –
• Escalation

16. BRONCHIOLITIS – RSV

17. BRONCHIOLITIS – RSV

18. DISCHARGE CRITERIA FOR BRONCHIOLITIS
• Oxygen Saturations maintained in air O2 Sats >94%.
• Is clinically stable,
• taking adequate oral fluids and
• has maintained oxygen saturation over 92% in air for 4 hours,
including a period of sleep.

19. VIRAL WHEEZE/ASTHMA
• Toddler (> 1 yr) to pre-school children (under 5 yrs) to school
children > 5 yrs
• Inhalers with spacer device – treatment of choice
• Life threatening – Nebs
• Salbutamol +/- Atrovent
• Steroids
• Reassess & Paeds referral (PAU if PEWS < 3)

20. BTS CLASSIFICATION OF WHEEZE/ASTHMA

21. BTS MANAGEMENT – FIRST LINE OF
TREATMENT

22. BTS MANAGEMENT – SECOND LINE OF
TREATMENT

23. BTS –
ASTHMA/WHEEZE
UNDER 2 YEARS

24. DKA
• DKA Calculator
• BSPED DKA Flowchart

25. AFEBRILE
SEIZURE/EPILESPY
• A to E Assessment
• Contemporaneous management
• DON’T FORGET ‘G’
• First fit
• Known epileptic
• Difficult fitter – advanced care
plan

26. INJURIES
• MOI – think major trauma – senior involve +/- Paeds trauma
team activation
• Presentation – timely or delayed
• Professional curiosity
• Patient safety – Resus or Cubicle
• Primary, secondary & tertiary victims in polytrauma Paeds
(unwell)
• Debrief

27. INJURIES – HEAD INJURIES
• NICE Head Injury guidance to follow
• MOI
• Scary sight for parents –
LOC, Drowsy, Irregular Breathing, Floppy, Palor
Usually come around in few minutes – observation

28. INJURIES – LIMB INJURIES
• Long Bone fractures
• Age-appropriate injuries (NAI vs
AI)
• MOI – corroboration
• Supracondylar Fractures
• Femur/TF Fractures in infants
• Toddler fracture vs Trampoline
fracture
• Limping child – traumatic vs
atraumatic

29. NON-ACCIDENTAL INJURIES
• Story – MOI, TOI (any delay – reason)
• Witness
• Corroborate – story vs injury sustained
• Low threshold
• Professional curiosity
• Pattern – bruising - Body Mapping

30. SICK CHILDREN
• Scary
• Team based-approach led by senior
• Paeds team involvement
• Systematic approach – A to E including
WETFLAG – APLS protocol
• Respiratory vs Cardiac arrest
• Rate limiting steps – IV/IO access
• History, Examination & Differentials
• Planning for further investigation &
management – SICK KIDS referral

31. SICK NEONATES &
INFANTS
• Unwell – SEPSIS
• Check BM - hypoglycemia common in
sick babies
• Metabolic – recurrent hypoglycemia –
send Ammonia in addition to BM, Lac,
Ketones
• Think NAI as differential – strip for
examination
• Surgical – failed to pass meconium
24-48 hrs
• Hirschprung disease, NEC, Pyloric
stenosis

32. ANY QUESTION?

33. SUMMARY
• Age-appropriate approach & management
• A to E assessment – ongoing & recurrent
• Talk to PED Nurses +/- Paeds SpR – concerns or no concerns
• Senior involvement +/- review
• Resources – AskEARL, PiP, NICE guidance, Senior think-tank,
Paeds Team
• CPD learning – Spottingthesickchild.org.uk; RCEMLearning
induction module

34. THANK YOU