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Orientation Manual for The Northern Hospital Emergency Department
CHAPTER 5: PAEDIATRICS
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Introduction
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Paediatric services within the hospital
o Paediatric unit
o If you need to admit a child
o If you need to transfer a child
Paediatric IV cannulae
o Cannula sizes
o Venepuncture
o Common paediatric tubes
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Urine collection
o Clean catch
o Suprapubic aspirate
o In – out catheter
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PIPER
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Outpatient paediatric services
o Referring to outpatients at TNH
o Referring to Outpatients at RCH
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X-rays in paediatrics
Practical tips
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Procedural sedation
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Paediatric surgical conditions
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Resources
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INTRODUCTION
Acute Paediatric Medicine is an important aspect of the Northern Hospital Emergency
Department’s practice.
Approximately 20% of the ED patients are less than 17 years of age i.e. Paediatric.
The Northern ED has a dedicated Paediatric area and Paediatric Treatment Room.
PAEDIATRIC SERVICES WITHIN THE HOSPITAL
Paediatric Unit
 The Child & Adolescent Health Unit (CAHU) admits children including neonates.
 There is also a Special Care Nursery at The Northern Hospital.
If you need to Admit a child
 There always needs to be comprehensive discussion with the Emergency Physician /
Emergency Department Paediatrician / ED Senior prior to referral to the Paediatric
Registrar.
 Notify the Nurse-in-Charge of the probable / definite admission.
 All neonates (<28 days old) need to be reviewed by an ED Paediatrician and/or
Paediatric Registrar prior to discharge.
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If you need to Transfer a child to another Hospital
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Always involve the Paediatric team for any transfer medical or surgical, as well as the
ED Consultant and Nurse-in-Charge prior to making any arrangements.
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Always liaise with the receiving Registrar or Fellow at the other end e.g.
Neurosurgery/ENT/Ophthalmology.
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You usually also need to speak to the Admitting Officer in the Emergency Department
at the receiving hospital as patients will go via the ED, except for emergency transfers
of critically ill patients when NETS/PETS will be involved.
PIPER (OLD NETS/PETS) – Paediatric Infant Perinatal Emergency Retrieval
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PIPER is the merged service of the previous NETS (Newborn Emergency Transport
Service) and PETS (Paediatric Emergency Transport Service). There is now only one
number that you need to contact. PIPER co-ordinates transfer of all critically ill
children to tertiary centres with ICU and other appropriate facilities.
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Always discuss potential transfers with the Emergency Senior and the Northern
Paediatric Team and then the Consultant On Call for PIPER - even if the patient is not
at the point of urgent retrieval as they can often provide guidance re the management
of the acutely ill child.
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PIPER:
1300 13 76 50
The central number which can be used to access all transfer services.
OUTPATIENT PAEDIATRIC SERVICES
We have a Paediatric Outpatient service for medical problems
Other Outpatient Services at TNH relevant to paediatrics include:
 Paediatric Surgery
 Paediatric Nephrology
 Paediatric Neurology
 Genetics
 Paediatric Respiratory
 Paediatric Rheumatology
 Paediatric Cardiology
 Paediatric ENT
 Orthopaedics
 Dermatology – through the Adult Dermatology Clinic
 Obesity Clinic (HELP Clinic) – through the Paediatric Outpatient Service
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Adolescent Gynaecology (Alison De Souza) – through general Gynaecology Clinic
Plastic Surgery – through the Adult Plastic Surgery Clinic
Dressings Clinic
Allergy clinic
Referring a child to Outpatients at The Northern Hospital
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Most patients in the first instance will be referred to the general medical paediatrics
outpatient clinic, unless specifically directed by the paediatric team to refer to a
specialist clinic
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Complete the referral form (purple) and the clerical staff can then fax to Outpatients.
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If you need to check availability/days of clinics, ring outpatients on 58417
(paediatrics) or for general enquiries ring 58850
Referring a child to Outpatient Services at the Royal Children’s Hospital
It is unusual to need to refer paediatrics outpatients to other facilities, but if you need to
access other specialty clinics at can be accessed through the Royal Children’s Hospital on
9345 5522
Examples may include certain burns patients, complex orthopaedics, complex pain
patients. In most instances the paediatric team will have discussed the case with you and
directed the appropriate referal
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Complete the RCH referral form
(http://www.rch.org.au/kidsconnect/referring/Make_a_referral_Make_your_referral_mo
re_effective/)
or write a referral using a Northern Hospital letterhead.
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Fax it to 9345 5034
(central fax number for all outpatient appointments at the RCH).
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Clearly state which clinic you want at the top of the referral, and don’t forget your
name and contact details.
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Don’t hesitate to discuss referrals with the Specialist Unit Registrar/Fellow.
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PRACTICAL TIPS
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ALL procedures MUST be done in the procedure room, unless it is a mature
adolescent. This is to avoid distress in other children and provides a safe place when
the child returns back to their cubicle. Procedures are clearly permitted within the
resuscitation cubicles.
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All set up for procedures must be done prior to the child entering the procedure room
to lower their anxiety.
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Always present your patients to a senior member of staff, even if just to say that the
child is well, that you’re happy and that you’re going to send the child home.
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Discuss all referrals to inpatient paediatrics and outpatient clinics with the ED
Consultant.
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Correspond with the family doctor and involve them in the patient’s care.
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Discuss with an ED senior doctor prior to performing procedures on children or
ordering investigations.
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Always ensure that the child has been weighed in the ED.
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There are distinct paediatric medication and IV fluid charts that need to be used when
ordering medication and fluid in children.
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Always use the Childrens AMH or the RCH clinical guidelines to direct your practice
and medication dosing.
PAEDIATRIC IV CANNULAE
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Familiarise yourself with the correct equipment.
Always seek assistance from senior staff.
Always use local anaesthetic gel unless clinically urgent.
Ensure you have an assistant who knows how to secure paediatric cannulae.
For stabilisation of cannula, steri-strips are placed around the cannula, then a
tegaderm over the top, then and 3 pieces of elastoplast to secure the splint, and finally
a bandage around the arm covering the cannula.
Always try the dorsum of the hand first.
The dorsum of the foot is another good site in infants under 12 months.
Avoid the cubital fossa as a first resort as a drip in this site is uncomfortable for the
child.
Call for assistance if you’ve had TWO attempts without success
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Cannula Sizes
Yellow(24G)
for neonates and young infants
Blue (22G)
for most other children
Pink (20G)
only for adolescents
Paediatric bloods (venepuncture)
 It is unusual to only do a venepuncture in children in the ED. Normally, a cannula is
inserted until the child is discharged in case additional bloods or intravenous
medication is required. This is to avoid a secondary procedure.
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Use local anaesthetic where possible – although this may be redundant in children
under the age of 12 months. Consider oral sucrose for pain relief / distraction.
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The antecubital fossa is usually the best site for venepuncture alone.
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Use paediatric tubes for blood specimens to minimise blood volume required.
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Be conscious of how much blood you take – 2ml is usually enough .In the older child
needing multiple investigations, 5ml is sufficient.
Common Paediatric Tubes
PURPLE (EDTA)
FBE, X-Match; Direct Coombs; G6PD screen
RED (serum)
Electrolytes; liver function; CRP; serology; enzymes
BLUE (heparin)
Coagulation
BROWN (serum)
Bilirubin specifically but can add other electrolytes, etc
Venous gas
As standard
Blood Culture
Use paediatric culture bottles – 0.5ml is the minimum volume
that is preferred; 0.5 – 1ml is ideal. In a critically ill child,
send as much as you can manage.
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URINE COLLECTION
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It is important to collect urine using proper and reliable methods
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Urine bags are no longer used in paediatrics as they are too unreliable.
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Urine should only be collected if it is likely that they have a urinary tract infection.
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The criteria is:
o Fever, no focus in males <1yo, females <2yo
o Older children with a history of recurrent urinary tract infection, or symptoms
consistent with a urinary tract infection
o Septic and unwell child with fever as full septic workup
Acceptable Urine Collection Methods
Clean catch
 is attempted in males that are not toilet trained ONLY. It cant be done in females due
to high contamination rates
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The nappy is removed.
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The perineum is cleaned with cotton balls/gauze and saline wiping from front to back
in single strokes.
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Parents +/- staff have the specimen jar opened and ready as soon as the nappy is
removed and attempt to catch a mid steam sample of the urine.
Suprapubic Aspirate (SPA)
 Do this only if experienced.
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It is the most sterile method of collection.
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Best test in children from 0 – 18 months.
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For further information on how to perform the procedure, consult the Royal
Children’s Hospital Clinical Guidelines
(accessed via ED Favourites or www.rch.org.au - see Urinary Tract Infection
Guideline).
IN-OUT Catheter
 Can be performed in any age group.
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Should not be performed in toilet-trained children unless they are critically ill and
unable to give a sample of urine.
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Generally performed when the SPA has been unsuccessful in the 0-18 months age
group or when other methods have been unsuccessful in those older than 20 months
of age.
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Can use bladder scanner to check bladder volume first (available in ED.)
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Size 6FG-feeding tube for babies and size 8FG feeding tube for older children.
N.B. always keep a sterile container handy during procedures as infants often void
when preparing for a procedure!
X-RAYS IN PAEDIATRICS
 Always assess the appropriateness of the radiological investigation and be sensitive
about the exposure of children to unnecessary radiation.
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Discuss with the ED Senior – CXRs etc should not be performed as “routine” tests.
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CT Brain scans to be performed when clinically indicated. Note that the radiation
exposure for a head CT is equivalent to approximately 200 chest x-rays. Consultant
approval is required for a CT scan.
PROCEDURAL SEDATION
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For procedures requiring conscious sedation, ie fracture manipulation, suturing,
always discuss with the ED consultant/ED Paediatrician/ED senior.
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The most commonly used agents are inhaled nitrous oxide or ketamine. Further
information regarding indications/contraindications and procedure can be found
on the RCH clinical practice guidelines (see below).
PAEDIATRIC SURGICAL CONDITIONS
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The Northern Hospital admits some children with acute surgical conditions,
including appendicitis and acute scrotum
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Children should be referred to the admitting surgical registrar, who will then liaise
with the Paediatric Surgeon on-call.
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All undifferentiated abdominal pain should be referred to the ED consultant/ED
Paediatrician/ED senior for assessment. If admission is required, the admitting
team will be the Paediatric Surgical team.
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Abdominal ultrasound scans and abdominal x-rays for undifferentiated abdominal
pain should not be done without consultation with the ED consultant/ED
Paediatrician/ED senior.
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Investigations should not delay assessment by the paediatric surgical team.
RESOURCES
RCH Clinical Practice Guidelines
(http://www.rch.org.au/clinicalguide/)
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An invaluable resource for the management of numerous childhood conditions,
complete with local considerations.
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This should be the first point of reference for diagnostic and management advice
Childrens AMH
 Access on the desktops as shortcuts in the yellow pod
Kids Health Info
 Numerous fact sheets for parents regarding common childhood conditions, including
asthma, bronchiolitis, croup, gastroenteritis, fever, head injury.
TNH Child & Adolescent Health website
 The TNH Paediatric Department website has links to all the relevant paediatric
resources as well as a bulletin board
Mims online
 Under ED favourites (medical)
UP TO DATE Website
 Under ED favourites (medical)
Your biggest resource should be the Emergency Physicians in the ED and the
Paediatric medical staff (Registrars & Consultants).
Do not hesitate to discuss cases with the relevant Paediatric Specialists outside the
Northern as required e.g. Neurosurgery, Ophthalmology, ENT – post discussion
with the ED Senior.
Dr Stefan Herodotou/ Dr Helen E. Stergiou
Dr Simon Hauser/ Dr Brendan Chan
Reviewed January 2013
Reviewed August 2015
Dr Loren Sher
Dr Rachael Coutts
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