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Orientation to Paediatrics in the Emergency Department of
The Northern Hospital
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 nominated Paediatric cubicles and a dedicated Paediatric
Treatment Room.
Paediatric Services within the Hospital
Paediatric Unit
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The Child & Adolescent Health Unit (CAHU) admits children including neonates.
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There is also a Special Care Nursery at The Northern Hospital.
If you need to Admit a child
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There always needs to be comprehensive discussion with the Emergency
Physician / Emergency Department Paediatrician / ED Senior prior to referral to
the Paediatric Registrar.
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Notify the Nurse-in-Charge of the probable / definite admission.

All neonates (<28 days old) need to be reviewed by an ED consultant/ED
Paediatrician/Paediatric Registrar prior to discharge.
If you need to Transfer a child to another Hospital
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Always involve the ED Consultant and Nurse-in-Charge from the outset.
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If the problem is a medical one always involve the Paediatric Registrar.
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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.
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NETS/PETS
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NETS (Newborn Emergency Transport Service) and PETS (Paediatric Emergency
Transport Service) are the services used to transfer 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 NETS/PETS - 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.
NETS/PETS
1300 13 76 50
The central number which can be used to access NETS, PETS and the
Emergency Departments of The Royal Children’s Hospital and Monash
Medical Centre.
Paediatric Services external to the ED
We have a Paediatric Outpatient service for medical problems
Other Outpatient Services at TNH relevant to paediatrics include:
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Paediatric Surgery
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Paediatric Nephrology

Paediatric Neurology

Genetics
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Paediatric Respiratory
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Paediatric Rheumatology
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Paediatric Cardiology
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Paediatric ENT
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Orthopaedics
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Dermatology – through the Adult Dermatology Clinic
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Obesity Clinic (HELP Clinic) – through the Paediatric Outpatient Service
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Adolescent Gynaecology (Alison De Souza) – through general Gynaecology Clinic
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Plastic Surgery – through the Adult Plastic Surgery Clinic
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Dressings Clinic
If you need to refer a child to Outpatients at The Northern Hospital
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Assess that the patient meets the criteria for referral (refer ED Clinical Guidelines)
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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
(paeds) or for general enquiries ring 58850
Other specialty clinics can be accessed through the Royal Children’s Hospital on 9345
5522
If you need to refer a child to Outpatient Services at the Royal Children’s Hospital
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Complete the RCH referral form
(http://www.rch.org.au/kidsconnect/referring/Make_a_referral_Make_your_refer
ral_more_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.
PRACTICAL TIPS
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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 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 the ED senior doctor prior to performing procedures on children or
ordering investigations.

Always ensure that the child has been weighed in the ED.

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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PAEDIATRIC IV CANNULAE
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Familiarise yourself with the correct equipment.
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Always seek assistance from senior staff.
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Always use local anaesthetic gel unless urgent.
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Ensure you have an assistant who knows how to secure paediatric cannulae.
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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.
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Always try the dorsum of the hand first.
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The dorsum of the foot is another good site in infants under 12 months.
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Avoid the cubital fossa as a first resort as a drip in this site is uncomfortable for
the child.
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Call for assistance if you’ve had 2 attempts without success
Cannula Sizes
Yellow(24G)
for 0 – 3 years of age
Blue (22G)
for children over 3 years of age and sick children over 2 years of age
Pink (20G)
only for adolescents
PAEDIATRIC BLOODS (VENEPUNCTURE)
Use a butterfly (23G or 25G) and syringe
Or
Syringe and needle (23G or 25G)
Or
Broken needle technique if you know how to do this in babies.
Use local anaesthetic where possible – although this may be redundant in children under
the age of 12 months.
The cubital fossa is usually the best site for venipuncture alone
Try to get your blood from the IV cannula where possible if one is indicated to avoid an
additional procedure.
Use paediatric tubes
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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
Blood Culture – usually Yellow top only for paediatrics and 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.
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.
Acceptable Urine Collection Methods
Clean catch
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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)
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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 to 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).
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IN-OUT Catheter
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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
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Always assess the appropriateness of the radiological investigation and be
sensitive about the exposure of children to unnecessary radiation - however if
imaging is required for diagnostic purposes it is to be performed.
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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.
PROCEDURAL SEDATION

For procedures requiring conscious sedation, ie fracture manipulation, suturing,
always discuss with the ED consultant/ED Paediatrician/ED senior.

The most commonly used agents are inhaled nitrous oxide and ketamine. Further
information regarding indications/contraindications and procedure can be found
on the RCH clinical practice guidelines (see below).
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PAEDIATRIC SURGICAL CONDITIONS

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 oncall.
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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.

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.
RESOURCES
Use the resources available in the ED:
RCH Clinical Practice Guidelines (http://www.rch.org.au/clinicalguide/)
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
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Under ED favourites (medical)
An invaluable resource for the management of numerous childhood conditions,
complete with local considerations.
This should be the first point of reference for diagnostic and management advice
RCH Pharmacopoeia ( http://ww2.rch.org.au/pharmacopoeia/pages/a-znames.html)
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For drugs and dosages in children (hard copy on bench-top in ED)
Kids Health Info
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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
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Under ED favourites (medical)
UP TO DATE Website
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Under ED favourites (medical)
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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