nsw rural paediatric emergency clinical guidelines second · nsw health 2014 rural paediatric...

Guideline

Ministry of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

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NSW Rural Paediatric Emergency Clinical Guidelines SecondEdition

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Document Number GL2014_007

Publication date 26-May-2014

Functional Sub group Clinical/ Patient Services - Baby and childClinical/ Patient Services - Medical Treatment

Summary Emergency Clinical Practice Guidelines to be used by PaediatricAdvanced Clinical Nurses for initial treatment of infants and childrenpresenting to emergency departments in rural areas. This Guideline,GL2014_007 replaces PD2011_047.

Author Branch NSW Kids and Families

Branch contact NSW Kids and Families 02 9391 9777

Applies to Local Health Districts, Chief Executive Governed Statutory HealthCorporations, Specialty Network Governed Statutory HealthCorporations, Affiliated Health Organisations, Public Hospitals

Audience Emergency Departments, Paediatric Units, Nursing

Distributed to Public Health System, Divisions of General Practice, NSW AmbulanceService, Ministry of Health, Private Hospitals and Day Procedure Centres,Tertiary Education Institutes

Review date 26-May-2017

Policy Manual Patient Matters

File No. H14/31240

Status Active

Director-General

GUIDELINE SUMMARY

NSW RURAL PAEDIATRIC EMERGENCY CLINICAL GUIDELINES

PURPOSE These Clinical Guidelines provide a clear standard of initial care for children who present to Emergency Departments where Medical Officers are not immediately available. It is intended that the Clinical Guidelines will be used by Paediatric Advanced Clinical Nurses to facilitate the early and appropriate clinical management of children who present to Emergency Departments with acute and life threatening conditions and to relieve pain and discomfort. This is the second edition of the document which has been developed in line with current best practice and advice from expert reviewers. This document is a companion document to the NSW Rural Adult Emergency Clinical Guidelines.

KEY PRINCIPLES These NSW Rural Paediatric Emergency Clinical Guidelines are underpinned by the following principles: A ‘graduated’ clinical response is required depending on the:

• Severity of the presenting emergency condition e.g. the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma

• Level of training and expertise of the nursing staff who initiate the management of the patient i.e. Registered Nurses with advanced clinical training will practice more advanced interventions. Nursing staff using these clinical guidelines are required to be appropriately educated, skilled and credentialed. The shaded portions contained in the treatment guidelines must only be used by RNs who are recognised as Advanced Clinical Nurses

• Legal requirements for nurses who initiate treatment and administer medications based on medication standing orders

• Need for flexibility to respond to input from senior clinical staff and medical officers to accommodate local circumstances.

The Clinical Guidelines reflect evidence based best clinical practice and expert consensus opinion, in regards to standardisation of initial clinical management of specific paediatric conditions and alignment with the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses. Any medication standing orders contained in these clinical guidelines will have no legal basis unless they are approved by the Local Health District Drug Therapeutic Committee (or local hospital Drug Therapeutic Committee if there is no District Committee), as specified in NSW Health Policy Directive PD2013_043, Medication Handling in NSW Public Health Facilities, (Section 7.4 Standing Orders). Each standing order must be signed and dated by an appropriate senior Medical Officer and by the Chairperson of the Drug Committee that is approving the standing order. The

GL2014_007 Issue date: May-2014 Page 1 of 2

GUIDELINE SUMMARY committee must review the standing order annually and re-endorse and date the standing order to confirm on-going approval.

USE OF THE GUIDELINE These guidelines are to be used for children up to their 16th birthday only and have been formatted to follow the generally accepted Airway, Breathing, Circulation and Disability (ABCD) approach for managing emergency/critically ill patients. Advanced Clinical Nurses have advanced knowledge and skills, have completed an advanced emergency or critical care nursing course or hold a graduate certificate/diploma in paediatric nursing – emergency stream and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. Where an Advanced Clinical Nurse utilises these guidelines the:

• Designated medical officer will be notified as soon as practicable • Medical Officer will review any patient who has been given medications

consistent with the standing orders contained within this document as soon as possible (must be within 24 hours). At the time of this review the Medical Officer must check and countersign the nurse record of administration on the medication chart.

A number of the incorporated procedures have been adapted from the NSW Health Acute Paediatric Clinical Practice Guidelines. Where applicable and advised, subsequent treatment and management should follow the NSW Health Paediatric Clinical Practice Guidelines.

REVISION HISTORY Version Approved by Amendment notes May 2014 (GL2014_007)

Deputy Secretary Population and Public Health

Second edition. Guidelines updated to align with:

• Parameters of Standard Paediatric Observation Chart (SPOC)

• Paediatric Clinical Practice Guidelines- particularly Recognition of the Sick Baby and Child;

• DETECT Junior; • Paediatric Sepsis Pathway and • Clinical Escalation and Response Systems.

July 2011 (PD2011_047)

Deputy Director-General Strategic Development

New policy- made obsolete.

ATTACHMENTS 1. NSW Rural Paediatric Emergency Clinical Guidelines

GL2014_007 Issue date: May-2014 Page 2 of 2

C HANGE

2nd EditionNSW Rural Paediatric Emergency Clinical

GuidelinesNSW Children’s Healthcare Network

Paediatric Clinical Nurse Consultant Group

2nd Edition

AcknowledgementsThese Guidelines were originally developed by the NSW Child Health Networks

Paediatric Clinical Nurse Consultant Group in consultation with the NSW Rural

Critical Care Task Force, NSW Rural Critical Care CNC Planning Group, the

Clinical Excellence Commission, and Statewide Services Development Branch,

between 2005-2012. There has been significant direction and contribution

by the specialist clinicians in the field. The considerable effort of all involved

is acknowledged. We also acknowledge the valuable contribution of the

critical readers.

NSW MINISTRY OF HEALTH NSW Kids and Families73 Miller StreetNORTH SYDNEY NSW 2060Tel: (02) 9391 9491Fax: (02) 9391 9928TTY: (02) 9391 9900

www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in partfor study training purposes subject to the inclusion of an acknowledgementof the source. It may not be reproduced for commercial usage or sale.Reproduction for purposes other than those indicated above, requires written permission from the NSW Ministry of Health.

This Clinical Practice Guideline is extracted from the GL2014_007 and as a result, this booklet may be varied, withdrawn or replaced at any time.

©NSW Ministry of Health 2014

SHPN (NKF) 140138ISBN 978-1-74187-000-8

Further copies of this report can be downloaded from the:NSW Health website: www.health.nsw.gov.au

Content within this publication was accurate at the time of publication.

May 2014

NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE i

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.

The NSW Rural Paediatric Emergency Clinical Guidelines

are to be implemented for the emergency management

of paediatric patients only.

A child is defined as up to their 16th birthday.

NSW Health PD2010_033 Children and Adolescents – Safety and Security in NSW Health Acute Facilities

Newborn and paediatric Emergency Transport Service

(NETS) 1300 36 2500

The NSW Rural Paediatric Emergency Clinical Guidelines are aligned with the Standard Paediatric Observation Charts, Clinical Emergency Response System, NSW Acute Paediatric

Clinical Practice Guidelines, DETECT Junior and the Paediatric Sepsis Pathway.

NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE ii


PAGE ii

Introduction ........................................................ 1

Abbreviations ...................................................... 4

Definitions ........................................................... 5

1. Assessing Children ........................................ 7

2. Recognition of A Sick Child ........................ 17

3. Airway Emergencies .................................... 21Anaphylactic Reaction ........................................... 21Croup ....................................................................25Foreign Body ......................................................... 28Seizures ................................................................. 30Unconscious Patient .............................................. 33

4. Breathing Emergencies ............................... 37Asthma ................................................................. 37Bronchiolitis ........................................................... 42

5. Circulatory Emergencies ............................. 45Paediatric Basic Life Support .................................. 45Paediatric Cardiac Arrest........................................ 46Gastroenteritis ....................................................... 48Shock .................................................................... 52

6. Disabilities .................................................... 55Suspected Bacterial Meningitis .............................. 55

7. Envenomation/Poisoning Emergencies ..... 59Poisoning .............................................................. 59Snake/Spider Bite .................................................. 63

8. Trauma Emergencies ................................... 67Severe Burns ......................................................... 67Drowning .............................................................. 73Head Injury ............................................................ 77

9. Other Emergencies ...................................... 82Abdominal Pain ..................................................... 82Febrile Neutropenia ............................................... 86

Formulary .......................................................... 88

Appendices ..................................................... 118Appendix 1: Rural and Remote Emergency

Trolley – Minimum Paediatric Requirements ................................. 118

Appendix 2: Additional Recommended Paediatric Equipment ..................... 120

Appendix 3: Paediatric Respiratory Assessment and Oxygen Therapy ... 122

Appendix 4: AVPU and The Modified Paediatric Glasgow Coma Scale ..... 123

Appendix 5: Primary and Secondary Survey .......124Appendix 6: Snakebite Observation Chart .........125Appendix 7: Paediatric Pain Assessment ............126Appendix 8: Burn Injury Referral/Retrieval Check List ..................................... 128 Appendix 9: Head Injury Risk Categories .......... 132Appendix 10: Guideline for Emergency Department Documentation ......... 135Appendix 11: Sedation Score .............................. 137

Contents

NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 1


1

Emergency Departments (EDs) in rural and remote

New South Wales (NSW) face a number of unique and

difficult challenges in trying to deliver quality paediatric

emergency care. In particular it can be difficult for staff

working in rural and remote EDs to acquire and retain

emergency expertise related to paediatric presentations.

This may lead to inequities in the standards of

emergency care delivered in rural and remote EDs.

A key function of the NSW Children’s Healthcare

Network Paediatric Clinical Nurse Consultant Group is

to identify and develop ways to ensure a more uniform

approach to the delivery of paediatric emergency care in

rural and remote EDs. One of the group’s strategies led

to the development in 2010 of a set of rural emergency

clinical paediatric guidelines which could be used by

rural and remote Registered Nurses (RNs) who have

undergone approved education, skills and credentialing.

The intention of these Guidelines is to ensure the early

management of children who present to emergency

departments where Medical Officers are not immediately

available. The guidelines include management of

immediately or imminently life-threatening conditions.

The Guidelines provide a clear standard of care for

paediatric emergencies in an attempt to ensure good

patient outcomes are achieved.

This is the second edition of the document and has

been developed in line with current best practice;

and requests and advice from expert reviewers. These

Guidelines are a companion document to the NSW Rural

Adult Emergency Clinical Guidelines, and so, the format,

clinical assessment, interventions and many of the

appendices for these Guidelines have been taken from

the 3rd Edition of the Adult Guidelines. The document,

like the Adult Guidelines, has been developed with the

following desirable features:

n formatting which allows for ‘graduated’ clinical

responses. These responses vary depending on the:

– degree of severity of the presenting paediatric

emergency condition. For example, the clinical

response to patients with mild to moderately

severe asthma is different to that for patients with

immediately life threatening asthma. This type of

graduated clinical approach has been used quite

successfully in ambulance service protocols for

many years.

– level of training and expertise of the nursing staff

who are initiating the management of the patient

– that is, formatting which allows for RNs with

advanced training to implement more advanced

interventions. RNs without this advanced training

and credentialing cannot perform the advanced

interventions. The use of shaded sections in the NSW Rural Paediatric Emergency Clinical

Guidelines indicate clinical interventions that can only be initiated by RNs who are recognised as Paediatric Advanced Clinical Nurses.

n incorporation of the various legal requirements

for nurses who initiate treatment and administer

medications based on standing orders.

n flexibility - guidelines need to be flexible enough to

allow local input from rural Medical Officers (MOs)

and RNs so that local practices can be incorporated.

n endorsement by relevant committees and divisions

within NSW Health.

n standardisation in the management of specific

paediatric conditions across NSW.

The guidelines are also formatted to follow the accepted

Airway, Breathing, Circulation, Disability (ABCD)

approach for managing paediatric emergency/critical

care patients. These guidelines are not for use in infants less than four weeks of age due to significant

pharmacological and physiological differences.

A number of these guidelines have been developed

from the NSW Health Acute Paediatric Clinical Practice

Guidelines. Where applicable and advised, subsequent

treatment and management should follow the NSW

Health Acute Paediatric Clinical Practice Guidelines.

The aims of the NSW Rural Paediatric Emergency Clinical

Guidelines are to:

n improve the emergency care and outcomes for

paediatric patients in the rural and remote health

care settings of NSW;

n provide readily accessible and user-friendly guidelines

for clinicians providing paediatric emergency care to

patients in rural and remote areas of NSW;



n assist rural and remote EDs in NSW achieve

benchmarking targets and best practice standards

for children with emergency presentations;

n address some of the current professional issues facing

rural and remote RNs by:

– providing a safe framework in which rural and

remote RNs can initiate management and care

of paediatric emergency patients;

– recognising and formalising the advanced role

many rural and remote RNs currently perform

when delivering care to critically ill or injured

paediatric patients with emergency conditions;

– providing a pathway by which credentialed

RNs can work toward continuing professional

development.

Nursing staff using these clinical guidelines are required

to be appropriately educated, skilled and credentialed.

The shaded portions contained in the treatment

guidelines must only be used by RNs who are recognised

as Paediatric Advanced Clinical Nurses.

Paediatric Advanced Clinical Nurses are those RNs

that have advanced knowledge and skills and have

been deemed competent to carry out these advanced

roles using contemporary assessment and ongoing

credentialing processes.

Credentialing of Paediatric Advanced Clinical Nurses (ACN)Registered nurses can be considered eligible to be

credentialed for Paediatric Advanced Clinical Nurse

roles if:

n they have successfully completed an advanced

emergency or critical care nursing course such as the

First Line Emergency Care Course (FLECC),

OR

n Graduate Certificate/Graduate Diploma in Paediatric

Nursing – Emergency stream

AND

n they can demonstrate recent and ongoing knowledge

and experience with managing emergency/critical

care paediatric patients.

Credentialing will be obtained and maintained by:

n completion of competency assessments as

recommended by the Children’s Healthcare Network

Regions in each Local Health District.

n the ACN maintaining appropriate documentation to

allow review of the usage of these rural emergency

guidelines.

Paediatric Advanced Clinical Nurses are required to be

re-credentialed annually or according to the Local Health

District Policy.

It will be the responsibility of the rural Local Health

Districts through their Children’s Healthcare Network

Regions, Critical Care Network Committee and Health

Service Managers to ensure compliance with these

requirements.

Implementation It is intended:

n when a Paediatric Advanced Clinical Nurse

implements these clinical guidelines, a Medical Officer

(MO) will be notified immediately to ensure their

early involvement with the management and care of

the paediatric patient.

n that any medication standing orders contained in

these clinical guidelines will be signed and authorised

by a MO appointed by the Local Health District. This

MO may be one of those servicing the Emergency

Department/s using these Guidelines.

n that MO review is required following the

administration of a drug according to the standing

orders contained within this document as soon as

possible (must be within 24 hours). At the time of

this review the MO must check and countersign the

nurse record of administration on the medication

chart.

n that any medication standing orders contained in

these clinical guidelines will have no legal basis

unless they are approved by the Local Health

District Drug and Therapeutics Committee (or local

hospital Drug Committee if there is no Local Health

District Committee), as specified in NSW Health

PD2013_043 Policy on Medication Handling in

NSW Public Health Facilities, (Section 5.2 Standing

Orders). Each standing order must be signed and

dated by an appropriate senior Medical Officer and



by the Chairperson of the Drug Committee that is

approving the standing order.

The committee must review the standing order

annually and re-sign and date to confirm on-going

approval.

This document should be read in conjuction with the

following documents:

n NSW Health PD2005_042 Guidelines for

Hospitals seeking to extend the practice of health

professionals.

n NSW Health PD2013_043 Policy on Medication

Handling in NSW Public Health Facilities.

n NSW Health PD2009_009 Paracetamol Use.

n NSW Health PD2010_009 Infants and Children:

Acute Management of Gastroenteritis.

n NSW Health PD2011_038 Recognition of a Sick Baby

or Child in the Emergency Department.


Acute Management of Bacterial Meningitis.


Acute Management of Abdominal Pain.


Acute Management of Asthma.


Acute Management of Bronchiolitis.


Acute Management of Fever.


Acute Management of Seizures.


Acute Management of Head Injury.


Acute Management of Croup.

n Australian Medicines Handbook, AMH Children’s

Dosing Companion 2013.

The paediatric clinical practice guidelines have e-learning

modules available at http://doh.edmore.com.au.



AbbreviationsABG Arterial Blood Gas

ACN Paediatric Advanced Clinical Nurse

ALS Advanced Life Support

ARC Australian Resuscitation Council

ATS Australasian Triage Scale

AVPU Alert, Voice, Pain, Unresponsive

BSA Body Surface Area

BGL Blood Glucose Level

CPR Cardiopulmonary Resuscitation

CRP C Reactive Protein

CSL Commonwealth Serum Laboratory

CVAD Central Venous Access Device

CXR Chest X-Ray

EAR Expired Air Resuscitation

ECG Electrocardiograph

ED Emergency Department

EDWPR Emergency Department Work Practice Review

EtOH Ethanol

FBC Full Blood Count

FLEC First Line Emergency Care course

GCS Glasgow Coma Score

GIT Gastrointestinal tract

GP General Practitioner

g Gram

hCG Human Chorionic Gonadotropin

hrs Hours

ICU Intensive Care Unit

IM Intramuscular

IO Intraosseous

IV Intravenous

J Joules

kg Kilogram

LFT Liver Function Test

LHD Local Health District

litres/min Litres per minute

LOC Level Of Consciousness

MDI Metered Dose Inhaler

min Minute

MO Medical Officer

mmol/L Millimols per Litre

mL Millilitre

MSU Mid Stream Urine

MVC Motor Vehicle Crash

NETS Newborn and paediatric Emergency

Transport Service

NG Nasogastric

O2 Oxygen

ORS Oral Rehydration Solution

PEFR Peak Expiratory Flow Rate

PO Per Oral

PPE Personal Protective Equipment

PR Per Rectum

RN Registered Nurse

RSV Respiratory Syncytial Virus

SBP Systolic Blood Pressure

SCI Subcutaneous Injection

Sec Seconds

SpO2 Pulse oximetry saturation

Stat Immediately and once only

TBSA Total Body Surface Area

U/A Urinalysis

UEC Urea Electrolytes Creatinine

UO Urine Output

UTI Urinary Tract Infection

VF Ventricular Fibrillation

VT Ventricular Tachycardia

Wt Weight



Definitionsn Continuous – Uninterrupted.

n Neonate – Less than 28 days old.

n Infant – One month to twelve months of age.

n Child/Paediatric – One year up to 16th birthday.

These are the definitions used for the purposes of this

document. It is acknowledged that paediatric inpatient

units usually admit 0-16 years [newborns excluded].

ReferencesFuller. J, Schaller-Ayers, J. 2000, Health assessment:

a nursing approach, 3rd edn. Lippincott. Philadelphia.

Australian Resuscitation Council, 2010, Guideline 12.1,

ARC Guidelines.

Australian Resuscitation Council, 2010, Guideline 13.1,

ARC Guidelines.

Children and Young Persons (care and protection ) Act

1998 section 3.


Assessing children Medical Officer must be notified immediately For paediatrics only


This page has been left blank intentionally


Assessing children

SECTION 1

If life-threatening activate your local rapid response protocol immediately



IntroductionInfants and children are anatomically and physiologically

different to adults. They have unique communication,

emotional, and developmental needs. Health

professionals performing clinical assessments on sick

children need

to be conversant with these differences and the

subsequent impact on the child’s response to injury

and/or illness.

Assessment of the sick child is always tailored to the

child’s level of distress and tolerance. Interventions to

support the seriously ill or injured child, always follows

the same plan:

n Airway

n Breathing

n Circulation/Fluids

n Disability/Dextrose

n Exposure/Environment

Important advice A number of factors should be taken into consideration

when assessing children in the Emergency Department,

including the presenting problem, the child’s behaviour,

vital signs, oxygen saturation, and the degree of parental/

caregiver concern. All of these factors combine to provide

the nurse with an indication of the severity of illness.

There are, however, a number of clinical signs, which

should always be considered as potentially very serious

and generally, require immediate medical review and

intervention.

These include:

Clinical severity prompts

Airway

– stridor

– choking

– obstruction

Breathing

– no breath sounds on auscultation

– irritability in an infant or restlessness in the older

child (may indicate hypoxia)

– inability of an infant to feed due to breathlessness

– grunting respirations (infants)

Circulation

– pallor

– mottling

– delayed capillary refill greater than 2 seconds

– tachycardia (for age) in an otherwise well looking

child or significant tachycardia in any child

– bradycardia for age

– hypotension

Disability

– lethargy

– poor response to painful stimuli

– readily compliant with painful procedures

– “normal” vital signs in a sick looking child




Remember:n Size and relative body proportions change with age.

n Treatment and management regimes are related to

age and weight.

n Infants and children are more prone to hypothermia,

due to their large body surface area to mass ratio.

It is very important to keep them warm.

n Infants and young children are prone to

hypoglycaemia. Check blood glucose level regularly.n Children have unique psychological needs.

All drug doses and fluids are calculated on body

weight. It is essential that all children are weighed

on presentation to the Emergency Department. If

exceptional circumstances exist and this is not possible,

then the following weight for age formula can be used

0-12 months wt kg = (0.5 x age in mths) + 4

1-5 yrs wt kg = (2 x age in yrs) + 8

6-12 yrs wt kg = (3 x age in yrs) + 7

An alternative to ascertaining the weight is the

Broselow™ Paediatric Emergency Tape.

Why children are different The following table provides a brief overview of the

important differences in infants and children and the

subsequent implications for your practice.

Airway and breathing When assessing respiratory rate, rhythm and pattern

count for a full minute.

Note: By approximately 8 years of age a child’s airway

anatomy and physiology approximates that of adults.

Differences Implications

Children less than 2 years have a proportionally large head and short neck.

Shorter and softer trachea.

Greater risk of neck flexion or overextension which may cause tracheal compression and airway obstruction.

Comparatively large tongue, a small mouth and soft oropharynx.

Easily obstructed, damaged and prone to swelling.

Infants less than 6 months of age are preferential nasal breathers.

More easily obstructed by secretions.

Secretions in the nose may impede airway patency.

Narrower airways. More easily obstructed by secretions and foreign bodies.

Diaphragmatic breathers.Impeded diaphragmatic contraction (caused for example by abdominal distension) can increase or lead to respiratory distress.

Epiglottis is horse shoe shaped and projects posteriorly at 45˚.

Intubation can be difficult.

The larynx is high and anterior.A straight blade is preferred when intubating an infant.

Children are more prone to aspiration.

Cricoid ring is the narrowest point of the airway and susceptible to oedema.

Uncuffed tubes are often used.

Intercostal muscle is underdeveloped with fewer type 1 fibres than adults. (Less than 5 years).

Ribs are more horizontal.

These muscles stabilise but do not lift the chest wall. They become easily fatigued and cannot sustain long periods of increased respiratory demand.

The cartilaginous chest wall is more compliant. The child’s ability to maintain functional residual capacity or increase their tidal volume during respiratory distress is compromised.

Chest wall very thin. Respiratory sounds are transmitted more readily.




Pulse oximetryPulse oximetry should not replace clinical assessment but is a useful adjunct to patient assessment. An age and site appropriate pulse oximetry probe must

be correctly positioned in order to ensure an accurate

reading. Typical paediatric sites are the finger, toe, pinna

(top) or lobe of the ear. Infant sites are the foot or palm

of the hand and the big toe or thumb. Immobile sites are

preferred in wiggling children (eg foot, palm of hand).

RememberWhile pulse oximetry is generally considered a safe

intervention, device limitations and false- positive/

negative results may lead to delayed or inappropriate

treatment. As with all assessments, it is important that

oxygen saturation is considered in terms of the total

clinical picture and not in isolation. Treatment should

never be delayed for a child who looks unwell but who

has an oximetry reading (or any vital sign measure)

within a normal range.

It is important that the oximetry probe is resited at least every two hours, due to the risk of pressure necrosis to the skin.

Oxygen therapyOxygen therapy is recommended to maintain oxygen

saturation (SpO2) greater than 94%.

A Medical Officer must be notified when a child requires

oxygen (O2) and if there are any changes to those

requirements.

When required appropriate delivery systems that may be

chosen and implemented include:

Paediatric non-rebreather bag and mask – for

children requiring high flow oxygen. The reservoir

bag must remain inflated and the oxygen flow rate

regulated so that the bag will only deflate by one third

on inspiration. Requires a minimal oxygen flow rate of

10 litres per minute. The bag must be pre-inflated with

oxygen before placing the mask on the child.

Simple face mask – available in two sizes and

appropriate for moderate to high oxygen flow rates.

Requires a minimum flow rate of at least 6 litres per

minute to effectively clear expired gases, however this is

dependent upon the child’s individual tidal volume.

Disposable infant head box – for infants requiring

oxygen where other methods of oxygen delivery are

not suitable. The headbox is placed over the infant and/

or the head of an infant lying in the supine position. To

ensure adequate carbon dioxide washout, the minimum

oxygen flow rate into the hood is 10 litres per minute.

Checking of oxygen concentration within the hood with

an oxygen analyser if available is desirable to confirm

oxygen content within the hood.

Bag-valve-mask – for children requiring assistance/

positive pressure ventilation. Use age appropriate bag

size. Minimum flow rate is 10 litres per minute. Ensure

valve is opening with breathing.

Low flow nasal prongs – Available in four sizes and

appropriate for conscious children requiring low flow

oxygen to maintain oxygen saturations. Maximum flow

rate is 3 litres per minute. Low flow nasal prongs are not

suitable for acutely unwell children as they cannot deliver

high rates of oxygen.

Refer to Appendix 3 for further information on paediatric

oxygen therapy.

CirculationPallor, tachycardia, restlessness, irritability, decreased

central capillary refill and cool peripheries may be

evidence of the early stages of circulatory failure.

Later signs include a slowing heart rate and decreased

volume of peripheral pulses. It is important also to

remember that fluid loss may be hidden and therefore

underestimated. The child with any of the above clinical

signs requires early intervention to restore circulating

blood volume with close observation and monitoring

maintained.




Differences Implications

Larger total circulating blood volume per kilogram of body weight than adults.

(Eg Infants have a blood volume of 80 mL/kg).

A relatively small amount of blood loss can be significant eg a 100 mL haemorrhage in a one-year-old child constitutes a loss of approx. 7-10% of the total circulating blood volume.

Higher basal metabolic rate - 2 to 3 times that of adults. Further demands are made by illness.

Vital signs are only one indication of a child’s circulatory status and can only be correctly interpreted within the context of a full physical assessment.

Normal Paediatric Ranges

Age – Years weight – Kg HR/min RR/min

less than 30 days 3.5 100-160 30-60

6 months 7 100-160 30-40

1 10 100-160 30-40

2 12 90 -140 20-40

4 16 90 -140 20-40

6 20 80 -120 20-30

8 24 80 -120 20-30

10 30 80 -120 20-30

greater than 12 40+ 60 -100 15-20

Expected Systolic Blood Pressure = 85+ (age in yrs x 2) mmHg

NSW Health Between The Flags, Standard Paediatric Observation Charts 2010

Heart rate: although there is no strong evidence for this, values measured 10% outside the normal range should be

considered as moderately severe and values 20% outside the normal range considered severe. Interpretation must

always occur in the context of the child’s activity level.

Blood Pressure The normal systolic blood pressure for a child older than

1 year can be calculated using the above formula. Use of

the correct sized blood pressure cuff is crucial. The cuff

width must be 2/3 the length of the upper arm or thigh.

RememberBradycardia is an ominous sign in children and indicates

cardio-respiratory collapse.

Hypotension is a late and pre terminal sign of circulatory

failure in children.




When considering vital signs within “normal range” it is important to remember that these should always be considered in relation to the presenting problem and not in isolation. For example, a febrile child would be expected to be tachycardic/tachypnoeic, and a “normal” heart or respiratory rate would warrant close observation and further review. Similarly, significant tachycardia under any circumstance should also be investigated, while bradycardia in any child is an ominous sign and requires immediate medical review and intervention.

Capillary refill time measured centrally on the sternum

(not peripherally ie fingers and toes) also provides a

good indication of circulatory status. Using a thumb,

apply pressure to the sternum for 5 seconds. Capillary

refill should be equal to or less than 2 seconds. A slower

response indicates poor perfusion.

Fluid and electrolytes

Children have Implications

High percentage of total body weight is water.

Greatest percentage of fluid located in the extracellular compartment.

A relatively small amount of fluid loss can lead to

circulatory collapse as adequate intracellular fluids

cannot be drawn on to support the circulatory system.

Large surface area to body weight ratio – greater insensible fluid losses.

Insensible fluid losses are influenced by illness, and

are increased further if the child is febrile, tachypnoeic,

or tachycardic.

High metabolic rate.

Illness increases the already high metabolic rate and as

a result insensible fluid loss. This in turn increases fluid

requirements.

Immature renal function.

Less efficient in excreting waste, concentrating or

diluting urine, and conserving sodium in times of fluid

loss or overload.

Increased fluid requirements per kg of body weight. Greater amount of fluid per kilogram of body weight is required than for the older child or adult.

Signs of dehydration

Mild (3%) Moderate (5%) Severe (10%)

Same as no clinical signs of dehydration plus

Same as mild plus

Lethargy

Tachycardia

Reduced skin turgor

Sunken eyes

Abnormal respiratory pattern

Same as moderate plus

Dry mucous Membranes

Poor perfusion – mottled, cool

limbs/slow capillary refill/altered

consciousness

Mild Tachycardia

Shock - thready peripheral pulses with

marked tachycardia and other signs of

poor perfusion stated above

Source: NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis




Maintenance fluid requirements As with medications, calculations for maintenance

paediatric fluids are based on the child’s body weight.

A child’s fluid requirements may alter depending on

the clinical problems they have been hospitalised with.

Therefore, once maintenance fluid requirements have

been calculated, actual fluid requirements may need to

be modified according to the child’s clinical condition.

For example, children presenting with dehydration

will require the calculation of maintenance fluid, then

additional fluid will need to be provided depending

on the degree of dehydration (see NSW Health PD

2010_009 Infants and Children: Acute Management of

Gastroenteritis).

One method for calculating maintenance fluid

requirements is outlined in the table below. Other

methods are described in the NSW Health PD

2010_009 Infants and Children: Acute Management of

Gastroenteritis.

Maintenance fluid requirements per day

First 0-10kg 100 mL/kg/24hrs

Next 11–20kg Plus 50 mL/kg/24hrs

Next greater than 20kg Plus 20 mL/kg/24hrs

NSW Health PD 2010_009 Infants and Children: Acute Management of Gastroenteritis

Maintenance fluid requirements per hour

First

0-10kg4 mL/kg/hr kg x 4 mL/hr = mL/hr

Next

11–20kg2 mL/kg/hr Plus kg x 2 mL/hr = mL/hr

Next greater

than 20kg 1 mL/kg/hr Plus kg x 1 mL/hr = mL/hr

NSW Health PD 2010_009 Infants and Children: Acute Management of Gastroenteritis Note: Rate should not be greater than 100mL/hr

Monitoring fluid balance As children are predisposed to imbalances of fluid and

electrolytes, an accurate fluid balance record should

be kept for all children admitted to the Emergency

Department. This is particularly important for children

receiving intravenous fluids and for those under 3 years

of age.

Management of intravenous therapy

Checklist for safe administration of IV fluids

n IV fluids administered via burette

n Pump with paediatric setting available where possible

n Strapping - non-restrictive, site visible, limb

immobilised with splint

n No more than 2 hours fluid in burette

n Site checked and recorded hourly for redness/swelling

n Fluid level checked hourly and recorded

n Assessment for signs of over hydration or

dehydration

DisabilityRapid assessment of consciousness can be made by

using the AVPU scale:

A AlertV responds to VoiceP responds only to PainU Unresponsive to pain

For a more detailed assessment of LOC a modified

paediatric GCS should be used.

Further discussion regarding the AVPU and the modified

paediatric Glasgow Coma Scale can be found in

Appendix 4.




The following table provides an overview including alerts when further investigation is required.

Age Normal behaviour Alerts

Infant

(less than 1 year)

Good eye contact.

Orientates to faces.

Visually track bright objects.

Moves limbs spontaneously.

Flexion is a normal body posture.

Able to be consoled by primary carer.

No eye contact.

Irritable.

High pitched or very weak cry.

Flexed rigid extremities/flaccid/unresponsive.

Toddler

(1-3 years)

Protest when separated from parents/primary carer.

Demonstrate stranger anxiety


Extreme irritability.

Lethargic and unresponsive.

Fails to protest when the parents leave.

Preschooler

(3-5 years)

Mistrustful and afraid of strange environments.

Curious about equipment and events.


Trusting and readily compliant.

Irritable and uncooperative.

Lethargic and unresponsive.

Shows no interest in events and procedures.

School age

(5-10 years)

Responds readily to painful stimulus. Will try to withdraw from pain.

Limited response and protest.

RememberGenerally parents know their children best, and recognise when they are unwell. Always listen to parents concerns.

Exposure and environmentInfants and children are more prone to hypothermia

due to their large body surface area to mass ratio. It

is very important to keep them warm whilst ensuring

appropriate exposure for assessment.

Remember Infants and young children are prone to hypoglycaemia. Check blood glucose level regularly.

Psychological considerationsThe child’s response to injury and illness is influenced

by previous experiences and their developmental level.

This is influenced by their age, cognitive abilities,

communication skills and family dynamics.

Emergency Departments are potentially noisy and

frightening places for children and their carers.




The following table is a summary of the key developmental phases during childhood and offers some practical

suggestions for your nursing practice.

Age Strategies to minimise anxiety in the ED

Infant

(less than 1 year)

Minimise separation from primary carer.

Use objects familiar to child.

Soothing gentle approach.

Use distraction techniques.

Prepare primary carer and encourage them to soothe and comfort the infant.

Toddler

(1-3 years)

Encourage toddlers to participate in choices.

Where possible maintain routine.

Allow loud protest to procedures.

Gently restrain by wrapping or holding during procedures.

Explain procedures immediately prior to them occurring and provide age appropriate explanations.

Avoid separation from primary carers where possible.

Provide praise.

Preschooler

(3-5 years)

Provide age appropriate accurate information.

Minimise separation from parents/primary carer.

Provide choices (when possible).

Age appropriate explanations.

Procedural play – allow the child to handle equipment.

Use puppets, dolls etc.

Allow verbalisation of fears and feelings.

School age

(5-12 years)

Include parents/primary carer.

Include the child in their care.

Explain procedures in advance.

Use models, drawings explanations.

Provide privacy.

Allow them to verbalise their fears and ask questions.

Adolescents

(13-15 yrs)

Encourage choices and decisions in care.

Realistic and honest explanations.

Models and diagrams used in explanations.

Provide and respect privacy.

Include the parents but consider adolescents needs and requests.

Encourage questions and clarifications.

Adapted from Colizza D, Prior M, and Green P. 1996, The Emergency Department Experience: The Developmental and Psychological Needs of Children. Topics in Emergency Medicine 18: 3. 27-40.




References

APLS Manual Australian Edition (5th) 2011 Wiley &

Blackwood.

Colizza D. Prior M. and Green, P. 1996, The Emergency

Department Experience.

The Developmental and Psychological Needs of Children.

Topics in Emergency Medicine 18: 3. 27-40.

Hill E. and Stoneham M.D. 2000, Practical applications

of pulse Oximetry, Update in Anaesthesia, 11:4. 1-2.

Hunter New England Area Health Service, 2005,

Paediatric Oxygen Therapy, Hunter Emergency Services

Policy, Hunter Area Emergency Guidelines Committee.

Kilham, H., Alexander, S., Wood, N., Isaacs, D.

Paediatrics Manual - The Children’s Hospital at

Westmead Handbook (2nd Edition 2009).

Lee C.A. Barrett C.A. and Ignatavicius, 1996, Fluid and

Electrolytes. A Practical Approach (4th edn.) Philadelphia,

F.A. Davis. Chapter 2 pp 14-28.

Mackway-Jones, K. Molyneux E. Phillips B. Wieteska

S. [ED], 2005, Advanced Paediatric Life Support. The

Practical Approach. 4th edn. BMJ Blackwell Publishing

Group Limited, Massachusetts.

NSW Child Health Network Paediatric Resuscitation Card

2012.

NSW Health PD 2010_009 Infants and Children: Acute

Management of Gastroenteritis.

Southall D. Coulter B. Ronald C. Nicholson S. Parke

S. 2002, International Child Health Care: A practical

manual for hospitals worldwide. BMJ Blackwell

Publishing Group, London.

Wong D. 1999, Balance and imbalance of body fluids.

In D.L. Wong. 1999, Nursing care of infants and children.

St Louis: Mosby.

NSW Health Between The Flags. Standard Paediatric

Observation Charts 2010.


SECTION 2


Recognition of a sick child Medical Officer must be notified immediately For paediatrics only


Remember: Generally parents know their children best and recognise when they are unwell. Listen to parents concerns.


Airway

– obstruction - complete

partial - stridor

– apnoea - including history of apnoea

Breathing

– bradypnoea

– tachypnoea

– chest recession

– noises; grunting, gasping, wheeze

– accessory muscle use

– nasal flaring

– oxygen saturations less than 94% in room air

Circulation

– tachycardia/bradycardia

– hypotension (late sign and is indicative of

impending arrest)

– capillary refill greater than 3 seconds (centrally)

– agitation

– poor perfusion

– neurovascular compromise

– altered alertness, level of activity/consciousness

– signs of dehydration

Disability

– AVPU - only responding to pain or unresponsive

– pain

– hyper/hypoglycaemia

– fever greater than 38.50 C. If less than 3 months

of age fever greater than 380 C per axilla or

hypothermic

– rash – non blanching petechiae or purpura

History prompts

n Age especially neonate (less than 28 days old)

n Parental concern

n Onset

n Events – trauma or history of trauma

n Re-presentation

n Co-morbidity

n Immunosuppressed

n Fluids in and out past 24 hours

n Immunisation status

n Exposure to anyone else who is sick

n Relevant past history

n Medication history/management

n Child at risk

n Allergies

Recognition of a sick child




Assessment Intervention

Position Position of comfort with carer

Airway Assess patency Maintain airway patency

Stabilise the C-spine with in-line immobilisation

(if there is a possibility of injury)

Breathing Respiratory rate and effort

SpO2

Auscultation

Assist ventilation if required

Apply O2 via a non-rebreather mask to maintain SpO2 greater than 94%

Circulation Skin temperature

Pulse – Rate/Rhythm

Capillary refill (sternum)

Blood pressure

Cardiac monitor

Colour

IV cannulation/IO needle insertion/pathology

If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus

Monitor vital signs frequently

Disability AVPU/GCS + pupils

BGL

Monitor LOC frequently

Finger prick BGL

If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; 0.5 mg stat for a child less than 25kg; IM Glucagon 1 mg stat for a child greater than 25kg

Monitor finger prick BGL every 15 minutes until within normal limits

Measure and test

Pathology

Pain score (1-3)

Pain score (4-6)

Pain score (7-10)

Temperature

U/A (clean catch)

Fluid input/output

Collect blood for FBC, UEC, BGL and blood culture. Consider group and hold in trauma patients

Oral Paracetamol 15 mg/kg stat. Single dose never to exceed 1gm and no more than 4gm in 24 hours.

Oral Oxycodone 0.1 mg/kg (maximum dose 5 mg) stat

IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary) to a maximum dose of 10 mg) OR If child greater than 10kg consider Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)

Per axilla

Collect urine for culture and analysis

Investigate hydration status

Fluid balance chart

Specific treatment

SpO2 Apply O2 to maintain SpO2 greater than 94%

Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask

Document assessment findings, interventions and responses in the patient’s healthcare record




Medication standing orders Always check for allergies and contraindications.

The weight of a child is mandatory for calculating drug and fluid doses prior to administration

Drug Dose Route Frequency

Oxygen 10 -15 litres/min Inhalation Continuous

Paracetamol

Precaution: Prior

to administration

determine recent

administration

of any medicines

containing

Paracetamol

(minimum dosing

interval is four

hours)

Dose is recommended for patients of normal or average build.*

15mg/kg/dose 4 hourly to a maximum of 60mg/kg/day.

Single dose never to exceed 1gm and no more than 4gms in 24 hours.

Oral Stat


Oxycodone 0.1 mg/kg (maximum 5 mg) Oral Stat

Fentanyl 1.5 microgram/kg (maximum 75 micrograms total dose)

Intranasal 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)

Morphine sulphate

0.1 mg/kg IV/IO Stat. (repeat once in 10 minutes if necessary to a maximum dose of 10 mg)

10% Glucose 2.5 mL/kg IV/IO Stat

Glucagon hydrochloride

Child less than 25kg; 0.5 mg

Child greater than 25kg; 1 mg

IM Stat

0.9% Sodium Chloride

20 mL/kg IV/IO Bolus


2 mL flush IV As required

* Refer to NSW Health PD2009_009 Paracetamol Use for other patients




Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as

possible. At the time of this review, the Medical

Officer must check and countersign the nurse’s

record of administration on the medication chart as

per NSW Health PD2013_043.

n If a Paediatric Advanced Clinical Nurse uses these

clinical guidelines, a Medical Officer will be notified

immediately to ensure their early involvement with

the management and care of the patient.

Precautions and notes.n Remember the younger patient may present with

more subtle symptoms and signs and the level of

suspicion should be higher.

n An age/developmentally appropriate pain scale must

be used to assess pain in children (refer Appendix 7).

n This guideline should be read in conjunction with

NSW Health PD2011_038 Recognition of a Sick Baby

or Child in the Emergency Department.

ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska




MIMS Online https://www.mimsonline.com.au <accessed

06/03/14>.

Northern Sydney Health Paediatric Triage Tool, 2004,

Adapted from Consistency of triage in Victorian

Emergency Department Education and Quality Report.

July 2001. Monash Institution of Health Services Research,

Clayton Victoria.

NSW Child Health Networks Paediatric Information Card,

2007.

NSW Health PD2011_038 Recognition of a Sick Baby or

Child in the Emergency Department.

NSW Health PD2009_009 Paracetamol Use <accessed

06/03/14>

Australasian Paediatric Endocrine Group National

Evidence-Based Clinical Care Guidelines for Type 1

Diabetes for Children, Adolescents and Adults 2011

http://www.apeg.org.au/Portals/0/guidelines1.pdf

<accessed 17/03/14>.

Australian Resuscitation Council Medications & Fluids

in Paediatric Advanced Life Support 2010 http://www.

resus.org.au/policy/guidelines/section_12/medications_

fluids_in_paediatric.htm <accessed 06/03/14>.

Authorising Medical Officer signature:

Name:

Designation:

Date:

Drug Committee approval:

Date:


SECTION 3


Airway Emergencies Medical Officer must be notified immediately For paediatrics only



Any acute onset of hypotension or bronchospasm

or upper airway obstruction where anaphylaxis is

considered possible even if typical skin features are not

present.

OR Any acute onset illness with typical skin features

(urticarial rash or erythema/flushing, and/or angioedema)

PLUS involvement of respiratory and/or cardiovascular

and/or persistent severe gastrointestinal symptoms.

History prompts

n Onset

n Exposure to known allergen for the patient

n Associated symptoms

– respiratory distress, peripheral vasodilation,

hypotension, urticaria, generalised redness and peri

orbital oedema

– young child may present floppy and pale

n Flushing, urticaria and angioedema can be absent in

up to 20% of cases

n Gastrointestinal symptoms: vomiting, abdominal pain,

incontinence


n Medication history

n Allergies

n History of asthma/atopy

n Introduction of new foods

Anaphylactic Reaction





PositionDo not allow child to stand or walk. If breathing is difficult allow them to sit in position of comfort with carer.

Cease/remove causative agent

Airway Assess patency

Stridor

Maintain airway patency

If stridor present give IM *Adrenaline 0.01mL/kg of 1:1,000 stat: If symptoms not reversed Adrenaline may be given every 5 minutes as needed.

**If hoarse voice present also consider nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted) If symptoms not reversed second dose may be given 10 minutes after initial dose

Hoarse voice and/or difficulty talking


SpO2

Wheeze

If patients cannot inhale adequately to use an MDI and spacer or requires oxygen therapy


Apply O2 to maintain SpO2 greater than 94%.


If wheeze present give IM *Adrenaline 0.01mL/kg of 1:1,000 stat if symptoms not reversed Adrenaline may be given every 5 minutes as needed.

If wheeze present give Salbutamol: child less than 20kg 6 puffs Salbutamol 100 micrograms dose MDI + spacer stat; child greater than 20kg 12 puffs Salbutamol 100 micrograms dose MDI + spacer stat

Child less than 20kg 2.5 mg Salbutamol nebule stat; child greater than 20kg 5 mg Salbutamol nebule stat. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min

Circulation Skin colour

Pulse – rate/rhythm

Blood pressure

Capillary refill

Cardiac monitor

If signs of shock give IM Adrenaline 0.01mL/kg of 1:1000 stat if symptoms not reversed Adrenaline may be repeated every 5 minutes as needed.

IV cannulation/IO needle insertion

If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus


Disability AVPU/GCS + pupils Monitor LOC frequently

Measure and test

Temperature

Fluid input/output

Per axilla

Fluid balance chart

Specific treatment

No response to IM Adrenaline and patient presents with signs of cardio respiratory collapse

IV/IO ***Adrenaline 0.1mL/kg of 1:10,000 Follow paediatric Basic Life Support algorithm







*Adrenaline 0.01mL/kg of 1:1,000 IM Stat. If symptoms not reversed Adrenaline may be repeated every five minutes as needed.

** Adrenaline 0.5 mL/kg of 1:1,000 (maximum 5 ml undiluted) Nebuliser Stat. If symptoms not reversed second dose may be given 10 minutes after initial dose

*** Adrenaline 0.1mL/kg of 1:10,000 IV/IO Consider if cardio respiratory arrest

Salbutamol Child less than 20kg; 6 puffs of 100 microgram dose = (600 micrograms)

Child greater than 20kg; 12 puffs of 100 microgram dose = (1200 micrograms)

Metered dose inhaler via spacer

Stat then repeat as required

Salbutamol Child less than 20kg; 2.5 mg nebule

Child greater than 20kg; 5 mg nebule

Inhalation

Nebuliser with a minimum oxygen flow rate of 8 litres per minute

Child less than 20kg; 2.5 mg nebule stat

Child greater than 20kg; 5 mg nebule stat


20 mL/kg bolus IV/IO Bolus


2 mL flush IV/IO As required



Precautions and notes.n *Adrenaline 10 micrograms/kg of 1:1,000 IM

equates to Adrenaline 0.01 mL/kg of 1:1,000 IM.

n **Nebulised Adrenaline is not recommended as

first-line therapy, but may be a useful adjunct to IM

Adrenaline if upper airway obstruction is present

n ***Adrenaline 10 micrograms/kg of 1:10,000 IV/IO

equates to Adrenaline 0.1mL/kg of 1:10,000 IV/IO

n For effective salbutamol delivery to the bronchial tree

the oxygen flow rate should be set at 8 litres per

minute




Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.

At the time of this review, the Medical Officer

must check and countersign the nurse’s record of

administration on the medication chart as per NSW

Health PD2013_043.





n Skin urticaria is absent in approximately 20% of

cases.

n Systemic allergic reactions can occur with urticaria,

angioedema and rhinitis, but are not anaphylactic

reactions as they are not life threatening.

n Death caused by anaphylactic reaction occurs most

commonly in the first 45 minutes after the patient

has contact with an allergen.

n Adrenaline is the most important drug for the

treatment of an anaphylactic reaction.

n The best site for intramuscular (IM) Adrenaline is the

anterolateral aspect of the middle third of the thigh

– the needle needs to be long enough to ensure that

the Adrenaline is injected into the muscle (Soar et al

2008:162).



Practical Approach, 4th edn. The child in shock, pp

107-109, BMJ Blackwell Publishing Group Limited,

Massachusetts.

Children’s Hospital Westmead Emergency Department

Policy for Anaphylaxis and Allergy, 2005.


06/03/14>.

NSW Health GL2012_003 Rural Adult Emergency Clinical

Guidelines 3rd Edition Version 3.1.

Royal Children’s Hospital Melbourne Policy on

Anaphylaxis 2011.

United Bristol Healthcare, Directorate of Children’s

Services, Nebuliser Guidelines 2003, http://www.

bristolpaedresp.org.uk/BCHNebuliserProtocol18.11.2003.

pdf <accessed 17/03/14>.

Soar J, Pumphrey R, Cant A, et al. for the Working

Group of the Resuscitation Council (UK). 2008.

‘Emergency treatment of anaphylactic reactions:

Guidelines for health care providers’, Resuscitation, vol

77, (2), no. 2.

Australian Prescriber Anaphylaxis Wallchart (2011)

Australian Prescriber August 2011, Vol 34 No. 4.


Name:

Designation:

Date:


Date:


SECTION 3





n Corresponds with either mild, moderate or severe

scale as described below

n Age less than 6 months

n Poor response to initial treatment

n Pre-hospital treatment- manage as more severe than

clinical signs indicate

n Inability to maintain own airway

History prompts

n Onset

n Parental concern


n Allergies


n Representation within 24 hours

n Previous history of severe croup

n Known structural airway abnormality

n Severe obstruction prior to presentation (also consider

foreign body)

Clinical manifestations of croup

Mild Moderate Severe

Stridor Nil or intermittent Persisting stridor at rest Persisting stridor at rest

Cough Barking Barking Barking or absent

Increased Respiratory Effort

No Some tracheal tug and/or chest wall recession

Marked tracheal tug and/or chest wall recession

Cyanosis/pallor No No Possibly

Level of Consciousness

Alert May be distressed but can be placated

Apathetic or restless agitated decreased LOC

Croup







Severe croup


Keep child calm

Minimise interventions

Give nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted). If symptoms not reversed second dose may be given 10 minutes after initial dose then oral *Dexamethasone 0.3 mg/kg stat OR if unable to tolerate oral medication give nebulised Budesonide 2 mg stat


SpO2

Mild

Moderate

Severe


Apply O2 to maintain SpO2 greater than 94%.


Continuous monitoring

No specific treatment

*Oral Dexamethasone 0.3 mg/kg stat OR if unable to tolerate oral medication nebulised Budesonide 2 mg stat

Nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 ml undiluted) repeat at 10 minutes if required plus *Oral Dexamethasone 0.3 mg/kg stat or nebulised Budesonide 2 mg stat if unable to tolerate oral medication

Do not disturb child unnecessarily



Capillary refill

Colour

Monitor vital signs frequently but do not disturb child unnecessarily

Disability AVPU/GCS Monitor LOC frequently

Keep child calm, minimise interventions

Specific treatment

Severe croup only Give nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted) If symptoms not reversed second dose may be given 10 minutes after initial dose









Adrenaline 0.5 mL/kg of 1:1,000 adrenaline (maximum 5mL) undiluted

Nebulised Stat. If symptoms not reversed second dose may be given 10 minutes after initial dose

*Dexamethasone 0.3 mg/kg Oral Stat

Budesonide 2 mg (1mg/2mL neb) Nebulised Stat

Prednisolone 1 mg/kg Oral Stat

Precautions and notes.n *If oral Dexamethasone is not available administer

oral Prednisolone 1 mg/kg stat.

n Oxygen saturations may be near normal in severe

croup, yet significantly lowered in some children

with mild to moderate croup.

n For ongoing management refer to NSW Health

PD2010_053 Infants and Children: Acute

Management of Croup.

ReferencesNSW Health PD2010_053 Infants and Children: Acute

Management of Croup.

Mackway-Jones K. Molyneux E. Phillips B. Wieteska





06/03/14>.











Name:

Designation:

Date:


Date:


SECTION 3






n Loss of consciousness

n Ineffective cough and increasing dyspnoea

n Inability to vocalise

n Apnoea

n Inability to establish patent airway

History prompts

n Universal choking sign (clutching the neck with the

thumbs and fingers) may be seen in older children

n Sudden onset of respiratory distress

n Paradoxical chest movements

n Associated symptoms: sudden onset of cough,

gagging and/or stridor


PositionPosition of comfort with carerIf unconscious, supine with head tilt/chin lift and jaw thrust


Partial Obstruction

Effective cough

Severe Obstruction

Ineffective cough and conscious

Ineffective cough and unconscious


Encourage coughing

Support and assess continuously

Perform 5 back blows

If the obstruction is not relieved perform 5 chest thrusts

Still not relieved continue alternating, 5 back blows with 5 chest thrusts

Open the mouth and carefully attempt to remove any visible object

Unable to remove foreign body-Commence CPR

Continuously reassess airway for presence of foreign body


SpO2

Auscultation


Apply O2 to maintain SpO2 greater than 94%




Capillary refill

Colour

Cardiac Monitor

Signs of respiratory/cardiac failure commence CPR



Specific treatment

Severe obstruction – Ineffective cough and unconscious

Unable to remove foreign body - Commence CPR


Foreign Body







Oxygen 10-15 litres/min Inhalation Continuous

Precautions and notes.n Back blows can be performed by placing the baby/

child along one of the rescuers arms in a head-down

position, with the rescuers hand supporting the

infant’s jaw in such a way as to keep it open, in the

neutral position. The rescuer then rests their arm

along the thigh, and delivers five back blows with the

heel of the free hand.

n If the child is too large to allow the use of the

single-arm technique, the same manoeuvres can be

performed by laying the child across the rescuer’s

lap. Older child (over 9 years) manage as for adult

choking-lay supine, turn onto side deliver up to 5

back blows, turn supine and perform chest thrusts.

n To perform chest thrusts identify the same landmark

points used for cardiac compressions. Chest thrusts

are given in the same position however are sharper

and delivered at a slower rate (one per second).

The infant should be placed in a head downwards-

supine position across the rescuers thigh. Children if

conscious may be treated in the sitting or standing

position, if unconscious-lying down.



Practical Approach. 4th edn. The child with breathing

difficulties, pp 80. BMJ Blackwell Publishing Group

Limited, Massachusetts.

Australian Resuscitation Council, 2010, Guideline 4:

Airway.











Name:

Designation:

Date:


Date:


SECTION 3





n Child seizing on arrival to the ED

n Unresponsive to pre-hospital treatment

n Seizure lasting greater than five (5) minutes

n Altered level of consciousness


History prompts

n Onset

n Events – mechanism of injury

n Fever/current febrile illness

n Associated symptoms:

– altered level of consciousness, pale, sweaty,

incontinence



n Allergies


Position

Position of comfort with carer

Do NOT restrain the patient

Lie supine/left lateral (after tonic phase and clonic movements cease)

Keep carer at hand


Consider oro or naso pharyngeal airway

Stabilise the C-spine with in-line immobilisation (if there is a possibility of injury)





Stop the seizures

Buccal Midazolam 0.3 mg/kg (to a maximum of 10mg) stat and repeat (once only) after 5 minutes if required OR

IM/IV/IO Midazolam 0.15 mg/kg stat and repeat (once only) after 5 minutes if required

It may be difficult to adequately manage the patient’s airway and breathing until the seizures have been stopped. Once this has occurred, it will be necessary to reassess/treat/maintain the patient’s airway and breathing.



Capillary refill

Blood pressure (post ictal)

Cardiac monitor



Monitor vital signs continuously

Seizures





Disability AVPU/GCS + pupils reactivity post ictal

BGL


Measure GCS post ictal

Finger prick BGL

If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg 0.5 mg stat; child greater than 25kg 1 mg stat


Measure and test

Pathology

Temperature

U/A (clean catch)

Fluid input/output

Collect blood for FBC, UEC, Calcium, Magnesium, Blood Culture


Nil by mouth

Fluid balance chart

Specific treatment

Stop the seizures Buccal Midazolam 0.3 mg/kg (to a maximum of 10mg) stat and repeat (once only) after 5 minutes if required OR IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required







Glucagon hydrochloride Child less than 25kg; 0.5mg

Child greater than 25kg; 1mgIM Stat

Midazolam 0.15 mg/kg (to a maximum dose of 5mg)

IM/IV/IO Stat and repeat (once only) after 5 minutes if required

Midazolam 0.3 mg/kg (to a maximum of 10mg)

BuccalStat and repeat (once only) after 5 minutes if required

0.9% Sodium Chloride 20 mL/kg IV/IO Bolus

0.9% Sodium Chloride 2 mL flush IV/IO As required








Health PD2013_043.






Name:

Designation:

Date:


Date:

Precautions and notes.n Warning: Respiratory and cardiovascular depression

can be severe after the administration of Midazolam

and requires close monitoring and treatment.

n Observe for features of the seizure and document.



Management of Seizures.

ReferencesLowenstien D.H. Alldredge B.K. 1998, Current concepts:

status epilepticus.

The new journal of medicine. Vol. 338. No 14,

pp 970 – 976.


06/03/14>.

NSW Health PD2009_065 Infants and Children: Acute



06/03/14>.

Australian Paediatric Endocrine Group, Clinical Practice

Guidelines, Type One Diabetes in Children and

Adolescents. Canberra, Australia, National Health

and Medical Research Council, 2005.



Australian Resuscitation Council, Guideline 12.4,

Medications & Fluids in Paediatric Advanced Life Support;

December 2010.


SECTION 3




ALERT: The most common error in the management of an unconscious patient is the inadequate management of Airway,

Breathing and/or Circulation


n Glasgow Coma Scale (GCS) of less than 9


History prompts

n Onset

n Events – mechanism of injury

n Associated preceding symptoms



n Allergies


Position Lie supine





SpO2

Auscultation


Consider oropharyngeal airway





Capillary refill

Blood pressure

Cardiac monitor

Colour


If shocked including: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus

Continuous cardiorespiratory monitor

If asystolic or bradycardic - refer to BLS/ALS flowchart

Unconscious Patient






BGL

Possible opiate overdose (characterised by pin point pupils and hypoventilation)


If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration

Consider oro-pharyngeal airway, airway opening manoeuvres and bag –valve mask to assist ventilation

Finger prick BGL

If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat


If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg/dose (maximum 2 mg) repeat as necessary

Measure and test

Pathology

Temperature

U/A

Fluid input/output

Collect blood for FBC, UEC, Blood cultures, consider toxicology, (consider group and hold in trauma patients)

Nil by mouth

Specific treatment


If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg/dose (maximum 2 mg) repeat as necessary.


Medication standing ordersAlways check for allergies and contraindications.

The weight of a child is mandatory for calculating drug and fluid doses prior to administration.




Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg IM Stat

Naloxone 0.1 mg/kg/dose (maximum 2 mg) IV/IO/IM Stat repeat as necessary.






Precautions and notes.n Consider causes – refer to specific Guidelines if

required eg:

– head injury

– anaphylaxis

n Be alert for acute opiate withdrawal after the

administration of Naloxone. The half-life of Naloxone

is much shorter than the opiate. Repeated doses of

Naloxone may be required.

n If IV/IO access is unavailable, both doses of Naloxone

may be given IM, although it should be noted that

this is not ideal as the IM route will take longer to

take effect.



Practical Approach. 4th edn. The child in shock, pp


Massachusetts.

NSW Health GL2012_003 Rural adult emergency Clinical

guidelines 3rd Edition Version 3.1.

Australian Paediatric Endocrine Group: Clinical Practice

Guidelines: Type One Diabetes in Children and

Adolescents. Canberra, Australia, National Health and

Medical Research Council, 2005.



Royal Children’s Hospital Melbourne Paediatric

Pharmacopoeia http://pharmacopoeia.hcn.com.

au/?acc=36422<accessed 06/03/14>.


Medications & Fluids in Paediatric Advanced Life

Support; December 2010.











Name:

Designation:

Date:


Date:


SECTION 4


Breathing Emergencies Medical Officer must be notified immediately For paediatrics only




n Correspond with either mild, moderate, severe or life-

threatening scale as described below


n Pre hospital treatment


History prompts

n Onset




n Trigger factors

n Past presentation/s admission/s (ICU/HDU/intubation)

n Allergies

n Age less than 12 months (exclude differential diagnosis)

n Parental concern


Clinical manifestations of acute Asthma

Mild Moderate *Severe *Life-threatening

Altered consciousness

No No Agitated Agitated, confused, drowsy

Accessory muscle use

No Minimal Moderate Severe

Oximetry in air Greater than 94% 90-94% Less than 90% Less than 90%

Talks in Sentences Phrases Words Words/Unable to talk

Pulse rate Normal for age Tachycardia Marked tachycardia Marked tachycardia or bradycardia#

Central cyanosis No No Likely to be present Likely to be present

Wheeze on auscultation

Variable Moderate-loud Often quiet Often quiet

Physical exhaustion

No No Yes Yes

Modified from: the National Asthma Council Asthma Management Handbook, 2006.* Any of these features indicate the episode is severe or life-threatening. The absence of any feature does not exclude a severe or life-threatening attack.# Bradycardia may be seen when respiratory arrest is imminent.

SECTION 4

Asthma





PositionSit upright



If the patient shows signs of asthma associated with anaphylaxis (exhibits decreasing LOC, increasing cyanosis of lips/mouth and bradycardia)


If the patient has asthma associated with anaphylaxis give IM *Adrenaline 0.01mL/kg of 1:1,000 stat (one dose only)


SpO2

Use of accessory muscles

Mild asthma

Moderate asthma

If patient cannot inhale adequately to use an MDI and spacer or require oxygen therapy

Severe asthma

Life-threatening asthma




Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer stat; child greater than 20kgs; 12 puffs Salbutamol 100 micrograms MDI + spacer stat

**Consider oral Prednisolone 1 mg/kg stat

Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer 3 x 20 minutely; Child greater than 20kgs; 12 puffs Salbutamol 100 micrograms MDI + spacer 3 x 20 minutely

Oral Prednisolone 1 mg/kg stat

Child less than 20kg; 2.5 mg Salbutamol nebule 3 x 20 minutely; Child greater than 20kg; 5 mg Salbutamol nebule 3 x 20 minutely. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min

Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available

Salbutamol: Load 4 mL of undiluted salbutamol nebule into nebuliser and aim for cannister to be 1/2 to 2/3 full at all times

Ipratropium Bromide:

Child less than 20kg; 250 micrograms 3 x 20 minutely; Child greater than 20kg; 500 micrograms 3 x 20 minutely

Oral Prednisolone 1 mg/kg stat or if oral not tolerated IV/IO Methylprednisolone 1 mg/kg stat

Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available

Salbutamol:

Load 4 mL of undiluted 0.5% Salbutamol Solution into nebuliser and top up as required

Ipratropium Bromide:


IV/IO Hydrocortisone 4mg/kg OR Methylprednisolone 1 mg/kg stat







Capillary refill

Cardiac monitor

IV cannulation/IO needle insertion/pathology; severe/life-threatening asthma



Measure and test

Pathology

Temperature

Collect blood for UEC, Venous Blood Gases if severe or life-threatening

Specific treatment

Severe/life-threatening Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available

Salbutamol

Load 4 mL of undiluted salbutamol nebule into nebuliser and aim for cannister to be 1/2 to 2/3 full at all times.

Ipratropium Bromide


IV/IO Hydrocortisone 4mg/kg OR Methylprednisolone 1 mg/kg stat






Salbutamol

Child less than 20kg; 6 puffs of 100 microgram dose = (600 micrograms)


Inhalation

MDI + Spacer

Mild:

Child less than 20kg; 6 puffs stat

Child greater than 20kg; 12 puffs stat

Moderate:

Child less than 20kg; 6 puffs 3 x 20 minutely

Child greater than 20kg; 12 puffs 3 x 20 minutely

Salbutamol

Child less than 20kg;

2.5 mg nebule


Inhalation

Nebuliser with a minimum flow rate of 8 litres per minute

Mild:



Moderate:

Child less than 20kg; 2.5 mg nebule 3 x 20 minutely

Child greater than 20kg; 5 mg nebule 3 x 20 minutely

Salbutamol

Load 4 mL of undiluted 0.5% Salbutamol solution into nebuliser and top up as required.

Inhalation Continuous nebuliser with a miniumum flow rate of 8 litres per minute

Severe/life-threatening:

Continuous until instructed by Medical Officer





Ipratropium Bromide

Child less than 20 kg; 250 micrograms (0.5 mL of 0.025%) solution made up to 4 mL with 0.9% Sodium Chloride

Child greater than 20kg; 500 micrograms (1 mL of 0.025%) solution made up to 4 mL with 0.9% Sodium Chloride

Inhalation

Nebuliser with a minimum oxygen flow rate of 8 litres per minute

Severe/life-threatening

Child less than 20kg; 250 micrograms 3 x 20 minutely

Child greater than 20kg; 500 micrograms 3 x 20 minutely

**Prednisolone 1 mg/kg Oral Stat

Methylprednisolone 1 mg/kg IV/IOStat - severe and life-threatening

(if oral Prednisolone not tolerated)

Hydrocortisone 4 mg/kg IV/IO Stat (one dose only)

*Adrenaline

(If the patient shows signs of asthma associated with anaphylaxis

0.01mL/kg of 1:1,000 IM Stat (if symptoms not reversed Adrenaline may be repeated every five minutes as needed.)


2mL flush IV/IO As required











Name:

Designation:

Date:


Date:




Precautions and notes.n *Adrenaline 10 micrograms/kg of 1:1,000 IM

equates to Adrenaline 0.01 mL/kg of 1:1,000 IM

n **Only administer Prednisolone in mild asthma if it

is a prolonged episode or there is a history of severe

asthma.

n For effective salbutamol delivery to the bronchial tree

the oxygen flow rate should be set at 8 litres per

minute

n Methylprednisolone is the preferred IV/IO steroid,

however if Methylprednisolone is unavailable give

IV/IO Hydrocortisone 4 mg/kg stat.

n There is substantial evidence that Ipratropium

Bromide is of limited use in acute episodes of mild

to moderate asthma.

n The use of short acting beta antagonists by

intermittent inhalation via MDI and spacer is now

recommended in the management of acute mild and

moderate asthma.

n Use a nebuliser instead of a MDI if the patient

cannot inhale adequately or requires oxygen.

Salbutamol 2.5 mg or 5 mg nebule can be made up

with 2 mL 0.9% Sodium Chloride.

n The best site for intramuscular (IM) Adrenaline is the

anterolateral aspect of the middle third of the thigh –

the needle needs to be long enough to ensure that

the Adrenaline is injected into the muscle (Soar et al

2008:162).



Management of Asthma.

ReferencesMIMS Online https://www.mimsonline.com.au <accessed

06/03/14>.

NSW Policy Directive PD2012_056 Infants and Children:

Acute Management of Asthma.

National Asthma Council Australia, 2006, Asthma

management handbook. Revised and updated.

National Asthma Council Australia.



http://www0.health.nsw.gov.au/policies/gl/2012/

GL2012_003.html <accessed 06/03/14>.

Mackway-Jones K. Molyneux E. Phillips B. Wieteska S.

[ED], 2005, Advanced Paediatric Life Support.

The Practical Approach. 4th edn. BMJ Blackwell

Publishing Group Limited, Massachusetts.


Anaphylaxis 2011.

United Bristol Healthcare, Directorate of Children’s

Services, Nebuliser Guidelines 2003. http://www.

bristolpaedresp.org.uk/BCHNebuliserProtocol18.11.2003.

pdf <accessed 17/03/14>.

Soar J, Pumphrey R, Cant A, et al. for the Working

Group of the Resuscitatio Council (UK). 2008.

‘Emergency treatment of anaphylactic reactions:

Guidelines for health care providers’, Resuscitation, vol

77, (2), no. 2.


SECTION 4







n Apnoea


History prompts


n The following infants are at risk of more serious

disease

– full term infant up to 3 months of age

– premature or low-weight for gestational age

– chronic lung disease

– congenital heart disease

n Parental concern

n Onset



n Difficulty feeding


n Allergies


Clinical manifestations of acute Bronchiolitis


Apnoea No Brief apnoeas Apnoeic episodes

Respiratory distress Minimal or none Moderate – some chest wall recession and nasal flaring

Severe – marked chest wall recession, nasal flaring and/or grunting

Hypoxia in air No Yes Yes, may be difficult to correct with oxygen

Level of Consciousness Alert Alert Increasingly tiring, exhaustion

Fever Fever (greater than 38.50 C present in 50% of infants with bronchiolitis)

Pulse Rate Normal for age Mild Tachycardia Tachycardia or Bradycardia



Bronchiolitis







Ensure nasopharynx clear


SpO2

Mild

Moderate/severe




Intermittent SpO2 monitoring

Continuous SpO2 monitoring



Capillary refill

Cardiac monitor

Colour

Mild

Moderate

Severe

IV cannulation/IO/ needle insertion/pathology for ‘severe’ bronchiolitis


Continue oral feeding

Continue oral feeding if well tolerated / consider IV fluid therapy

Nil by mouth - IV fluid therapy


Measure and test

Pathology

Temperature

Fluid input/output

U/A

Collect blood for UEC, FBC, Blood Culture, BGL, Venous blood gas (only if IV inserted)

Fluid balance chart

Ward U/A

Specific treatment

Oxygen therapy

Severe


Nil by mouth








2 mL flush IV As required





Health PD2013_043.






Name:

Designation:

Date:


Date:

Precautions and notesn The child should be assigned to the most severe

grade in which any clinical feature occurs.

n Treatment of fever should be considered in moderate

to severe Bronchiolitis as it may reduce metabolic O2

requirements.

n RSV is a common cause of Bronchiolitis and is very

infectious; precautions should be taken to avoid

cross-infection in particular hand washing.



Management of Bronchiolitis.


Management of Bronchiolitis.


06/03/14>.




SECTION 5

Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only


PAGE 45

Assess for RESPONSE

Open and clear AIRWAY — Position head with chin lift or jaw thrust

Assess BREATHING — Look / Listen / FeelIf patient unresponsive and not breathing normally then GIVE 2 RESCUE BREATHS

Attach monitor/DEFIBRILLATOR as soon as possible ASSESS RHYTHM

Assess CIRCULATION – Commence COMPRESSIONS ifa pulse is not palpable within 10 seconds or less than 60 beats/min

and the patient is unresponsive and not breathing normally.15 compressions : 2 breaths

Compression rate 100 beats/min Compression depth 1/3 of the chest wallHand position: lower half sternum

Paediatric ‘Basic’ Life Support Flow Chart for Healthcare Providers

DR

A

B

C

D

Check for DANGER — Hazards / Risks / Safety

SEND (or call) for helpS

Adapted from the ‘Resus4Kids’ Paediatric Advanced Life Support for Health Care Providers flow charts based on the Australian Resuscitation Council Advanced Life Support for Infants and Children Guideline 12.3 December, 2010

Paediatric Basic Life Support




PAGE 46

Paediatric Cardiorespiratory Arrest

Healthcare Provider CPRCompression to Ventilation Ratio 15 : 2

Minimise interruptions to chest compressions

Immediately recommence

CPR for 2 minutes

Continue CPR for 2 minutes

One DC ShockBiphasic or

Monophasic 4 Joules/kg

Attach Defibrillator – ECG Monitor

Assess Rhythm

During CPR- Ensure high flow oxygen- Establish or verify IV or Intraosseous access- Check electrode / pad positions & contact

CONSIDER AND CORRECT ■ Hypoxaemia■ Hypovolaemia Give IV / Intraosseous fluid Bolus 0.9% Normal Saline 20mL/kg■ Hypo/hyperthermia■ Hypo/hyperkalaemia or other electrolyte disorders■ Tamponade■ Tension pneumothorax■ Toxins / Poisons / Drugs■ Thromboembolism

CONSIDERAdvanced airway (LMA) or prepare for intubation

VassopressorGive Adrenaline 10 micrograms/kg after 2nd shock and then every 2nd cycle (4 minutes) IV / Intraosseous

AntiarrythmicGive Amiodarone 5mg/kg IV / Intraosseous immediately after third shock for VF or VT only

Adrenaline10 micrograms/kgIV / Intraosseous

(0.1mL/kg 1:10 000)Give immediately

then every second cycle (≈ 4 minutes)

NON SHOCKABLEAsystole / PEACompromising

Bradycardia

SHOCKABLE

VF / Pulseless VT

Return of Spontaneous Circulation?Commence post resuscitation care. Follow Recognition of a Sick Child (Page 11)

Adapted from the Australian Resuscitation Council Advanced Life Support for Infants and Children Guideline 12.3 December, 2010






Adrenaline 0.1mL/kg of 1:10,000 per dose IV/IO 4 minutely

Amiodarone5 mg/kg (300 mg maximum dose) diluted/

flushed with 5% GlucoseIV/IO Stat


0.9% Sodium Chloride 5 mL Flush IV/IO As required

5% Glucose 10-20mL mL Flush IV/IO As required

Precautions and notes.n *Adrenaline 10 micrograms/kg of 1:10,000 IV/IO

equates to Adrenaline 0.1 mL/kg of 1:10,000 IV/IO.

n Minimum requirements for an emergency trolley are

outlined in Appendix 1.

ReferencesAustralian Resuscitation Council, 2010, Any attempt at

resuscitation is better than no attempt Chapter 12.3

Flowchart for the Sequential Management of Life-

Threatening Arrhythmias in Infants and Children http://

www.resus.org.au/policy/guidelines/index.asp <accessed

16/03/14.


06/03/14>.













Name:

Designation:

Date:


Date:


SECTION 5









History prompts

n Age

n Parental concern

n Onset


n Exposure to anyone else who is sick


n Consider alternative diagnosis if there is; abdominal

distension, bile-stained vomiting, fever greater than

39o C, blood in vomitus or stool, severe abdominal

pain, vomiting in the absence of diarrhoea, headache


n Medication history/management at home

Clinical manifestations of acute dehydration


Same as no clinical signs

of dehydration plus

Dry mucous

Membranes

Mild Tachycardia

Same as mild plus

Lethargy

Tachycardia

Reduced skin turgor

Sunken eyes

Abnormal respiratory pattern

Same as moderate plus

Poor perfusion –mottled, cool limbs/slow capillary

refill/altered consciousness

Shock - thready peripheral pulses with marked

tachycardia and other signs of poor perfusion

stated above

Source: NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis

Gastroenteritis








SpO2





Mild

Moderate

(not shocked)

Severe


Capillary refill

Cardiac monitor

Colour

IV cannulation/IO needle insertion/pathology - severe dehydration

*Trial of oral fluids 0.5 mL/kg every 5 minutes

*Trial of oral fluids 0.5 mL/kg every 5 minutes



Disability AVPU/GCS

BGL


Finger prick BGL



Measure and test

Pathology

U/A (clean catch)

Fluid input/output

Collect blood for UEC, BGL.

Consider FBC


Fluid balance chart

Specific treatment

Severe dehydration

Signs of shock

To reduce vomiting a one off dose of oral Ondansetron may be considered


Oral Ondansetron 0.2 mg/kg stat (Single dose, maximum 8 mg)







Oral Rehydration Solutions. Eg Gastrolyte, Hydralyte, Pedialyte

0.5 mL/kg Oral Every 5 minutes


Glucagon Hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1mg

IM Stat

Ondansetron 0.2 mg/kg (maximum 8 mg) Oral Stat















Name:

Designation:

Date:


Date:




Precautions and notesn The child should be assigned to the most severe

grade in which any clinical feature occurs.

n *Oral replacement therapy (fluids) in order of

preference;

– continue breastfeeding – small frequent feeds

– Oral Rehydration Solution (ORS) eg Gastrolyte

or Hydralyte

– 1 part juice or lemonade to 4 parts water (only if

ORS consistently refused and child is not clinically

dehydrated)

n There are no indications for the use of anti-

emetic, anti-motility, anti-diarrhoeal agents in

the management of gastroenteritis in infants and

children, however a one off dose of Ondansetron

(maximum 8 mg) may be considered.

n For ongoing management and fluid regimes refer

to NSW PD2010_009 Infants and Children: Acute





06/03/14>.

MIMS Australia 2013. MIMS Annual 37th edn. St

Leonards.

Australian Paediatric Endocrine Group: Clinical Practice

Guidelines: Type One Diabetes in Children and

Adolescents. Canberra, Australia, National Health and






SECTION 5





Full PPE measures must be considered

Position Lie supine



SpO2






Capillary refill

Blood pressure

Cardiac monitor

Colour

IV cannulation/IO needle insertion/pathology. If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus



n Tachycardia

n Poor brain perfusion

– restlessness

– altered level of consciousness

n Poor skin perfusion

– cold

– pale

– sweaty

– capillary refill greater than 2 seconds

– rash

n Hypotension

History prompts

n Onset

n Events:

– vomiting/diarrhoea

– infection

– gastric/abdominal pain

– UTI (known/suspected)

– pregnancy

– mechanism of injury

– history or evidence of trauma

– poisoning

n Anaphylactic shock must be excluded and is treated

differently

n Poor feeding

n Fever

n Age less than 3 years

n Medication history (child’s and household members)

n Allergies

Shock






BGL


Finger prick BGL



Measure and test

Pathology

Temperature

U/A (clean catch)

Fluid input/output

Blood loss/PV loss

Collect pathology for Blood Culture, venous pH, FBC, UEC, group and hold


Urine hCG post-menarchal females

Fluid balance chart

Consider In-dwelling catheter and hourly urine measurement

Nil by mouth

Monitor

Specific treatment

Fluid resuscitation IV cannulation/IO needle insertion x 2, pathology.






Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg

IM Stat












Health PD2013_043.






Name:

Designation:

Date:


Date:

Precautions and notesn Manage fever to decrease metabolic oxygen demand.

n In Paediatric practice, septicaemia is the commonest

cause of a child presenting in shock, so unless an

alternative diagnosis is very clear (such as trauma,

anaphylaxis or poisoning), collection of blood

sample for culture should be attempted prior to

administration of antibiotics but should not delay treatment.



Practical Approach. 4th edn. The child in shock, pp


Massachusetts.


Leonards.


Anaphylaxis 2011.




06/03/14>.



Adolescents, Canberra, Australia, National Health and






SECTION 6


Disabilities Medical Officer must be notified immediately For paediatrics only



Full Personal Protective Equipment must be worn at all times

Position

Completely undress and inspect all body surfaces for rash




SpO2





Pulse -rate/rhythm

Capillary refill

Blood pressure

Cardiac monitor

Colour





n Appearance of rapidly developing non-blanching

petechial or purpuric rash (bruised haemorrhagic

type/does not blanch ie skin colour does not fade

under pressure) which may be only several lesions

n Associated signs and symptoms include: fever or

hypothermia, cerebral oedema, bulging fontanelle,

high pitched cry, lethargy, irritability, neck stiffness

(greater than 3 years), photophobia (greater than 3

years)

n Seizures

History prompts


n Parental concern

n Onset


– altered/abnormal level of consciousness, pallor,

irritability (global signs of meningeal irritation)


– contact with someone with meningitis

– head trauma/surgery or infection

– apnoea or history of apnoea

– maternal history Group B streptococcus if less than

3 months old

n Medication history including administration of prior

antibiotics


n Allergies

Suspected Bacterial Meningitis





DO NOT DELAY ANTIBIOTIC ADMINISTRATION (See Therapeutic Guidelines)


BGL

Seizures


Finger prick BGL



Buccal Midazolam 0.3 mg/kg stat (maximum dose of 10mg) and repeat (once only) after 5 minutes if required OR IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required

Measure and test

Pathology

Temperature

U/A (clean catch)

Fluid input/output

Collect blood for FBC, UEC, BGL, blood cultures

Monitor


Nil by mouth

Fluid balance chart

Specific treatment

Non-blanching petechial/ purpuric rash or the unwell child with a high index of suspicion for bacterial meningitis

Early administration of steroids to children greater than 3 months who have NOT been pre treated with antibiotics has shown to reduce severe hearing loss by 60%

Urgently contact MO

Urgently administer antibiotics

n 0-3 months IV/IO Ampicillin 50 mg/kg (maximum 2 g) stat or IV/IO Benzyl penicillin 60 mg/kg (maximum 2.4g) stat plus IV/IO Cefotaxime 50 mg/kg (maximum 2 g) stat (slow push over 5 - 10 minutes)

n 3 months - 15 years IV/IO Cefotaxime 50 mg/kg (maximum 2 g) stat or IV/IO Ceftriaxone 50mg/kg/dose (maximum 2 g) stat (slow push over 5 - 10 minutes)

*Greater than 3 months IV/IO Dexamethasone 0.15 mg/kg

(maximum 4 mg) stat - immediately prior to the administration of 1st dose of antibiotics








Glucagon hydrochlorideChild less than 25kg; 0.5 mg Child greater than 25kg; 1 mg

IM Stat

Ampicillin 50 mg/kg (maximum 2 g) IV/IO Stat

Benzyl penicillin 60 mg/kg (maximum 2.4 g) IV/IO Stat

Cefotaxime 50 mg/kg (maximum 2 g) IV/IO Stat

Ceftriaxone 50 mg/kg (maximum 2 g) IV/IO Stat

Dexamethasone 0.15 mg/kg (maximum 4 mg) IV/IO Stat

Midazolam0.15 mg/kg (to a maximum dose of 5mg)

IM/IV/IOStat and repeat (for seizures) after 5 mins if required (for seizures)

Midazolam 0.3 mg/kg (maximum 10 mg) BuccalStat and repeat (for seizures) after 5 mins if required (for seizures)

0.9% Sodium Chloride. 20 mL/kg IV/IO Bolus








Health PD2013_043.






Name:

Designation:

Date:


Date:




Precautions and notesn IM antibiotic administration is not preferred in this

setting as supervening shock and hypotension may

lead to failure of absorption of the injected antibiotic.

n The younger the patient, the more subtle the

symptoms and signs and the higher the level of

suspicion.

n Prior antibiotics modify the presentation and

diagnostic yield, and should always be part of the

history.

n For ongoing management refer to the NSW

Health PD2013_044 Infants and Children: Acute

Management of Bacterial Meningitis.


Management of Bacterial Meningitis.

NSW Health PD 2009_009 Paracetamol Use.










GL2012_003.html <accessed 06/03/14>.


Leonards.





SECTION 7


Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only



n Decreased LOC

n Hypotension


n Symptoms suggestive of opiate overdose

– pin-point pupils

– hypoventilation

n Seizures

History prompts

n Time of incident

n Route of exposure

n Type of contaminate/poison/drug

n Amount

n Potentially harmful

n Information (if any) obtained from Poisons

Information Centre

n Reason – accidental/intentional


n Potential access to any drugs (including methadone,

illicit drugs, medications, alcohol)



n Allergies


Position Lie supine



SpO2

Auscultation






Blood pressure

Capillary refill

Cardiac monitor




Continuous cardiac monitor if tachycardic or abnormal rhythm

Poisoning






BGL


Seizures

Contaminant on skin, eyes, clothing


If GCS less than 9 and not rapidly improving, the patient may require endotracheal intubation by a MO to protect the airway from aspiration

Finger prick BGL



If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg (maximum 2 mg) repeat as necessary

Buccal Midazolam 0.3 mg/kg (to a maximum dose of 10mg) stat and repeat (once only) after 5 minutes if required OR

IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required

Remove contaminant (ensure safety of patient and staff member – follow protocols)

Measure and test

Pathology

Temperature

U/A

Fluid input/output

Collect pathology for FBC, UEC, toxicology venous blood gas

Collect urine for drug screen if unexplained symptoms exist

Fluid balance chart

Specific treatment

Presentation within one hour of ingestion (and conscious)

Contact Poisons Information Centre 131 126

Oral/nasogastric Activated charcoal 1 g/kg stat (maximum 50 g)









IM Stat


IM/IV/IO Stat and repeat after 5 minutes if required (once only)


BuccalStat and repeat after 5 minutes if required (once only)

Naloxone 0.1 mg/kg (maximum 2 mg) IV/IO/IM Stat Repeat as necessary

Activated charcoal 1 g/kg (maximum 50 g) Oral/nasogastric Stat








record of administration on the medication chart

as per NSW Health PD2013_043.



immediately to ensure their early involvement

with the management and care of the patient.


Name:

Designation:

Date:


Date:




Precautions and notesn Contact Poisons Information 131 126

n Activated charcoal most beneficial if given within

the first hour of ingestion.

n Be alert for acute opiate withdrawal after the

administration of Naloxone. The half-life of Naloxone

is much shorter than the opiate. Repeated doses of

Naloxone may be required.

n If IV/IO access is unavailable, both doses of Naloxone

may be given IM, although it should be noted that

this is not ideal as the IM route will take longer to

take effect.

n All intentional poisoning must be admitted for

assessment no matter how trivial the poisoning

may be.

.

ReferencesPaediatric Emergency Department Poison Protocol http://

www.med.monash.edu.au/paediatrics/resources/poison.

html<accessed 06/03/14>.

Royal Children’s Hospital Melbourne, Acute Poisioning

- Guidelines For Initial Management http://www.rch.

org.au/clinicalguide/guideline_index/Acute_Poisoning_

Guidelines_For_Initial_Management <accessed

13/03/14>.


S. [ED] 2005 Advanced Paediatric Life Support. The

Practical Approach, 4th edn. General approach to

poisoning and envenomation, pp 341-345, BMJ

Blackwell Publishing Group Limited, Massachusetts.


Leonards.







Royal Children’s Hospital Melbourne Paediatric

Pharmacopoeia http://pharmacopoeia.hcn.com.

au/?acc=36422<accessed 06/03/14>.





SECTION 7





ALERT: Do not remove pressure immobilisation bandage


n Neurotoxic paralysis/diplopia/dysphagia

n Convulsions

n Abdominal pain/headache, nausea/vomiting

History prompts

n Events

– time of bite, number of bites, time and type of

first aid applied, pre-hospital treatment, drug/

alcohol intoxication, activity since bite, bite site/

locations


– weakness, paralysis, headache, nausea, vomiting,

abdominal pain, altered LOC, severe localised pain

(spider bite), localised swelling, diaphoresis, excess

salivation, painful lymph node, ptosis

n Relevant past history/previous envenomation or

antivenom administration


n Allergies


PositionPosition of comfort with carer

Keep patient immobile



SpO2

Auscultation




Circulation First aid

Skin temperature


Blood pressure

Capillary refill

Cardiac monitor

Apply pressure immobilisation bandage and splinting to all victims of snake and Funnel web spider bite




Disability AVPU/GCS + pupils Monitor LOC frequently

If GCS less than 9 and not rapidly improving, the patient may require endotracheal intubation by a MO to protect the airway from aspiration

(be aware that totally paralysed patients may be fully conscious and will require anaesthesia for intubation)

Snake/Spider Bite





Measure and test

Signs of systemic snake envenomation

Pathology

Temperature

U/A

Fluid input/output

Electrocardiography

Whole blood clotting time (in glass tube)

Collect blood for FBC, UEC, Creatinine Kinase, coags, group and hold

Monitor

Check for myoglobin (blood in urine)

Maintain Fluid Balance Chart

12 lead ECG

Specific treatment

Systemic envenomation

Funnel web envenomation

Red back spider envenomation

Anaphylactic reaction to antivenom

Immunisation status

Hydration

MO to consider appropriate antivenom

Antivenom to patients with signs and symptoms: perioral tingling and tongue, twitching, increased sweating, lachrymation, salivation, piloerection, hypertension, nausea ± malaise, dyspnoea – pulmonary oedema, decreased conscious state/coma

Ice to bite site (do NOT apply pressure immobilisation bandage)

Consider Red back spider antivenom

IM *Adrenaline 0.01mL/kg of 1:1,000 stat

Check immunisation status and consider tetanus immunisation requirements when patient stable

Nil By Mouth




*Adrenaline 0.01mL/kg of 1:1,000 IM Stat

















Precautions and notesn *Adrenaline 10 micrograms/kg of 1:1,000 IM

equates to Adrenaline 0.01mL/kg of 1:1,000 IMn Apply pressure immobilisation bandage at the same

pressure as for a sprained ankle.

n A window may be cut in the pressure immobilisation

bandage to obtain a specimen for Venom Detection

Kit analysis.

n Antiserum dose is not based on the patient’s size/

weight but on the amount required to neutralise the

toxin, therefore in general children will receive the

full adult dose.

n IM injections should be avoided (except Boostrix/

ADT booster) in snakebite victims because of

coagulopathy.

n Whole blood clotting test may be performed to

determine the length of time blood takes to clot. It is

performed by placing 5 - 10 mL of venous blood into


Name:

Designation:

Date:


Date:

a glass tube and measuring the time taken for the

blood to clot. Normal time is less than 10 minutes.

n A snake/spider bite observation chart is

recommended for recording vital signs and specific

signs associated with snake and spider bites/

envenomation – (Refer Appendix 6).

n Children who have completed a full primary

immunisation course no greater than 5 years ago will

not require further immunistaion.

n Individuals who have no documented history of

receiving a primary vaccination course (3 doses)

of tetanus toxoid – containing vaccines should

receive a complete primary course. Please refer to

Primary Vaccination in The Australian Immunisation

Handbook 10th Edition 2013.

n IM injections should be avoided in snakebite victims

because of coagulopathy, however consideration

should be given to Tetanus vaccination if required

ReferencesMIMS Online https://www.mimsonline.com.au <accessed

06/03/14>.

Stewart, C. 2003. Snake bite in Australia: First aid and

envenomation management, Accident and Emergency

Nursing Vol 11(2), pp 106-111.


S. [ED] 2005, Advanced Paediatric Life Support, The

Practical Approach. 4th edn. General approach to the

child with poisoning and envenomation pp 341-345,

BMJ Blackwell Publishing Group Limited, Massachusetts.



http://www.Snakebite & Spiderbite Clinical Management

Guidelines 2007 - NSW<accessed 29.07.2009>.

Cameron, P. Jelinek, G. Everitt, I. Browne, G. Raftos, J.

Text book of Paediatric Emergency Medicine. Elsevier.

2006 pp 527.

NSW Health 2013, GL2014_005 Snake and Spiderbite

Clinical Management Guidelines Third Edition.


SECTION 8


Trauma Emergencies Medical Officer must be notified immediately For paediatrics only


Refer to the NSW Health Severe Burn Injury Guideline (Appendix 8) Any child meeting this criteria must be transferred to definitive care.

History prompts

n Onset – time of burn

n Events:

– mechanism of injury/exposure

– history of electrical/thermal/chemical/radiation burns

– confined space

– first aid measures - defined


– cough, hoarse voice, sore throat, sooty sputum,

stridor, neck/facial swelling, singed nasal or facial

hair, confusion

n Relevant past medical history

n Assess for possibility of non accidental injury


n Tetanus immunisation status

n Allergies

The burn surface is cooled with running water 8-25oC

for a minimum of 20 minutes; this is beneficial within the

first three (3) hours only.

Prevent hypothermia and keep the patient warm. If the

patient has suffered chemical burns, ensure staff are

adequately protected from contamination.

Always brush dry chemicals off (use PPE) before applying

cool water.


n Airway/facial/neck burns

n Burns to hands, feet, perineum

n Electrical burns including lightning injuries

n Chemical burns

n Circumferential burns of limbs or chest


Position Position of comfort with carer/clinical status


Evidence of airway burn;

hoarse voice, stridor, sore throat, sooty sputum, facial swelling


Consider early endotracheal intubation by MO




SpO2


Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask to all patients except those with minor burns

Severe Burns






Blistering


Capillary refill

Blood pressure

Cardiac monitor

Constrictive non adhered clothing or jewellery

IV cannulation/IO needle insertion x 2 /pathology

If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus PLUS for burns greater than 10% TBSA use Modified Parkland formula for fluid replacement (Appendix 8)

Continuous cardiorespiratory monitor (especially for electrical burns and lightning strikes)


Remove


BGL


Finger prick BGL

Measure and test

Primary survey

Pain score (1-3)

Pain score (4-6)

Pain score (7-10)

Secondary survey

Pathology

Temperature

U/A

Fluid input/output

Assess TBSA

Burns greater than 10% TBSA

Repeat

Oral Paracetamol 15 mg/kg stat. Single dose never to exceed 1gm and no more than 4gms in 24 hours.

Oral liquid Oxycodone 0.1mg/kg (maximum 5mg) stat

IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary to a maximum dose of 10mg) OR if child greater than 10kg consider Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)

Non pharmacological measures must be considered early – supportive and distractive techniques Commence

Collect blood for FBC, UEC, BGL, (consider group and hold, myoglobin, ABG/venous blood gas)

Avoid hypothermia

Ward U/A

Monitor – maintain UO at 2 mL/kg/hour Fluid balance chart

Calculate total body surface area burnt

Use paediatric burns assessment chart

Nil orally if burns TBSA greater than 10-15%

For burns greater than 10% TBSA, consider indwelling catheter to measure and record urine output every hour

Modified Parkland formula (see appendix 8): in the first 24 hours post burn give IV/IO Compound Sodium Lactate (Hartmann’s) solution 4mL x kg body weight x % TBSA burnt. Give 50% of total amount first 8 hours from time of burn; give the remaining 50% over the next 16 hours





Specific treatment

Liquid chemical

Powder chemical

Electrical/lightning strike

Circumferential burns

Burn wounds

Gastrointestinal care

Immunisation status

Copious water irrigation

Brush off prior to copious water irrigation. Staff must use Personal Protective Equipment

Maintain UO greater than 2 mL/kg/hour

Elevate the affected limb above the level of the heart. Perform neurovascular observations every 15 minutes

If transferring within 8 hours wrap the burns with cling wrap. If the face is burnt paraffin ointment should be applied

If there is a delay in transfer wound management should be in consultation with the burn surgeon who will receive the patient or with NETS. Do not use Silver Sulphadiazine (SSD) cream without consulting the tertiary burns service and do not apply to the face

Patients with major burns must remain nil by mouth until after consultation with the appropriate burns unit

Check immunisation status and consider tetanus immunisation requirements when patient stable







Paracetamol

Precaution: Prior to administration determine recent administration of any medicines containing Paracetamol (minimum dosing interval is 4 hours)


15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.


Oral Stat


Fentanyl1.5 microgram/kg (maximum 75 micrograms total dose)

Intranasal5 minutely (titrated to pain and sedation)

Morphine sulphate 0.1 mg/kg IV/IO Stat

Compound Sodium Lactate

(Hartmann’s) solutionAs per Modified Parkland formula IV/IO As per formula


















Precautions and notesn Consult with burns specialist (or NETS) early.

n Children have different body surface area

proportions: Use the Paediatric Rule of Nines, and adjust for age by taking 1% BSA from the

head and adding ½% BSA to each leg for each year

of life after 1 year until 10 years.(Adult proportions

are reached at 10Yrs.) (Refer to Appendix 8)

n For ongoing fluid management in children,

maintenance fluids should be added to the fluid

calculated with the Modified Parkland Formula.

n Do not use ice to cool burn.

n Be cautious in administration of Morphine if there

is an altered level of consciousness, respiratory


Name:

Designation:

Date:


Date:

compromise or hypotension. Use of sedation

scores may be beneficial in reassessment.

n Refer to burn injury Referral/Retrieval Criteria Checklist; Burns Transfer Flow Chart; Burn Patient Emergency Assessment and Management Chart; Assessment of Total Body Surface Area (TBSA) and Burn Distribution; Resuscitation Fluids (Refer Appendix 8)

n Children who have completed a full primary

immunisation course no greater than 5 years ago will

not require further immunisation.

n Individuals who have no documented history of

receiving a primary vaccination course (3 doses)

of tetanus toxoid – containing vaccines should

receive a complete primary course. Please refer to

Primary Vaccination in The Australian Immunisation

Handbook 11th Edition January 14.


S. [ED] 2005, Advanced Paediatric Life Support, The

Practical Approach. 4th edn. The burned or scalded child,

pp 199-204 BMJ Blackwell Publishing Group Limited,

Massachusetts.


Leonards.




GL2012_003.html <accessed 06/03/14>.


06/03/14>.

NSW Health Guideline GL2008_012 Burn Transfer

Guidelines - NSW Severe Burn Injury Service - 2nd

Edition http://www0.health.nsw.gov.au/policies/gl/2008/

GL2008_012.html <accessed 06/03/14>.


SECTION 8





n Altered level of consciousness

n Wheezing

n Crepitations

n Pink frothy sputum

n Tachycardia

n Respiratory or cardiac arrest

History prompts

n In diving accidents or the unconscious submersion

victim, spinal and skull fractures must be considered

n Consider

– the possibility of associated drug and or alcohol

use

– attempted self harm

– syncope or seizure as a precipitating event

– circulatory arrest

n Hyperventilation before breath holding underwater

n Duration of immersion

n Water temperature

n Time of accident, time of rescue, time of first

effective CPR

n History or evidence of traumas


Position

Sit upright depending on clinical condition


Position supine if C – spine injury is suspected


If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration




Drowning






SpO2

Wheeze

If patient cannot inhale adequately to use an MDI and spacer and requires oxygen

Auscultation




If SpO2 falls below 94% with O2 consult MO

If wheeze present give inhaled Salbutamol:

Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer stat; Child greater than 20kg; 12 puffs Salbutamol 100 micrograms MDI + spacer stat

Child less than 20kg; 2.5 mg Salbutamol nebule stat;

Child greater than 20kg; 5 mg Salbutamol nebule stat. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min

Consider risk of pneumothorax, especially if rapid ascent from a significant depth



Capillary refill

Blood pressure

Cardiac Monitor

Colour

Remove wet clothing – cover with blankets, (passive warming). Do NOT actively rewarm unless < 34°C

IV cannulation/IO needle insertion /pathology




BGL


Finger prick BGL



Measure and test

Pathology

Temperature

U/A

Fluid input/output

Chest x-ray

Collect blood for FBC, UEC, serum glucose, ABG/venous blood gas if available.

Avoid hypothermia

Core temperature if possible

Fluid balance chart

Nil by mouth

Consider In-dwelling catheter and hourly measures

If available

Specific treatment

Gastric distension No attempt should be made to empty the stomach by external pressure. Consider gastric decompression with an oro or nasogastric tube








Glucagon Hydrochloride

Child less than 25kg 0.5 mg

Child greater than 25kg 1 mgIM Stat

Salbutamol

Child less than 20kg; 6 puffs of 100 microgram dose = (600 micrograms)


Inhalation

MDI + Spacer

Child less than 20kg; 6 puffs stat

Child greater than 20kg; 12 puffs stat

Salbutamol

Child less than 20kg; 2.5 mg nebule


Inhalation Nebuliser with a minimum oxygen flow rate of 8 litres per minute











Health PD2013_043.






Name:

Designation:

Date:


Date:




Precautions and notesn The new definition of drowning includes both cases

of fatal and nonfatal drowning. ‘Drowning is the

process of experiencing respiratory impairment

from submersion/immersion in liquid’ (WHO

2005). Drowning outcomes are classified as death,

morbidity. WHO states that the terms wet, dry,

active, passive silent and secondary drowning

should no longer be used (WHO 2005). Therefore a

simple, comprehensive, and internationally accepted

definition of drowning has been developed.

n Hypothermia makes assessment of the circulation

difficult.

n Resuscitation attempts should continue even after

prolonged immersion.

ReferencesAdvanced Life Support Group, Advanced Paediatric

Life Support Australia and New Zealand, The Practical

Approach 5th edn.

Royal Children’s Hospital Melbourne, Clinical Practice

Guideline, Near Drowning http://www.rch.org.au/

clinicalguide/guideline_index/Near_Drowning <accessed

13/03/14>

ILCOR Advisory Statements, 2003, Recommended

Guidelines for Uniform Reporting of Data from

Drowning, The “Utstein Style.” [Online] Available: http://

circ.ahajournals.org/content/108/20/2565.full <accessed

06/03/14>.


Guidelines 3rd Edition Version 3.1 http://www0.health.

nsw.gov.au/policies/gl/2012/GL2012_003.html.

Ward M. RNSH Emergency Department Guideline,

Emergency Department Presentations with Associated

Hypothermia.

Zuckerbraun N.S and Saladino R.A 2005, Paediatric

Drowning, current management strategies for immediate

care Clinical Practice Emergency Medicine 6(1) pp 49-56.

Australasian Paediatric Endocrine Group National

Evidence-Based Clinical Care Guidelines for Type 1

Diabetes for Children, Adolescents and Adults 2011

http://www.apeg.org.au/Portals/0/guidelines1.pdf

<accessed 17/03/14>.


Leonards.

World Health Organization (WHO), Department

of Injuries and Violence Prevention World Health

Organisation, 2003, Facts about injuries: Drowning

http://www.who.int/violence_injury_prevention/

publications/other_injury/en/drowning_factsheet.

pdf?ua=1 <accessed 06/03/2014>.





SECTION 8





n Modified paediatric Glasgow Coma Score less than

14

n Correspond with either low risk, intermediate risk,

high risk scale (Refer Appendix 9)

n Loss of consciousness with a history of trauma

n Visible deformities (fracture of skull or facial bones)

n Ecchymosis around eyes or ears

n CSF leak from nose or ears

n Inequality or non-reactivity of pupil/s

n Age less than 1year regardless of signs and symptoms

n Seizure greater than1hour post injury

n Suspected fracture of skull (boggy haematoma)

n Known/suspected C-spine injury

n Full or bulging fontanelle

History prompts

n Events–high risk mechanism of injury


– headache, confusion, irritability, memory loss,

nausea, vomiting, dizziness, speech, motor and/or

visual disturbances, seizure, persisting drowsiness,

lethargy, irritability, headache or behaviour change



n Allergies


n Consider non-accidental injury


PositionPosition head up 30o unless contraindicated






SpO2






Blood pressure

Capillary refill

Cardiac monitor



15 minutely for high risk category patients


Continuous monitoring for high risk category patients

Head Injury






Low risk

Intermediate risk

High risk

Severe head injury (GCS less than 9)

BGL

Seizures


If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration.


May be discharged after medical review. Hourly observations until discharge.

Half hourly observations for 4-6 hours until GCS 15 is sustained for 2 hours, then hourly observations until discharge

Consider transfer

CT scan if acute deterioration or persisting symptoms (Refer Appendix 9)

Continuous cardiorespiratory and oxygen saturation monitoring

BP and GCS every 15-30 minutes

Urgent CT

Transfer/retrieval

Trauma call-retrieval to nearest paediatric referral centre

Finger prick BGL



Buccal Midazolam 0.3 mg/kg (maximum dose 10mg) stat and repeat (once only) after 5 minutes if required ORIM/IV/IO Midazolam 0.15mg/kg (to a maximum dose of 5mg) stat and repeat (once only) after 5 minutes if required

Measure and test

Pathology

Primary survey

Secondary survey

Neurological observations

Temperature

U/A

Fluid input/output

Pain score (1-3)

Pain score (4-6)

Pain score (7-10)

Collect blood for FBC, UEC (consider drug/alcohol blood levels)

Repeat

Commence

Monitor frequently

Protect from hypo/hyperthermia

Test for presence of blood

Fluid balance chart

Nil by mouth if decreasing level of consciousness

GCS 14 or 15 and patient not nil by mouth

Oral Paracetamol 15 mg/kg stat Single dose never to exceed 1gm and no more than 4gms in 24 hours.Oral liquid Oxycodone 0.1 mg/kg (maximum dose 5mg)

IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary to a maximum dose of 10 mg) OR Intranasal **Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms/kg)

Non pharmacological measures must be considered early-supportive and distractive techniques








Paracetamol

Precaution: Prior to administration determine recent administration of any medicines containing Paracetamol (minimum dosing interval is 4 hours).

Dose is recommended for patients of normal or average build.*15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.


Oral Stat



IM Stat


IM/IV/IOStat and repeat (once only) after 5 minutes if required


BuccalStat and repeat (once only) after 5 minutes if required


**Fentanyl1.5 microgram/kg (maximum 75 micrograms total dose)


Morphine sulphate 0.1 mg/kg IV/IOStat.(repeat once in 10 minutes if necessary to a maximum dose of 10 mg)


Specific treatment

Severe High risk

Severe head injury

Seizures

Refer for urgent CT

Trauma call

Buccal Midazolam 0.3 mg/kg (to a maximum dose of 10mg) stat and repeat (once only) after 5 minutes if required ORIM/IV/IO Midazolam 0.15mg/kg (to a maximum dose of 5mg) stat and repeat (once only) after 5 minutes if required













Health PD2013_043.






Name:

Designation:

Date:


Date:

Precautions and notesn **Intranasal Fentanyl is contraindicated in

children where a base of skull fracture is suspected or if bleeding nose

n If blood or fluid is draining from the nose or ear

suspect a fractured base of skull.

n Do NOT insert nasopharyngeal airway or nasogastric

tube in a patient suspected of having a fractured base

of skull or nasal bone fracture.

n The provision of opioid analgesia is not

contraindicated once the life-saving surgical and

neurological evaluation has been performed.

n Be cautious administering Morphine or Fentanyl if

there is an altered level of consciousness, respiratory

compromise or signs of shock. Use of sedation scores

may be beneficial in this reassessment.

n A scalp laceration or intracranial bleed can result in

significant blood loss in infants and toddlers.

n For explanation of head injury risk categories (Refer

Appendix 9)

n If suspected non-accidental injury refer to the NSW

Health PD2011_024 Infants and Children: Acute

Management of Head Injury.

n For ongoing head injury management refer to the











Leonards.


06/03/14>

National Institute for Health and Care Excellence 2014

Guideline, Head injury: Triage, assessment, investigation

and early management of head injury in children, young

people and adults http://publications.nice.org.uk/head-

injury-cg176<accessed 06/03/14>.

Royal Children’s Hospital Melbourne 2012 Sucrose (oral)

for procedural pain management in infants http://www.

rch.org.au/rchcpg/hospital_clinical_guideline_index/

Sucrose_oral_for_procedural_pain_management_in_

infants/<accessed 06/03/14>.

Dunning, J., Patrick Daly, J., Lomas, J-P., Lecky, F.,

Batchelor, J., Mackway-Jones, K. Derivation of the

children’s head injury algorithm for the prediction of

important clinical events decision rule for head injury in

children. Archives of Disease in Childhood 2006;91:885-

891.

Minor head trauma in infants and children: Evaluation.

http://www.uptodate.com/contents/minor-head-trauma-

in-infants-and-children-evaluation?source=sear&selected

Title=26%7E143. <accessed 03//04/14>



Support; December 2010


SECTION 9


Other Emergencies Medical Officer must be notified immediately For paediatrics only



n Signs of shock

n Bile stained vomiting

n Bloody stool

n Distension

n Localised tenderness to right upper or lower quadrant

of abdomen

n Inguinoscrotal pain or swelling

n Rapid onset

History prompts

n Nature of onset

n Parental concern


– nature of pain/radiation

– nausea, vomiting

– diarrhoea

– last menstrual period/symptoms of pregnancy

– urinary symptoms

– weight loss


n Immunocompromised


n Events – mechanism of injury (if trauma involved)

n Allergies






SpO2

Assist ventilation if required if required





Capillary refill

Blood pressure

Colour




Disability AVPU/GCS

BGL


Finger prick BGL



Abdominal Pain





Measure and test

Abdominal assessment

Pain score (1-3)

Pain score (4-6)

Pain score (7-10)

Pathology

Temperature

U/A (clean catch)

Fluid input/output

Look, listen feel

Oral Paracetamol 15 mg/kg stat if not nil by mouth.


Oral liquid Oxycodone 0.1 mg/kg (max dose 5mg)

IV/IO Morphine 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10 mg) OR Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) 75 micrograms total dose

Non pharmacological measures must be considered early – supportive and distractive techniques

Collect blood for FBC, UEC, (consider LFT’s, amylase, coags, group and hold)

Collect urine for culture and analysis, Urine hCG

Fluid balance chart

Specific treatment

Hydration/input

Nausea and vomiting

Nil by mouth

Record and report - fluid balance chart









Paracetamol

Precaution: Prior to administration determine recent administration of any medicines containing Paracetamol (minimum dosing interval is 4 hours).


15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.


Oral Stat



IM Stat

Oral liquid Oxycodone 0.1mg/kg (max 5mg) Oral Stat

Fentanyl1.5 microgram/kg (maximum 75 microgram total dose)


Morphine sulphate 0.1 mg/kg IV/IOStat.(repeat once in 10 minutes if necessary to a maximum dose of 10 mg)











Health PD2013_043.



immediately to ensure their early involvement

with the management and care of the patient.

Precautions and notesn Early administration of Morphine Sulphate in patients

with acute abdominal pain does not reduce the

detection rate of serious pathology but may actually

facilitate it.

n Redcurrant jelly stool is suggestive of intussusception

which is a surgical emergency.



Management of Abdominal Pain.


Management of Abdominal Pain.


06/03/14>.


Leonards.





Royal Children’s Hospital Melbourne 2012 Sucrose (oral)

for procedural pain management in infants http://www.

rch.org.au/rchcpg/hospital_clinical_guideline_index/

Sucrose_oral_for_procedural_pain_management_in_

infants/<accessed 06/03/14>.





Name:

Designation:

Date:


Date:


SECTION 9








SpO2






Capillary refill

Blood pressure

Cardiac Monitor

Colour

Access CVAD/IV Cannulation/IO needle insertion/pathology

If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give CVAD/IV/IO 0.9% Sodium Chloride 20 mL/kg bolus


Disability AVPU/GCS

BGL


Finger prick BGL

Measure and test

Pathology

Temperature

U/A (Clean catch)

Fluid input/output

Collect blood for FBC, UEC, Blood Cultures, group and hold

Per axilla (do not take rectal temperatures in

Haematology/Oncology patients)


Fluid balance chart

Specific treatment

Contact Paediatrician/Oncologist as soon as practicable.

Anticipate antibiotics as indicated in patients journal or febrile neutropenia guideline. Plan for administration of IV Antibiotics within 30 minutes.



n Haematology/Oncology patient presents with fever during treatment or ceased treatment within the last 3 months

n Aplastic anaemia or chronic neutropenian CVAD insitun Received chemotherapy within the last 6 weeks n Absolute neutrophil count less than 1.0x109/L

within the last 7 days n Hodgkin’s disease n Less than12months of agen Clinical presentation suggestive of shock

History prompts

n Recipients of bone marrow transplant in the last

12 months

n A single axillary temperature greater than or

equal to 38.50C or a temperature greater than or

equal to 380C on at least 2 occasions 1 hour apart

within a 12 hour period

n Medical history

n Treatment history

n See patient journal

n Parental concern

Febrile Neutropenia








0.9% Sodium Chloride 20 mL/kg CVAD/IV/IO Bolus

0.9% Sodium Chloride 2 mL flush CVAD/IV/IO As required





Health PD2013_043.





Precautions and notesn Administration of antibiotics within 30 minutes

is the gold standard. Urgent consultation with the treating oncology team must occur

n Child must be assessed within 15 minutes of

presentation to ED or onset of fever in the inpatient

setting.

n Child must be nursed in protective isolation.

n Fever is a common occurrence with multiple causes.

In the febrile Haematology/ Oncology patient

consider infection until proven otherwise.

n Neutropenic hosts have a decreased ability to

manifest an inflammatory response: signs and

symptoms may be subtle. Absence of fever in cancer

patients with localising signs does not mean that the

infection is controlled or insignificant.

n Do not wait 1 hour for topical local anaesthetic to

work in the febrile neutropenic child.

ReferencesSydney Children’s Hospital 2008 Clinical Standards

Practice Manual 2008, Centre for Children’s Cancer and

Blood disorders, Clinical Guidelines for the management

of the febrile Haematology/oncology patients.


Leonards.


Name:

Designation:

Date:


Date:


Activated Charcoal.......................................................89Adrenaline ...................................................................90Amiodarone Hydrochloride ..........................................91Ampicillin sodium ........................................................92Benzylpenicillin sodium ................................................93Budesonide (Pulmicort) ................................................94Ceftriaxone Sodium .....................................................95Cefotaxime Sodium .....................................................96Compound Sodium Lactate (Hartmann’s Solution) .......97Dexamethasone ...........................................................98Fentanyl .......................................................................99Glucagon Hydrochloride ............................................10010% Glucose .............................................................102Hydrocortisone sodium succinate (Solu-Cortef) ..........104Ipratropium Bromide (Atrovent) .................................105Midazolam hydrochloride...........................................106Morphine sulphate. ...................................................107Naloxone ...................................................................108Ondansetron ..............................................................109Oxycodone ................................................................110Paracetamol (oral) ......................................................111Prednisolone ..............................................................113Salbutamol sulphate (Ventolin) ...................................1140.9% Sodium Chloride ..............................................116

Formulary index


Activated charcoalDrug category: Detoxifying agents, antidotes

Drug Name Activated Charcoal

Indications/DosesPoisoning

1 g/kg oro/nasogastric stat (maximum 50 g)

Contraindications

Poisoning with; strong acid, alkali, Iron sulfate, other Iron salts, cyanides, sulfonylureas including tolbutamide, malathion, dicophane (clofenotane), Li, ethanol, methanol, ethylene glycol, hydrocarbons, lithium, iron compounds, potassium and other metallic ions, fluoride, hydrocarbons.

Unprotected airway. Decreased LOC, GI tract not intact, significant fluid, electrolyte abnormalities. Do not give repeat doses or to infants less than 1 year.

Interactions Oral medications

Pregnancy

Activated charcoal is not absorbed from the gastrointestinal tract and is not expected to pose a risk to the fetus during pregnancy. However, the cathartic effect of sorbitol may cause diarrhoea resulting in electrolyte disturbances or dehydration. Should be used during pregnancy only when necessary. The potential risk to the fetus of both the poisoning and the treatment need to be balanced against the risk of failing to detoxify the mother.

PrecautionsCentral Nervous System depression, GIT disturbances and recent surgery, children 1 to 11 years, diarrhoea may lead to electrolyte disturbance

Modified from:

MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>

Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>

Australian Injectable Drugs Handbook, Fifth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>


AdrenalineDrug Category: Parenteral adrenergic agents

Drug Name Adrenaline

Indications/Doses Anaphylactic reaction 0.01mL/kg 1:1,000 IM Stat. If symptoms not reversed, Adrenaline may be given every 5 minutes as needed.

Asthma 0.01mL/kg 1:1,000 IM Stat. If symptoms not reversed, Adrenaline may be given every 5 minutes as needed.

Cardiorespiratory Arrest (Advanced Life Support) 0.1mL/kg of 1:10,000 IV/IO every 4 minutes

Croup 0.5 mL/kg (undiluted) nebulised 1:1,000 to a maximum of 5 mL

Contraindications

Interactions

Sympathomimetics cause additive effects. Beta blockers antagonise therapeutic effects of Adrenaline; digitalis potentiates proarrhythmic effects of Adrenaline; tricyclic antidepressants; Monoamine Oxidase Inhibitors potentiate cardiovascular effects of Adrenaline; phenothiazine causes a paradoxical decrease in blood pressure.

Pregnancy

Category A

Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed. Adrenaline may delay the second stage of labour by inhibiting contractions of the uterus.

Precautions

Adverse effects include cardiac ischaemia or dysrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid haemorrhage; use with caution in hypertension, cardiovascular disease, and cerebrovascular insufficiency; phenothiazines can cause a paradoxical decrease in blood pressure comment as above

Modified from:



Australian Injectable Drugs Handbook, Fifth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>

NSW Health PD2010_053 Infants and Children: Acute Management of Croup

NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>


Amiodarone HydrochlorideDrug Category: Antiarrhythmics

Drug Name Amiodarone Hydrochloride

Indications/DosesCardiorespiratory Arrest (Advanced Life Support)

5 mg/kg/dose IV/IO (maximum 300 mg/dose) stat (Dilute with 5%Glucose)

ContraindicationsDocumented history of hypersensitivity; systemic lupus erythematosus, digitalis induced dysrhythmias, torsade de pointes, second or third degree heart block (without pacemaker) symptomatic bradycardia (without pacemaker) or sick sinus syndrome.

Interactions

Increases effect and blood levels of theophylline, quinidine, procainamide, phenytoin, methotrexate, flecanide, digoxin, cyclosporine, beta-blockers and anti coagulants; and disopyramide increases cardiotoxicity; co-administration with calcium channel blockers may cause additive effects, further decreasing myocardial contractility; cimetidine may increase amiodarone levels.

Pregnancy

Category C

Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Avoid use 3 months before and during pregnancy; may cause thyroid dysfunction and bradycardia in the fetus.

PrecautionsHypotension (most common adverse effect), bradycardia, and Atrio-Ventricular block may occur. Phlebitis is an issue. Incompatible with 0.9% Sodium Chloride. Overly rapid administration can cause hypotension.

Modified from:



Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>



Ampicillin sodiumDrug Category: Antibiotic

Drug Name Ampicillin sodium

Indications/DosesSuspected Bacterial Meningitis

Infants 0-3 months old 50 mg/kg IV/IO stat (maximum 2 g) per dose infuse slowly.

Contraindications History of hypersensitivity to beta-lactam antibiotics

Interactions Gentamicin

Pregnancy

Category A

Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed

PrecautionsSerious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics.

Modified from:




NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis


Benzylpenicillin sodiumDrug Category: Antibiotic

Drug Name Benzylpenicillin sodium

Indications/DosesSuspected Bacterial Meningitis

Infants 0-3 months old 60 mg/kg IV/IO stat (maximum 2.4 g) per dose infuse slowly.

Contraindications History of hypersensitivity reactions to beta-lactam antibiotics.

Interactions

Intravenous solutions of benzylpenicillin are physically incompatible with many other substances including certain antihistamines, some other antibiotics, metaraminol tartrate, noradrenaline acid tartrate, thiopentone sodium and phenytoin sodium, may effect glucose in urinalysis

Pregnancy

Category A


PrecautionsSerious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics.

Modified from:







Budesonide (Pulmicort)Drug Category: Corticosteroids

Drug Name Budesonide (Pulmicort)

Indications/DosesCroup

2 mgs (1mg/2mL nebules) undiluted nebulised stat

Contraindications Known history of hypersensitivity to Budesonide

Interactions Ketoconazole and Itraconazole can increase systemic exposure to budesonide. This is of limited clinical importance for short-term (one to two weeks) treatment with CYP3A inhibitors, but should be taken into consideration during long-term treatment.

Pregnancy

Category A


PrecautionsBudesonide is not indicated for rapid relief of bronchospasm. Pulmicort is, therefore, not suitable as sole therapy for the treatment of status asthmaticus or other acute exacerbations of asthma where intensive measures are required.

Modified from:






Ceftriaxone SodiumDrug Category: Antibiotic

Drug Name Ceftriaxone Sodium

Indications/DosesSuspected Bacterial meningitis

Children greater than 3 months old 50 mg/kg IV/IO stat (maximum 2 g) per dose

Contraindications Allergy to the cephalosporins

Interactions Chloramphenicol. Ceftriaxone is incompatible with calcium; do not give via calcium containing solutions i.e do not mix with Hartmann’s

Pregnancy

Category B1

Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals [1] have not shown evidence of an increased occurrence of fetal damage.

PrecautionsRenal, hepatic impairment; vitamin K synthesis; prolonged use; history of GI disease (esp colitis); pregnancy; lactation

Modified from:







Cefotaxime SodiumDrug Name Cefotaxime Sodium

Indications/DosesSuspected Bacterial meningitis

50 mg/kg IV/IO stat (maximum 2 g) per dose (slow push over 5-10 minutes).

Contraindications Known hypersensitivity to Cefotaxime or other cephalosporin antibiotics.

Interactions Gentamicin

Pregnancy

Category B1 Drugs that have been taken by only a limited number of pregnant women and women of

childbearing age, without an increase in the frequency of malformation or other direct or

indirect harmful effects on the human fetus having been observed. Studies in animals [1]

have not shown evidence of an increased occurrence of fetal damage.

Precautions Arrhythmia.

Modified from:






Compound Sodium Lactate (Hartmann’s Solution)Drug Category: Intravenous Fluids

Drug Name Compound Sodium Lactate (Hartmann’s Solution)

Indications/DosesBurns

IV/IO as per Parkland formula

ContraindicationsClinical states adversely affected by sodium, severe impairment of renal function, lactic acidosis, congestive cardiac failure

Interactions Administration via the same line as blood products may lead to coagulation. Concomitant administration with potassium sparing diuretics and angiotensin (ACE inhibitors) may cause severe hyperkalaemia.

Pregnancy

Category C

Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.

Precautions Sodium retention, Pregnancy, Corticosteroids.

Modified from:





DexamethasoneDrug Category: Systemic Corticosteroids

Drug Name Dexamethasone

Indications/Doses Croup 0.3 mg/kg oral stat

Suspected Bacterial Meningitis in children greater than 3 months of age0.15 mg/kg IV/IO stat

Contraindications Uncontrolled infections. Known hypersensitivity to dexamethasone

Interactions Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Oral contraception.

Pregnancy

Category A


Precautions Live vaccines, cirrhosis or hypothyroidism may enhance the effect of corticosteriods

Modified from:







FentanylDrug Name Fentanyl

Indications/Doses Recognition of a sick child 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)

Burns 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)

Head injury 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)

Abdominal pain 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)

Contraindications

Known hypersensitivity to opioid analgesics. CNS depression. Raised intra cranial pressure,

concomitant monoamine oxidase inhibitors. Children less than 1 year. Bleeding from the

nose.

Interactions CNS depressants. Monoamine oxidase inhibitors

Pregnancy

Category C

Drugs that, owing to their pharmacological effects, have caused or may be suspected of

causing harmful effects on the human fetus or neonate without causing malformations.

These effects may be reversible.

Precautions Respiratory depression, impaired renal or hepatic function

Modified from:



Australian Injectable Drugs Handbook, Fourth Edition

http://aidh.hcn.com.au/index.php <accessed 06/03/14>

Bezzina, A. 2006. Intranasal Medication Administration Guidelines: Use of Mucosal Atomiser Device.

Wollongong Hospital, Wollongong.


Glucagon HydrochlorideDrug Category: Glucose-elevating Agents

Drug Name Glucagon Hydrochloride

Indications/DosesRecognition of the Sick Baby and ChildIf IV access unavailable:n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/Ln Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

SeizuresIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

Unconscious patient If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

Gastroenteritis If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

Shock If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

Suspected bacterial meningitis If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

PoisoningIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

DrowningIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

Head injuryIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

Abdominal pain If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L

Contraindications Documented hypersensitivity, Phaeochromocytoma, insulinoma, glucagonoma

Interactions May enhance the effects of anticoagulants

Pregnancy

Category B2

Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals[1] are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage


Modified from:




NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis

NSW Health PD2011_038 Recognition of a Sick Baby or Child in the Emergency Department


NSW Health PD2013_053 Infants and Children: Acute Management of Abdominal Pain

NSW Health PD2009_065 Infants and Children: Acute Management of Seizures

NSW Health PD2011_024 Infants and Children: Acute Management of Head Injury


Drug Name Glucagon Hydrochloride

PrecautionsGlucagon will have little or no effect if patient is fasting or suffering from adrenal insufficiency, chronic hypoglycaemia or alcohol induced hypoglycaemia.


10% GlucoseDrug Category: Glucose-Elevating Agents

Drug Name 10% Glucose

Indications/Doses Seizures 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Unconscious patient 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Gastroenteritis 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Shock 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Suspected bacterial meningitis 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Poisoning 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Drowning 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Head injury 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Abdominal pain 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L

Contraindications Avoid in dehydrated patients in a diabetic (hyperglycaemic) coma

Interactions Do not administer simultaneously with blood products via the same infusion line

Pregnancy

Category C

Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible

Precautions

May cause nausea, monitor fluid balance, electrolyte concentrations, and acid-base balance closely. Glucose administration may produce vitamin B-complex deficiency. Thrombophlebitis.

Fluid and/or solute overloading, serum electrolyte disturbance, over hydration, congested states, pulmonary oedema


Modified from:











Australian Resuscitation Council, Guideline 12.4, Medications & Fluids in Paediatric Advanced Life Support; December 2010


Hydrocortisone sodium succinateDrug Category: Systemic Adrenal steroid hormones

Drug Name Hydrocortisone sodium succinate (Solu-Cortef)

Indications/DosesSevere and life-threatening asthma

4 mg/kg IV/IO stat

ContraindicationsKnown hypersensitivity, systemic fungal infections; premature infants; live attenuated vaccines.

Interactions

Thiazide diuretics may increase the risk of hyperglycaemia caused by hydrocortisone. Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Decreases the efficiency of the following medications; Aspirin, Insulin, oral anti-diabetic medication, oral contraceptive pill

Pregnancy

Category C

Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible

Precautions Cirrhosis or hypothyroidism may enhance the effect of corticosteroids

Modified from:




NSW Health PD2012_014 Infants and Children – Acute Management of Asthma



Ipratropium Bromide Drug Category: Bronchodilator

Drug Name Ipratropium Bromide (Atrovent)

Indications/DosesSevere and life-threatening asthma

Child less than 20kg; 250 micrograms 3 x 20 minutely via nebuliser. Child greater than 20kg; 500 micrograms 3 x 20 minutely via nebuliser

Contraindications Documented hypersensitivity to ipratropium

Interactions

Drugs with anticholinergic properties may increase toxicity. Cardiovascular effects may increase with Monoamine Oxidase Inhibitors, tricyclic antidepressants and sympathomimetic agents. Disodium cromoglycate inhalation solutions containing benzalkonium chloride. Beta-Adrenergics and xanthine

Pregnancy

Category B1

Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage.

PrecautionsCaution in glaucoma (protect eyes if nebuliser in use), hyperthyroidism, diabetes mellitus, cardiovascular disorders and cystic fibrosis. May cause bronchoconstriction in some patients with hyper reactive airways

Modified from:







Midazolam Drug Category: Sedatives, hypnotics

Drug Name Midazolam hydrochloride

Indications/Doses Seizuresn 0.3 mg/kg (to a maximum dose of 10mg) buccal stat and repeat after 5 minutes if required (once

only). n 0.15mg/kg IM/IV/IO stat (to a maximum of 5mg) and repeat after 5 minutes if required (once only).

Head injury (if seizures)n 0.3 mg/kg (to a maximum dose of 10mg) buccal stat and repeat after 5 minutes if required (once


Suspected bacterial meningitis (if seizures)n 0.3 mg/kg buccal (to a maximum dose of 10mg) stat and repeat after 5 minutes if required (once


Poisoning (if seizures)n 0.3 mg/kg (to a maximum dose of 10mg) buccal stat and repeat after 5 minutes if required (once

only). n 0.15mg/kg IM/IV/IO stat (to a maximum of 5mg) and repeat after 5 minutes if required (once

only).

Contraindications Documented hypersensitivity; pre-existing hypotension

Interactions

The sedative effects of neuroleptic, tranquillizers, antidepressants, sleep inducing drugs, analgesics, anaesthetics, antipsychotics, anxiolytics, antiepileptic drugs and sedative antihistamines may be enhanced by the administration of midazolam. Pre medication, alcohol and barbiturates may increase the sedative effect of midazolam.

Pregnancy

Category C


PrecautionsRespiratory depression, apnoea, cardiovascular depression and cardiac arrest. Pharmacokinetics in children has not been established in children less than 8 years and may differ from adults.

Modified from:









Morphine SulphateDrug Category: Analgesics

Drug Name Morphine sulphate.

Indications/Doses Recognition of a sick child 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)

Burns (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)

Head injury (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)

Abdominal pain (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)

Contraindications Documented hypersensitivity; severe respiratory disease, coma.

Interactions Respiratory depressant and sedative effects may be additive toxicity in the presence of other medication.

Pregnancy

Category C


PrecautionsCaution in hypotension, nausea, vomiting, supraventricular tachycardia; has vagolytic action and may increase ventricular response rate. Caution in patients with severe renal, hepatic dysfunction, may cause excessive sedation or coma.

Modified from:






Naloxone Drug Category: Sedatives, hypnotics

Drug Name Naloxone

Indications/Doses Unconscious patient 0.1mg/kg/dose (maximum 2 mg) IV, IO, IM, Sub Cutaneous, repeat as necessary

Poisoning 0.1mg/kg/dose (maximum 2 mg) IV, IO, IM, Sub Cutaneous, repeat as necessary

Contraindications Documented hypersensitivity.

Interactions Decreases analgesic effects of opioids. Effects of partial agonists eg buprenorphine, tramadol only partially reversed by naloxone

Pregnancy

Category B1

Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage

Precautions

Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence; if patients do not respond to multiple doses of naloxone, consider alternative cause of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. Be cautious of administration to neonates whose mothers are known or suspected to be addicted to opioids, as it may cause an abrupt and complete reversal of opioid effect and acute withdrawal syndrome

Modified from:





Royal Children’s Hospital Melbourne Paediatric Pharmacopoeia http://pharmacopoeia.hcn.com.au/?acc=36422<accessed 06/03/14>


OndansetronDrug Category: Antiemetics

Drug Name Ondansetron

Indications/DosesGastroenteritis

0.2 mg/kg oral stat (one dose only) (Maximum dose 8 mg)

Contraindications Hypersensitivity to any component of the preparation

Interactions May reduce the analgesic effect of tramadol. phenytoin, carbamazepine and rifampicin increase the oral clearance time and reduces the blood concentration of Ondansetron. Avoid the concomitant use of drugs that prolong the QT interval.

Pregnancy

Category B1

Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage.

Precautions Subacute intestinal obstruction, not recommended in breast feeding

Modified from:






Oxycodone Drug Category: Narcotic analgesic

Drug Name Oxycodone

Indications/Doses Recognition of a sick child

Oral Oxycodone 0.1 mg/kg (maximum 5 mg) stat

Burns

Oral Oxycodone 0.1 mg/kg (maximum 5 mg) statHead injuryOral Oxycodone 0.1 mg/kg (maximum 5 mg) stat

Abdominal pain

Oral Oxycodone 0.1 mg/kg (maximum 5 mg) stat

ContraindicationsKnown hypersensitivity to opioid analgesics. CNS depression. Respiratory Depression, raised intra cranial pressure, concomitant monoamine oxidase inhibitors. Children less than 1 year old.

Interactions CNS depressants. Monoamine oxidase inhibitors

Pregnancy

Category C

Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.

Pregnancy Respiratory depression, hypotension; hypovolaemia; impaired renal or hepatic function

Precautions

Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence; if patients do not respond to multiple doses of naloxone, consider alternative cause of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. Be cautious of administration to neonates whose mothers are known or suspected to be addicted to opioids, as it may cause an abrupt and complete reversal of opioid effect and acute withdrawal syndrome

Modified from:




Paracetamol (oral) Drug Category: Analgesic and antipyretic

Drug Name Paracetamol (oral)

Indications/Doses Recognition of the sick childDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.


BurnsDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.


Head injuryDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.


Abdominal painDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.


Contraindications Documented hypersensitivity. Patient is nil orally

Interactions Anticoagulants; drugs affecting gastric emptying; hepatic enzyme inducers including alcohol, anticonvulsants

Pregnancy

Category A

Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.

PrecautionsPrior to administration determine recent administration of any medicines containing Paracetamol. Caution in severe renal or hepatic dysfunction


Paracetamol (oral) continued

Drug Category: Analgesic and antipyretic

Modified from:







NSW Health PD2009_009 Paracetamol Use


PrednisoloneDrug Category: Systemic corticosteroid

Drug Name Prednisolone

Indications/Doses Asthma

Mild 1 mg/kg oral stat-if prolonged episode or a history of severe asthma

Moderate 1 mg/kg oral stat

Severe 1 mg/kg oral stat-if tolerated orally

Croup 1 mg/kg oral stat-if tolerated orally and Dexamethasone unavailable

Contraindications Documented hypersensitivity to Prednisone, Tuberculosis, systemic fungal infection

Interactions Live vaccines (should not use); alcohol; antacids; antidiabetics; diuretics; hepatic enzyme

inducers eg phenytoin and rifampicin; cyclosporin; ketoconazole; anticoagulants.

Pregnancy

Category A


Precautions Patients who are immunosuppressed, live vaccines

Modified from:





NSW Health PD2012_056 Infants and Children: Acute Management of Asthma



Salbutamol sulphate (Ventolin) Drug Category: Bronchodilator

Drug Name Salbutamol sulphate (Ventolin)

Indications/Doses

Anaphylactic reaction

Metered dose inhaler + spacer; n Child less than 20kg; 6 puffs of 100 microgram Metered Dose Inhaler + spacer

stat if wheeze presentn Child greater than 20kg; 12 puffs of 100 microgram Metered Dose Inhaler + spacer

stat if wheeze present

Nebulisern Child less than 20kg; 2.5 mg nebule stat (if patients cannot inhale adequately to use an MDI

and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule stat (if patients cannot inhale adequately to use an MDI

and spacer or requires oxygen therapy)

Asthma

Mild - Metered Dose Inhaler + spacer n Child less than 20kg 6 puffs of 100 microgram Metered Dose Inhaler + spacer stat n Child greater than 20kg 12 puffs of 100 microgram Metered Dose Inhaler + spacer stat

ModerateMetered Dose Inhaler + spacer n Child less than 20kg; 6 puffs of 100 micrograms Metered Dose Inhaler + spacer

repeat every 20 minutes n Child greater than 20kg; 12 puffs of 100 micrograms Metered Dose Inhaler + spacer

repeat every 20 minutes

Nebulisern Child less than 20kg; 2.5 mg nebule repeat every 20 minutes (if patients cannot inhale

adequately to use an MDI and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule repeat every 20 minutes (if patients cannot inhale

adequately to use an MDI and spacer or require oxygen therapy)

Severe/life-threateningContinuous nebulisern Load 4 mL of undiluted 0.5% Salbutamol Solution into nebuliser and

top up as required

Drowning n Child less than 20kg; 6 puffs of 100 microgram Metered Dose Inhaler + spacer

stat if wheeze presentn Child greater than 20kg; 12 puffs of 100 microgram Metered Dose Inhaler + spacer

stat if wheeze present

Nebulisern Child less than 20kg; 2.5 mg nebule stat (if patients cannot inhale adequately to use an MDI

and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule stat (if patients cannot inhale adequately to use an MDI

and spacer or require oxygen therapy)


Salbutamol sulphate (Ventolin) continued

Drug Category: Bronchodilator

Drug Name Salbutamol sulphate (Ventolin)

Contraindications History of hypersensitivity; Can cause paradoxical bronchospasm; allergic reactions

Interactions May increase cardiovascular effects of other sympathomimetics

Pregnancy

Category A


PrecautionsMay cause tachycardia, nausea and tremors. Caution in patients with co-existing cardiovascular disease. Hypokalaemia can occur with high dose particularly in combination with other potassium depleting medications.

Modified from:







0.9% Sodium ChlorideDrug Category: Intravenous Fluids

Drug Name 0.9% Sodium Chloride

Indications/Doses IV/IO Cannula Flush - 2mL Medication dilution - as per medication protocol. Indications/Doses For the following conditions:

Recognition of a sick child IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Anaphylactic reaction IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Seizures IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Unconscious patient IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Cardiorespiratory arrest - Advanced Life Support IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Shock IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Gastroenteritis IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Suspected bacterial meningitis IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Poisoning IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Snake/spider bite IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Burns IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Drowning IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Head injury IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)


0.9% Sodium Chloride continued

Drug Category: Intravenous Fluids

Drug Name 0.9% Sodium Chloride

Indications/Doses continued

Abdominal pain IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Febrile neutropaenia CVAD/IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)

Contraindications

Interactions Amiodarone

Pregnancy

Category A


PrecautionsCongestive cardiac failure, severe renal impairment, sodium retention. Do not use if the solution is not clear.

Modified from:








NSW Health PD2010_063 Infants and Children: Acute Management Fever




Ideally the following equipment should be stored on a freely moving mobile trolley with IV pole

It is recommended that Paediatric contents are stored in a separate drawer

Essential Paediatric EquipmentBroselow™ Tape

Infant Scales

Note: The Paediatric requirements listed below are in addition to the minimum adult requirements as listed in the

NSW Rural Adult Emergency Clinical Guidelines (appendix 1) Please refer to the adult guidelines for rural and remote

emergency trolley – minimum requirements.

AirwayETT 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6mm uncuffed

LaryngoscopeSmall handle with batteries x 2

Blade – straight size 1, curved size 1 & 2

Oropharyngeal rigid sucker Small (paediatric size)

Oropharyngeal airway 000, 00, 1

Introducer Small and medium paediatric bougie or introducing stylet (6Fg, 10Fg)

Tape Zinc oxide (brown) 1 inch roll

Other Magills forceps infant (18cm) and child (20cm)

Breathing

Self-inflating resuscitation bags with reservoir bag, pressure relieving valve, and oxygen tubing

Preterm (240mL)

Paediatric (450mL)

Clear resuscitator masks Sizes 00, 0, 1, 2

Y Suction catheters Sizes 6Fg, 8Fg, 10Fg

Rural and Remote Emergency Trolley – Minimum Paediatric Requirements

APPENDIX 1


Circulation

Needleless T piece extension tubing

X 3 paediatric size

Indwelling urinary catheter 6Fg, 8Fg, 10Fg, 12Fg

Arm boards Paediatric

Adhesive tapes Brown tape ½ inch, or paediatric IV site dressing

Intraosseous Manual or battery operated insertion device with paediatric and adult size needles

OtherECG dots (Paediatric)

Defib pads x 2 packets (Paediatric)

NG tube (size 8Fg, 10Fg, 12Fg)

Paediatric Advanced Life Support algorithm

ReferenceNSW Health PD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3 Paediatric Medicine and Surgery, June 2010

Resuscitation Standards for Clinical Practice and Education Provision Australian Resuscitation Council, Australian Council of Critical Care Nurses http://www.resus.org.au/policy/documents/clinical_standards_for_resuscitation_march08.pdf <accessed 06/03/14>


Airway and breathingNasopharyngeal airway Sizes 6, 7

Cervical collar Laerdal stiffneck, Pedi-select collar, Baby ‘No-neck’

Oxygen mask (Hudson) Paediatric

Nasal prongs Infant, paediatric

Non – rebreather mask Paediatric

Stethoscope Paediatric

Pulse oximeter with pleth (waveform)

Sensors (probes): infant finger/ear/ finger/forehead sensor

Spacer and mask for metered dose inhaler

Paediatric size

Nebuliser Mask Paediatric

Circulation

Amethocaine 4% and/or EMLA gel

For cannulation

Tourniquet Paediatric friendly

Pathology tubes Paediatric tubes and blood culture bottles

Intravenous solutions 0.9% Sodium Chloride + 5.0% Glucose, 0.45% Sodium Chloride + 5.0% Glucose

Glucometer

DisabilityGlasgow Coma Scale Modified (paediatric)

Additional Recommended Paediatric Equipment

APPENDIX 2


Environment, Comfort & SafetyThermometer Axilla Probe, paediatric tympanic, flexible rectal probe (optional)

Heat source Overhead heater or other heat source (optional)

Distraction activities box

Oral use only medication syringes

1mL, 3mL, 5mL, 10mL

Cot / bed with rails in situ Bunny rugs, cot sheet & blankets

Infant formula Disposable bottle & teat, feeding cup

Gastrolyte, Hydrolyte or similar

Ice blocks and solution

Trial of oral fluids chart

Kitchen scales (1g increments)

To weigh nappies

Disposable nappies

ReferenceNSW Health PD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3 Paediatric Medicine and Surgery, June 2010

Resuscitation Standards for Clinical Practice and Education Provision Australian Resuscitation Council, Australian Council of Critical Care Nurses http://www.resus.org.au/policy/documents/clinical_standards_for_resuscitation_march08.pdf <accessed 06/03/14>


The child’s oxygenation status should be assessed in a

well-lit room by assessing clinical signs and symptoms,

and recording baseline observations. Temporary exposure

of the child, including the head, thorax and abdomen is

an essential part of respiratory assessment.

Assessment of child presenting with rapid or laboured breathing.n Increased work of breathing [tracheal tug/costal or

sternal recession/ see-saw breathing]

Effort mostly on inspiration or expiration?

– inspiration-upper airway obstruction likely

– expiration-lower airway obstruction likely

n Causes of inspiratory obstruction

– croup, foreign body aspiration, bacterial tracheitis,

tonsillar abscess, epiglottitis and

diphtheria (rare in the immunised child in Australia)

n Causes of expiratory obstruction

– wheeze +/- crackles (asthma, bronchiolitis, lower

respiratory tract infection, anaphylaxis, foreign

body).

n Rapid breathing (without increased work of breathing)

– anxiety, fever, pain, pneumonia, severe anaemia

and metabolic acidosis, including starvation, sepsis,

diabetic ketoacidosis, and salbutamol overdose,

heart failure.

Management of the tachypnoeic or dyspnoeic child:n Hypoxia – treat with high flow inhaled O2. It should

be suspected particularly in the agitated, combative

or ‘naughty’ child (particularly if out of character), and

confirmed with oximetry or capillary blood gas (see below)

n Hypercapnoea may be increasingly recognised with

the use of end-tidal CO2 monitors, and treated with

continuous positive airways pressure, for example in

infants with a Neopuff®.

n Care should be taken to avoid over-extension or

flexion of the child’s neck to avoid increasing upper

airways obstruction. Often the best position for a

conscious child is sitting on a carer’s lap, to try to

minimise distress, and O2 consumption.

n Wheezing will often respond to salbutamol in the

child over the age of 12 months – see asthma

guideline for dosage. Bronchodilators are less likely

to be helpful before the first birthday, and may

occasionally make matters worse.

Monitoring oxygen levels and oxygen delivery n Oximetry probe of the correct size should be

positioned appropriately and baseline observations

recorded in room air.

n An oximetry reading greater than 94% in room air is

desirable.

n Oximetry readings less than 94% with or without

clinical signs and symptoms of respiratory distress or

hypoxia, indicate the need for supplementary oxygen

in the acutely ill child.

n Not all children with increased oxygen requirements

exhibit respiratory symptoms, eg the shocked child,

drug overdoses, seizures, trauma and dehydration.

n All nebulised medication should be administered via

wall or cylinder oxygen to maximise effectiveness,

irrespective of the child’s needs for continuous

supplementary oxygen between medications.

n When receiving oxygen therapy the child should be

continuously monitored by use of oximetry for 2 hours

initially. A minimum of hourly spot oximetry readings

should be attended in conjunction with hourly pulse,

respirations and assessment of respiratory status, ie

chest recession, tracheal tug, nasal flaring, arousal,

activity level and level of consciousness.

n Full explanation should be given to both the child

and carer regarding the importance of continuous

monitoring and observation.

n Any increase in oxygen demands or deterioration

in the child’s condition should be reported to the

Medical Officer immediately.

ReferenceHNE Health (2005) ‘Paediatric Oxygen Therapy’ Hunter

Emergency Services Policy, Hunter Area Emergency

Guidelines Committee.

Mackway-Jones, K. Molyneuz, E., Phillips, B. & Wieteska

[Eds]. (2005) Advanced Paediatric Life Support - The

practical approach 4th edn. BMJ Books, London

Aehlert, B. (2007) Mosbsy comprehensive pediatric

emergency care (2nd. ed.) Elsevier: St Louis. Chapter 4

Respiatory Distress and Failure p 87-142 & Chapter 5

Respiratory Interventions p 143-217

Paediatric Respiratory Assessment

APPENDIX 3


The AVPU scale is a useful method of rapidly measuring

the level of consciousness.

A ALERTV responds to VOICEP responds to PAINU UNRESPONSIVE

If there are any concerns regarding the child’s level of

consciousness the modified Glasgow Coma Scale should

be used.

MODIFIED GLASGOW COMA SCALE

Best Eye Opening ResponseSpontaneous 4

To voice 3

To pain 2

Nil 1

Best Verbal ResponseAppropriate conversation Infant-appropriate words/social smile/fixes and follows

5

Confused but recognizable speech Infant – cries but is consolable

4

Some words, inappropriate mumble Infant – Persistently irritable

3

Groans Infant – Restless, agitated

2

Nil 1

Best Motor ResponseObeys Commands 6

Localises pain 5

Withdraws to pain 4

Flexor/decorticate response to pain 3

Extensor/decerebrate response to pain 2

Flaccid paralysis 1

Total = Eye opening + Best verbal response + Best motor response = 3 - 15

A GCS Score less than < 9 requires urgent airway management.

A GCS Score less than <14 requires immediate medical attention.



Mackway-Jones, K. Molyneuz, E., Phillips, B. & Wieteska

[Eds]. (2005) Advanced Paediatric Life Support –

The practical approach 4th edn. BMJ Books, London.

AVPU and the Modified Paediatric Glasgow Coma Scale

APPENDIX 4


This is a systematic approach used for patient assessment

and treatment when the patient has life-threatening

conditions or injuries. The Primary/Secondary Survey

emphasises the importance of prioritising and instigating

the correct sequence of care.

Noten Infants and young children are prone to hypothermia.

Although it is important to expose children for

assessment, it is necessary to provide external heating

like warm blankets/towels or overhead heating

during this procedure.

n Hypothermia in the infant and young child can hasten

or lead to more serious illness.

The Primary Survey consists of a rapid patient

assessment and treatment of any immediately life-

threatening conditions.

This will involve simultaneous assessment and treatment

of the following:

n Airway with cervical spine controln Breathing and ventilationn Circulation and haemorrhage control n Disability – neurologicaln Exposure (undress the patient).

Secondary Survey is a systematic assessment of

the patient from head to toe, so that each body

system is reviewed. It includes patient history

and commencement of relevant investigations.

Using a systematic approach:

n Head and Facen Neckn Chestn Abdomenn Pelvis and Genitalian Upper and Lower Limbsn Backn Vital signsn History – Including mechanism of injury past

and present medical history and relevant family history

n Investigationsn Documentation.

Throughout the Secondary Survey the patient requires

continuous monitoring and assessment, if there is any

deterioration, the Primary Survey should be repeated.

ReferenceSkinner. D, Driscoll. P, Earlam. R. (2000). ABC of Major

Trauma. BMJ. 3rd Edition. Cambridge University Press.

Primary and Secondary Survey

APPENDIX 5


ReferenceNSW Health 2013, GL2014_005 Snake and Spiderbite Clinical Management Guidelines Third Edition.

Patient surname Date of bite Time of bite

Forename Date of birth Type of snake

MRN number Number of bites

DateTimeTime after biteGeneral

Pulse rateBlood pressureTemperature

Specific

Regional lymph node tendernessLocal bite site painBite site swellingHeadacheNauseaVomitingAbdominal pain

Paralytic Signs

PtosisOpthalmoplegiaFixed dilated pupilsDysarthriaDysphalgiaTongue protrusionLimb weaknessRespiratory weaknessPeak flow rate

Myolytic Signs

Muscle painMyoglobinuria

Coagulopathy Signs

Persistant blood oozeHaematuriaActive bleeding

Renal

Urine outputLaboratory Key Tests

INR/prothrombin time aPTTFibrinogenXDP/FDPPlatelet countCKCreatinineUreaK+

Antivenom

Type/amount/timeReaction

Snakebite Observation Chart

APPENDIX 6


Effective pain management in the paediatric patient

begins with an accurate, developmentally appropriate

assessment of pain. This includes parent and/or child self

reports (eg pain ladder, faces scales) and the assessment

of behaviour eg crying, whimpering, lack of interest

in play and surroundings, irritability, general activity

and physical parameters eg tachycardia, tachypnoea,

sweating.

It is desirable that infants and children are not separated

from their parents or primary care giver during clinical

assessment or whilst undergoing invasive procedures

such as IV cannulation, NG tube insertion.

Remember to incorporate supportive and distractive

techniques into all pain management strategies.

These include utilising games, puzzles, familiar toys,

music, video/TV viewing, reading, cuddling, support from

parents and pacifiers (dummies, security object etc).

The following list indicates behaviours that would

prompt you to undertake a more formal pain assessment.

n Limited movement

n Distressed/irritable/grimacing

n Obvious deformity

n Guarding or posturing

n Inconsolable

The age and development of the infant or child will

influence how they might behave when in pain. The

following table provides a guide to age related pain

behaviours.

Age Behaviours

Infants

Young infant – rigid, thrashing, reflex withdrawalLoud cryFacial expressionKnees drawn to chestIrritableStimuli/responseOlder infant-physical resistance

Young Child

Scream/cryThrashingUncooperative (need restraining)Cling to parentSeek comfortRestless/irritable

School Age

As previous plusStalling behaviors “wait until”, “in a minute”Muscle rigidityClenched fistGritted teethClosed eyesFrown

Adolescent

Less vocal protestLess motor activityMore verbal communication –“it hurts”Increased muscle tensionBody control

Paediatric Pain Assessment

APPENDIX 7


NoteRepeated pain assessment is essential.

Pain Assessment Tools

Infant - 7 years: FLACC Behavioural Assessment Tool (report of observer).

Scoring: Add the score for each category to give a total pain score out of 10. Document on appropriate chart.

Reference: Hunter New England Four Hourly Graphic Chart HNEMR11

Children > 7 yo: Visual Analogue Scale (VAS) or Verbal Rating Scale (VRS) (report of patient).

Document score on appropriate chart.

CATEGORIESSCORING

0 1 2

Face No particular expression or smile.

Occasional grimace or frown, withdrawn, disinterested.

Frequent to constant quivering chin, clenched jaw.

Legs Normal position or relaxed. Uneasy, restless, tense. Kicking, or legs drawn up.

Activity Lying quietly, normal position, moves easily.

Squirming, shifting back and forth, tense. Arched, rigid or jerking.

Cry No cry (asleep or awake).

Moans or whimpers, occasional complaint.

Crying steadily, screams or sobs, frequent complaints.

Consolability Content, relaxed.Reassured by occasional touching, hugging or being talked to, distractible.

Difficult to console or comfort.

Reference: (Merkel et al. 1997).

Instructions to the child: “These faces show how much something can hurt. From no pain (indicate face on the left),

the faces show more and more pain, to the face that shows very much pain (indicate the face on the right). Point to the

face that shows how much you hurt”. Scoring: Score the selected face 0, 2, 4, 6, 8 or 10 counting from left to right.

The scale is intended to measure how patients feel inside, not how their face looks. Document on appropriate chart.

Hicks et al. pain 2001

Children > 3 yo: Faces Pain Scale – Revised (report of patient)

NO PAIN WORST PAINMODERATE PAIN

0 1 2 3 4 5 6 7 8 9 10


GuidelineTitle: Burn Transfer Guidelines – NSW Severe Burn Injury Service – Second Edition

page 14 of 21

NSW Severe Burn Injury Service Burn Transfer Flow Chart Medical Retrieval Referral Minor Burns

Meets Medical Retrieval • Intubated patients • Head and neck burns • Burns>10% in children or >20% in

adults • Burns with associated inhalation • Burns with significant co-morbidities

e.g. trauma • Electrical/chemical injury • Significant pre-existing medical disorder • Circumferential to limbs or chest

compromising circulation or respiration

Needs referral but not medical retrieval • Burns >5% children or >10% adults• Burns to hands, feet, face,

genitalia, perineum and major joints• Burns with a pre-existing medical

condition eg diabetes • Children with suspected non-

accidental injury & adults with assault, self inflicted injury

• Pregnancy ( 2nd 3rd trimester RNSH)

• Spinal cord injury -RNSH • Extremes of ages

Minor burns are treated in consultation with the referring doctor as an outpatient; either locally (at original place of care) or on referral to an ambulatory burns clinic for assessment.

Contact NETS for children AMRS Adults up to16th birthday 1800 65 0004 1300 36 2500

The Children’s Hospital at Westmead Catchment Area: All children’s referrals to the age of 16 in all areas of NSW

Concord Repatriation General Hospital Catchment Area: South Eastern Sydney/Illawarra, Sydney West, Sydney South West, Greater Southern٭, Greater Western٭, ACT

Catchment Area: North Sydney/Central Coast, Hunter/New England, North Coast٭ ٭refer to Burns Units in adjoining states

Contact Burn Ambulatory CareCHW: 9845 1850 (b/h) 9845 1114 (a/h) CRGH: 9767 7775 (b/h) 9767 7776 (a/h) RNSH: 9926 7988 (b/h) 9926 8941 (a/h)

Set up conference call with receiving ICU/Burn Unit, facilitates communication with primary referral site

CHW ICU 9845 1171 CRGH ICU 9767 6404 RNSH ICU 9926 8640

CHW: Surgical Registrar on-call notified Tel. 9845 0000 then page Surgical Registrar CRGH: Burns Registrar on-call notified Tel 9767 5000 then page Burns Registrar RNSH: Burns Registrar on-call notified Tel 9926 7111 then page Burns Registrar

Not referred to service

AMRS/NETS will coordinate transfer between primary hospital and the receiving hospital

The on call registrar will offer advice and arrange a bed in liaison with Bed Management and the Burns Unit. They are responsible for receiving the patient. The referrer will make the ambulance booking.

Referred to service

Any issues or problems with these processes or if further advice is required, The NSW Severe Burn Injury Service Manager can be contacted on 02 9926 5641.

Royal North Shore HospitalCatchment Area: NorthSydney/Central Coast, Hunter/NewEngland, North Coast

Hospitals near state border areas mayrefer to Burns Units in adjoining states

Reference NSW Health. 2008. Burns Transfer Guidelines – NSW Severe Burns Injury service. 2nd edn. (GL2008_012).

Burn Injury Referral/Retrieval Check List

APPENDIX 8



page 15 of 21

Appendix 1: Burn Patient Emergency Assessment & Management Chart

To be used for patients requiring transfer to a specialised burn unit.

Place patient label here or: MRN: Name: D.O.B. Sex: AMO: Ward:

Presentation Date: ____________ Time: ___________ Trauma Call: � YES � NO

Burn Date: _____________ Burn Time: ___________ Triage Category: ___________

Weight (kgs): _____________ Doctor: _______________________________________

Burn Mechanism: ________________________________________________________________ ________________________________________________________________________________ First Aid given (as defined below): � NO � YES Specify ___________________________

FIRST AID • At least 20 mins cold running water (8 - 25°C). Effective up to 3 hours post injury.• Protect against hypothermia, keep rest of body warm. Cease cooling if body temp <35°C

PRIMARY SURVEY Airway � Normal � Neck/facial burns with swelling � Burn in confined space � Intubated � Hoarse Voice / Stridor / Cough / Carbonaceous material – mouth / nose / sputum C Spine � Normal � At Risk � Immobilised Breathing RR ___ Air Entry ______ O2 sats ___ FiO2 ___ Effort - normal/shallow/increased Burn circumferential around chest / torso / neck? � Yes � No Circulation HR _____________ BP ________ / _________ Central capillary refill � 1-2 seconds � > 2 seconds � Absent Any circumferential burns? � No � Yes, specify area/s _____________________ Peripheral capillary refill � 1-2 seconds � > 2 seconds � Absent Disability Level of consciousness (AVPU): __________ Pupils: (L) ___ mm (R) ___ mm AVPU = A – Alert, V - Response to Vocal stimuli, P - Responds to Painful stimuli, U - UnresponsiveEnvironment Patient Temp. ____°C @ _____________ (time/date) Temp route ___________ Remove clothing and jewellery Keep unburnt areas warm Warm IV fluids � No � Yes �N/A Warm blankets � No � Yes � N/AAssess % Total Body Surface Area (TBSA) burnt using Rule of Nines (see page 2) TBSA body chart completed? � No � Yes By whom? _______________

Fluid Resuscitation (see page 3 for specific fluid calculations) � Not required Large bore IVCs (2 for >20%, 1 for >10%) or CVL inserted? � No � Yes Bloods taken: � FBC � EUC � BSL � Coags � COHb � Drug screen IDC Inserted? (if % TBSA > 10% or perineum) � No � Yes Nasogastric tube inserted? (if % TBSA > 15%) � No � Yes Co-existing injuries? � Yes � Possible (eg blast / electrical injury) � No Specify ________________________________________________________________________

PAIN MANAGEMENT Morphine is the drug of choice for acute pain following burns. If allergic use appropriate alternative. • Adults Stat IV morphine 2mg, repeat every 5mins as required Max. 0.2mg/kg• Children Stat IV morphine 0.1mg/kg, repeat every 15mins as required Max. 0.3mg/kg• Reassess every 5 minutes and discuss with appropriate medical staff if analgesia insufficient • Minor burn Oral analgesia (eg paracetamol +/- codeine / oxycodone, etc) may be adequate Analgesia given prior to presentation: � No � Yes Specify _____________________________ Pain Score ____________ Time ____ (use age appropriate pain rating scale) Analgesia given ______________ Dose _______ Time _______ Effective � No � Yes

IMMUNISATION Immunisations up to date? � No � Yes Specify __________________________________ Tetanus status: � Primary course given � Give Immunoglobulin if < 3 doses � Last dose of booster _________ � Give booster if last booster > 5yrs ago

Burn Patient Emergency Assessment & Management Chart




ASSESSMENT OF % TOTAL BODY SURFACE AREA (TBSA) AND BURN DISTRIBUTION

Total Body Surface Area Rule of Nines Palmar

Palm + fingers = 1%

BURN DISTRIBUTION (shade affected areas on diagram below)

PaediatricFor every year of life after 12

months take 1% from the head and add ½% to each leg,

until the age of 10 years when adult proportions

Shade affected area

Total % TBSA = ______

NB Faint erythema not included in % TBSAassessment

NB Difficult to accurately assess burn depth within the first 24 - 48 hrs post injury

(Patient’s hand)

Adult

Assessment of % Total Body Surface Area (TBSA) and Burn Distribution




page 17 of 21

RESUSCITATION FLUIDS (if > 10% TBSA for children, >15% for adults)

Weight ________ kg Modified Parkland Formula = 3-4 mls x weight (kg) x % TBSA burn

to be given as Hartmann’s solution in 24hrs following the injury (see Transfer Guidelines) 3-4 mls x ________kg x _________% TBSA = total fluids for 1st 24hrs

* NB This is a guide only - Titrate fluids to urine output*Total resuscitation fluids in 24hrs _______ mls

Start time ______ Finish time _______50% Replacement in 1st 8hrs following injury _______ mls Total Fluid given prior to admission _______ mls Subtract Fluid already given = fluid to be given to complete 1st 8hrs _______ mls Hourly rate for replacement (within 1st 8 hrs) mls/hr

Start time ______ Finish time _______ Remaining 50% of Replacement in next 16hrs _______ mls Hourly rate for replacement (in subsequent 16 hrs) _______ mls/hr

Start time _______ Finish time ______ Maintenance fluids (for children < 30kgs only) _______ mls/hr

MAINTENANCE FLUIDS (Not applicable for adults) Children < 30kg require maintenance fluids (N/2 Saline + 2.5% Dextrose) in addition to resus. fluids.

Up to 10kg 100ml/kg/day 10-20kg 1000mls plus 50ml/kg/day (for each kg >10kg and <20kg)20-30kg 1500mls plus 20ml/kg/day(for each kg > 20kg)

URINE OUTPUT • Children 1ml/kg/hr (range 0.5 – 2ml/kg/hr) • Adults 0.5 – 1 ml/kg/hr • 2ml/kg/hr required for pigmented urine such as myoglobinuria / haemoglobinuria

REFERRAL CRITERIA Refer to Transfer Guidelines (“Referral” meaning contact with not necessarily transfer to Burn Unit)

• Partial/full thickness burns in children >5% TBSA, in adults >10% TBSA. • Any priority areas are involved, i.e. face/neck, hands, feet, perineum, genitalia and major joints. • Caused by chemical or electricity, including lightning. • Any circumferential burn. • Burns with concomitant trauma or pre-existing medical condition. • Burns with associated inhalation injury. • Suspected non-accidental injury. • Pregnancy with cutaneous burns NB All paediatric burns (<16 yrs) fitting any of the above criteria need referral to The Children’s Hospital at Westmead (CHW). Adult burns fitting above criteria need referral to the adult unit at Royal North Shore Hospital (RNSH) or Concord Repatriation General Hospital (CRGH) (dependent on area health service intake area). For contact details see Transfer Guidelines.

DRESSING For transfer to specialist unit within 8 hrs apply cling film to burnt areas (Vaseline gauze/white paraffin for face). Do not wrap circumferentially. For delayed transfer > 8hrs apply antimicrobial dressing such as Vaseline gauze (eg Bactigras) or silver dressing, after discussion with burn unit. For burns not requiring transfer to specialist unit • give pre med analgesia 30mins prior to procedure (eg paracetamol +/ oxycodone, etc) • clean wound with chlorhexidine 0.1%, saline or clean water • apply appropriate dressing such as silver dressing or Vaseline gauze (see Minor Burn Management). Contact Burn

Unit for advice if required. • make follow-up appointment and advise on care and analgesia for home usage and pre-dressing.



LOW RISK INTERMEDIATE RISKHIGH RISK *CHALICE criteria (any feature)

HISTORY

Witnessed loss of consciousness nil less than 5 minutes greater than 5 minutes

Anterograde or retrograde

amnesianil possible greater than 5 minutes

Behaviour normalmild agitation or

altered behaviourabnormal drowsiness

Episode of vomiting

without other causenil or 1 2 or persistent nausea 3 or more

Seizure in non-epileptic patient nil impact only yes

NAI suspected no no yes

Headache nil persistent persistent

Co morbidities nil present present

Age greater than 1 year less than 1 year any

MECHANISM

Motor Vehicle Accident (MVA)

(pedestrian, cyclist or occupant)low speed less than 60 km/ph greater than 60 km/ph

Fall less than 1 metre 1-3 metres greater than 3 metres

Other low impactmoderate impact

or unclearhigh speed projectile or object

EXAMINATION

GCS 15 fluctuating14-15less than 14 or

less than 15 if under 1 year old

Focal neurological abnormality nil nil present

Injury *high risk features (see below)

High risk injury:

a) penetrating injury, or suspected depressed skull fracture or base of skull fracture.

b) scalp bruise, swelling or laceration greater than 5 cm, or tense fontanelle in infants less than 1 year of age.

*High risk adapted from the Archives of Disease in Childhood 2006, children’s head injury algorithm for the prediction of important clinical

events (CHALICE) study group, Derivation of the children’s head injury algorithm for rule for head injury in children the prediction of important

clinical events.

Head Injury Risk Categories

APPENDIX 9


Note: Children less than 1 year

n require greater vigilance due to difficulty in clinical

assessment and greater risk of abusive head injury

(Non accidental injury)

n a high index of suspicion for intracranial injury must

exist for these patients, if no other intermediate risk

factors present may be managed as low risk after

consultation with paediatric experts.

Inflicted head injury n If inflicted head injury is suspected consult

with paediatric referral hospital to discuss

the indicators of the case.

n If inflicted head injury is agreed child

should be transferred to a paediatric

tertiary referral centre

n Notify Department of Community Services.

MANAGEMENTLow risk n may be discharged after medical review if have

responsible carers

n must be able to return easily to the hospital in case

of deterioration.

Intermediate risk n admission and observation required for 4-6 hours

post injury

n GCS must be sustained at 15 for 2 hours

n CT indicated if acute deterioration or persisting

symptoms at 6 hours post injury

n may be discharged at conclusion of observation

period if GCS 15, asymptomatic child has responsible

carers and a normal CT (if performed)

n children who fail these categories should be

discussed with a paediatric expert or neurosurgical

unit.

High risk n urgent CT

n transfer/retrieval

n *if unable to be performed should have observation

for a minimum period of 24 hours.

Severe head injury- GCS less than 9

n trauma call +/- retrieval to nearest paediatric

referral centre.

NoteGiven the issues of distance and dislocation for families

if a child requires transfer to a larger centre, the benefits

of a CT scan have to be weighed against the risk of

delay of diagnosis resulting from an “observation only”

policy. All high risk patient who cannot have immediate

CT scanning should at a minimum, have prolonged

observation in hospital for at least 24 hours and until

clinically improved.

IDENTIFICATION OF ACUTE DETERIORATIONn a drop of one point in the GCS for at least 30

minutes (greater weight should be given to a drop in

the motor score of the GCS)

n a drop of greater than two points in the GCS

regardless of duration or GCS sub-scale

n development of severe or increasing headache or

persistent vomiting

n development of agitation or abnormal behaviour

n clinical signs suggestive of seizure activity

n clinical signs consistent with coning or unilateral/

bilateral pupillary deterioration

– Cushing’s reflex: hypotension, bradycardia and

irregular respirations

– extensor posturing or hemiparesis

– pupillary signs: sluggish reaction or unilateral/

bilateral pupil dilation

Note: The younger the child, the more non-specific the clinical

signs of elevated intracranial pressure.


ReferenceNSW Health PD2011_024 Infants and Children: Acute


Dunning, J., Patrick Daly, J., Lomas, J-P., Lecky, F.,

Batchelor, J., Mackway-Jones, K. Derivation of the

children’s head injury algorithm for the prediction of

important clinical events decision rule for head injury in

children. Archives of Disease in Childhood 2006;91:885-

891. http://adc.bmj.com/cgi/content/full/91/11/885

<accessed 13.03.14>.

Minor head injury in infants and children,

http://www.uptodate.com/patients/content/topic.do?

topicKey=~vPPvq9tDRC2EMW&selectedTitle=26~143&

source=sear <accessed 13/03/14>.


Guideline for emergency department documentation

TRIAGE DOCUMENTATION STANDARD

1. Date and time of assessment

2. Name of triage officer

3. Chief presenting problem(s)

4. Limited, relevant history

5. Relevant assessment findings

6. Initial triage category allocated

7. Re-triage category with time and reason (if applicable)

8. Assessment and treatment area allocated

9. Any diagnostic, first aid or treatment measures initiated

(Australasian College for Emergency Medicine – ATS Guidelines Revised Nov 13)

Guideline for Emergency Department Documentation

APPENDIX 10


PRIMARY SURVEY DOCUMENTATION

A – Airway (& Cervical-Spine)

Patency, airway noises, mechanism of injury (spinal, head, inhalation injury) airway adjuncts (oro/nasopharyngeal/ LMA /ETT)

B – Breathing Respiratory rate, rhythm and depth, work of breathing, oxygen delivery device and amount

C – Circulation Skin colour, warmth and diaphoresis, capillary refill, pulses, overt bleeding, IV cannula (position and size) & fluids, (commence a fluid balance chart if fluids are administered)

D – Disability (neurological)

– Discomfort (pain assessment)

A – alertV – responds to voiceP – responds to painful stimuliU – unresponsive

Pupils size & reaction

(PEARL)

Pain assessmentand score

+ BGL

E – Exposure & Environment

Head-to-toe or focused assessment (identified abnormalities and environmental hazards during exposure)

HISTORY(source – the patient, care giver or Ambulance Officer)

M – mechanism of injury / illness I – injuries sustained / illness progression S – signs & symptoms T – treatment (pre presentation) / transport

ONGOING ASSESSMENTTriage category 1- 3Record vital signs at time of assessment and frequency according to patient clinical presentations

Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (ie alcohol/other drug use, smoking, skin integrity and falls screening)

Triage category 4 Record vital signs at time of assessment and at least one further set prior to discharge or according to the patient’s clinical presentation

Triage category 5 Record vital signs at time of assessment and relevant to presentation

Documented Observations – respiratory rate, oxygen saturations (SpO2)– oxygen device, and litres /minute – pulse, blood pressure, temperature– level of consciousness – GCS & pupils– blood glucose level (BGL)– pain score (0-10) and assessment – ECG – cardiac rhythm (if monitored)– neurovascular observations (if relevant)– weight (if relevant)– any investigations commenced /completed & outcome

A – allergiesM – medications (prescription, over the counter, herbal) P – past medical / surgical history L – last meal / last menstrual period / last immunisation E – events leading up to presentation

PLAN What plan has been put in place for this patient?

Document in a concise and clear manner: -– procedures, interventions, outcome & evaluation chronologically– standing orders or guidelines if commenced– notification – who has been told– comply with legal reporting responsibilities

EVALUATION Reassess patient and document outcomes

DISCHARGE – Time of departure– Destination– Referrals

• Document discharge information including any instructions or education given to the patient or family

• If patient not prepared to wait to be seen – document advice given to the patient or family

Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (ie alcohol/other drug use, smoking, skin integrity and falls screening)


Evidence indicates that a decrease in respiratory

rate is a late and unreliable indicator of respiratory

depression following opioid administration. Sedation

has been found to be a reliable early clinical indicator

of respiratory depression and should be monitored

following opioid administration using a sedation score.

Sedation Score

Behaviours

0 None

1 Mild, occasionally drowsy, easy to rouse

2 Moderate, constantly or

frequently drowsy easy to rouse

3 Severe, somnolent,

difficult to rouse

4 Normal sleep

The patient is scored according to the scale above.

The aim is to keep the sedation score below 2 regardless

of the route of opioid administration. A sedation score of

2 means that the patient is constantly drowsy or groggy

but still easy to rouse – eg they wake up easily but

cannot stay awake during conversation.

ReferenceNational Health and Medical Research Council,

1999, Acute pain management: scientific evidence,

Commonwealth of Australia, Canberra

Sedation Score

APPENDIX 11

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