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Preface

As medicine is a rapidly changing field, new treatment guidelines are likely to arise and they
are continuously changed, therefore, The Department of Pediatrics in Basra Medical College
authored this booklet with care to determine the best management plan for selected common
pediatric emergencies and reflect generally accepted practices in managing children in the
emergency department through using a well-designed, consensus guidelines.
We hope "Common Pediatric Emergency Guidelines booklet" be a helpful and interactive
way to enhance emergency medicine learning and as guide for managing children in the
emergency department. This booklet is adjuvant with other references for the pediatric
emergency medicine learning.

Pediatric Department
Basra Medical College

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 List of content

Subject page number

1. Preface 1
2. List of content 2
3. Stages in the management of sick child 3
4. Chart 1. Stages in the management of sick child admitted to hospital 4
5. Chart 2.Triage of all sick children 5-6
6. Guideline for the management of dehydration in children with diarrhea 7-9
7. Initial management of complication of severe acute malnutrition 10-11
8. Admission criteria to nutrition rehabilitation ward 12
9. Initial measures to a child suspected poisoning 13
10. Management of a child with organophosphate poisoning 14
11. Management of acute painful episodes at hospital 15-16
12. Pain assessment tools 17
13. Management of acute blood reaction 18-19
14. Management of acute asthma exacerbation 20
15. Management of anaphylaxis 21
16. Management of status epileptics 22
17. Diabetic ketoacidosis management protocol 23
18. Neonatal hyperbilirubinemia management guidelines 24-25
19. References 26

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 Stages in the management of the sick child
These charts describes a process for managing sick children as soon as they arrive to hospital
 First stage : quick screening (triage) to identify those who need emergency treatment and
those should be given priority, such as very young infants and severely malnourished
children.
 Every child should be fully assessed by pediatric history and examination, and a “directed”
search for symptoms and signs that are relevant to the presenting problems of the child.
 The nutritional and immunization status of all children should be checked.
 feeding should be assessed in all under-2-year-olds and very low weight-for-age children.
 Before reaching a diagnosis, all potential differential diagnoses should be considered
 If inpatient care needs, the child’s progress in response to treatment in hospital should be
monitored
 When to discharge the child ,this should be planned for accordingly.
 Continuing care or follow-up
 If outpatient care decided , it is important to teach the mother how to give all treatments at
home and to advise her when to return with the child in case of an emergency and for follow-
up.

Chart 1 : Stages in the management of the sick child admitted to hospital:

summary of key elements

Chart 2. Triage of all sick children

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Reference :guidelines for care at the first-referral level in developing countries.
Note: go to the reference for additional charts

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 Guidelines for the management of Dehydration in Children with
Diarrhea
The three essential elements in the management of all children with diarrhea are rehydration
therapy, zinc supplementation and counseling for continued feeding and prevention
Classification of the severity of dehydration

classification Signs and symptoms Treatment

Severe Two or more of the following signs: Give fluids for severe
dehydration ■ lethargy or dehydration (see diarrhea
unconsciousness treatment plan C in hospital)
■ sunken eyes
■ unable to drink or drinks poorly
■ skin pinch goes back very slowly (≥ 2 s)
Some Two or more of the _Give fluid and food for some
dehydration following signs: dehydration (see diarrhea
■ restlessness, treatment plan B)
irritability _ After rehydration, advise
■ sunken eyes mother
■ drinks eagerly, thirsty on home treatment and when to
■ skin pinch goes back slowly return immediately
_ Follow up in 5 days if not
improving.
No Not enough signs to Give fluid and food to treat
dehydration classify as some or diarrhea at home
severe dehydration (See diarrhea treatment plan A)
_ Advise mother on when to
return immediately
_ Follow up in 5 days if not
improving.
Diarrhea treatment plan C:
Treat severe dehydration quickly
Give ORS by mouth while the drip is being set up. Give 100 ml/kg Ringer’s lactate solution
(or, if not available, normal saline), divided as follows:
age First give 30 ml/kg in: Then give 70 ml/kg in
Infants(< 12 months) 1 hour 5 hour

Children(12 months to 5 years) 30 minute 2.5 hour

Repeat once if radial pulse is still weak or not detectable.

■ Reassess the child every 15–30 min. If hydration status is not improving, give the IV drip
more rapidly.
Watch for over-hydration.
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Give ORS (about 5 ml/kg per h) as soon as the child can drink: usually after 3–4 h (infants)
and 1–2 h (children).
■ Reassess an infant after 6 h and a child after 3 hours
Classify dehydration. Then choose the appropriate plan (A, B or C) to continue treatment.
If intravenous (IV) fluid can't be given immediately
Are you trained to use a nasogastric tube for rehydration?
Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg per h for 6 h (total,
120 ml/kg).

■ Reassess the child every 1–2 h:

If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly.
If hydration status is not improving after 3 h, send the child for IV therapy.
■ After 6 h, reassess the child and classify dehydration. Then, choose the appropriate plan (A,
B or C) to continue treatment.

Diarrhea treatment plan B:

Give the recommended amount of ORS in the clinic over 4 hour
Determine amount of ORS to give during first 4 hour:

2 years
12 months
Age ≤ 4 months 4 to ≤ 12 months to ≤ 5 years
to ≤ 2 years

Weight 12–19 kg
< 6 kg 6–< 10 kg 10–< 12 kg

ORS 900–1400 ml
200–400 ml 400–700 ml 700–900 ml
amount

Use the child’s age only when you do not know the weight.
The approximate amount of ORS required (in ml) can also be calculated by multiplying the
child’s weight (in kg) by 75.
If the child wants more ORS than shown, give more.

 Show the mother how to give ORS solution.

Give frequent small sips from a cup.
If the child vomits, wait 10 min, then continue, but more slowly.
Continue breastfeeding whenever the child wants.
After 4 hour:
Reassess the child and classify him or her for dehydration.
Select the appropriate plan to continue treatment.
Begin feeding the child in the clinic.
If the mother must leave before completing treatment:
Show her how to prepare ORS solution at home.
Show her how much ORS to give to finish the 4-h treatment at home.
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Give her enough ORS packets to complete rehydration.
Also give her two packets as recommended in plan A
 Explain the four rules of home treatment:
Give extra fluid.
Give zinc supplements.
Continue feeding.
Know when to return to the clinic.
Diarrhea treatment plan A:
Treat diarrhea at home
1. Give as much extra fluid as the child will take
Tell the mother to:
 Breastfeed frequently and for longer at each feed
 If the child is exclusively breastfed, give ORS or clean water in addition to breast milk
 If the child is not exclusively breastfed, give one or more of the following: ORS solution,
food-based fluids (such as soup, rice water and yoghurt or clean water)
It is especially important to give ORS at home when:
The child has been treated according to plan B or plan C during this visit.
The child cannot return to a clinic if the diarrhea gets worse.
Teach the mother how to mix and give ORS.
Give the mother two packets of ORS to use at home.
Show the mother how much fluid to give in addition to the usual fluid intake:
≤ 2 years: 50–100 ml after each loose stool
≥ 2 years: 100–200 ml after each loose stool
Tell the mother to:
Give frequent small sips from a cup.
If the child vomits, wait 10 min. Then continue, but more slowly.
Continue giving extra fluid until the diarrhea stops.

2. Give zinc supplements.

Tell the mother how much zinc to give:
≤ 6 months: half tablet (10 mg) per day for 10–14 days
≥ 6 months: one tablet (20 mg) per day for 10–14 days
Show the mother how to give zinc supplement:
For infants, dissolve the tablet in a small amount of clean water, expressed milk or ORS in a
small cup or spoon.
Older children can chew the tablet or drink it dissolved in a small amount of clean water in a
cup or spoon.
Remind the mother to give the zinc supplement for the full 10–14 days.
3. Continue feeding.
4. Know when to return to the clinic

Reference: Guide line for the management of common childhood illnesses. WHO, 2nd
edition 2013
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Initial Management of complication of Severe Acute Malnutrition
(Critical Care Pathway "CCP" )

Hypothermia Hypoglycemia
Anemia
Shock
Dehydration

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Admission Criteria to Nutrition Rehabilitation Ward

Old Criteria Recent criteria

Children with SAM should first be assessed

with a full clinical examination to confirm
Admit to inpatient care (NRC) all whether they have:
children : 1- medical complications and;
2- whether they have an appetite.
1- Whose Wt. for length / height Children who have appetite (pass the appetite
is below -3 SD. test) and are clinically well and alert should be
treated as outpatients.
Or;
Children who have:
2- Have bilateral symmetrical 1- medical complications,
edema (regardless of the degree 2- severe edema (+++), or;
of edema). 3- poor appetite (fail the appetite test) or
4- present with one or more IMCI danger
signs should be treated as inpatients.

Reference :guideline for management of severe acute malnutrition

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 Initial measures for a child suspected poisoning

Stabilization of the patient's condition ABCs

Accurate history who(age) weight, when, what

Physical assessment vitals, consciousness, pupils

Laboratory evaluation: CBC, Electrolytes, Serum glucose,

LFT, RFT

Drug screening
Others: ECG, Chest X-ray, Abdominal X-ray as indicated

Decontamination
● Gastric lavage 15 ml/kg
normal saline most
effective when used Enhancing Excretion Antidotes
within one hour of the
ingestion ● Urinary Alkalinization ● Early and appropriate
●Hemodialysis use of an antidote is a
● Activated Charcoal key element in managing
main stay(1-2 gm/Kg) ● Multiple dose activated
charcoal the poisoned patient
● Induce vomiting Syrup
of epicac
● Whole Bowel Irrigation

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Management of A child With Organophosphate Poisoning

 Resuscitation is the mainstay ABCs Carful attention to airway and

breathing
 Intubation and ventilation if necessary
 Fluid and electrolyte replacement

 Atropine is part of ABC to control symptoms antagonizes the

muscarinic acetylcholine receptor (organophosphate , carbamate)
 Dose: 0.05 mg/kg repeated every 5-10 min as needed, dilute in (2ml ) of
normal saline

Decontamination of skin and GIT:

 Skin: washing all exposed skin with soap and water and immediate
removal of all exposed clothing.
 GIT decontamination: within 1-2 hr, protect the airway, conscious
GCS>12, gastric lavage ,activated charcoal

 Pralidoxime breaks the bond between the organophosphate and the

enzyme. It is effective if used before the bond (ages ) and becomes
permanent (18hr-2,3days).
 Pralidoxime is not necessary for carbamate poisonings.
 Dose: 25-50mg/kg over 5-10 min (max 200mg/min) can be repeat after
1-2hr then 10-12 hr as needed.

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 Sickle Cell Anemia
Managing of Acute Painful Episodes (Vaso-Occlussive Crisis) at
Hospital

All patients with painfull crisis

A full history and examination, searching for precipitating factors of pain and
for symptoms/signs of following complications:
● Acute chest syndrome
● Splenic sequestration
● Aplastic crisis
● Osteomylitis
● Septicemia
● Stroke

Clinically assess all patients for monitoring of:

● Degree of pallor and jaundice
● Blood pressure, pulse rate, temperature, respiratory rate , and oxygen
saturation
● Liver and splenic size
● Assess site and severity of pain using an age-appropriate pain scoring tool

Find an IV access, send Investigations (all patients) for:

● CBC, LDH, baseline CXR.
And if indicated send for:
● LFT, BUN, CRP, ESR , blood culture…etc.

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 Sickle Cell Anemia
Managing of acute painful episodes (vaso-occlussive crisis) at
hospital, cont.,
An analgesic ladder is used according to the severity of pain and a pain tool
must always be used to monitor effectiveness of pain relief every 15-30 min to
increase (decrease) dose and /or add other painkiller.
Paracetamol / Ibuprofen (if not already administered)

Paracetamol ± codien + NSAID

Morphine (oral + intranasal/ intravenous) + paracetamol +

NSAID

For all patients

Offer all patients who Others measures (treatment of Other non-

are taking an opioid: precipitating factors: • pharmacological measures:
● Laxatives on a ● Hydration( IV fluid) ● Rest and reassurance
regular basis ● Antibiotics (treatment of infection) ● Massage to site of pain
● Anti-emetics as ● Distraction techniques
● Oxygen
needed ● Warmth
● Blood transfusion ( when severe anemia
● Antipruritic as ● Position of maximum
or Hb decline 2 g from baseline or if there
needed is respiratory symptoms) comfort

If there’s no pain and no other

indications for admission: discharged
with:
If the pain is not improving: ● A supply of oral analgesia
Continue analgesic management and ●Instructions to increase fluid intake
other evaluation measures either in ●Antibiotics if there is any evidence of
emergency department or consider infection
transfer to inpatient ward
● Consider Hydroxyurea for chronic
unremitting pain
● A follow-up appointment

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Pain Assessment Tools

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 Transfusion reaction guideline

Symptom of acute transfusion reaction

 Fever or chills or rigor.

 Urticaria or flushing.
 Hypo/Hypertension or collapsed or tachycardia.
 Nausea or vomiting.
 Pain: chest or back or loin or IV site.
 Unexplained bleeding : hematuria.
Immediate action

 stop the transfusion

 check blood unit ,patient ID and labels
 inform medical staff
 make observation charts of vital signs every 15 minutes until the patient
become stable
 keep IV line open with a normal saline
 don’t throw away the blood products
 call for a hematologist
Management of severe transfusion reaction (*)

 maintain airway, breathing and circulation (A B C)

 return back the blood unit and the set to the bank
 give normal saline 0.9%.
 send for investigation CBC, urea, electrolyte, bleeding profile, and marker
for hemolysis(LDH, bilirubin, haptoglobin )
 call for hematologist or ICU doctor
 monitor urine output (consider diuretics)
 give broad spectrum antibiotics if you suspect bacterial contamination
 Inotropes may be needed for the hypotension
 Give FFP for management of DIC
 Assisted ventilation may be needed for respiratory distress

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 Transfusion reaction guideline

Main signs/symptoms

Fever >1 Dyspnea

C from urticaria or
the hypoxia
basline

Observation Antihistamine,
Resume the
Anaphylaxis
Patient stable transfusion at a
slower rate

Yes NO NO
Yes

ABO incompatibility
Febrile non
bacterial Circulatory
hemolytic Treat for
contamination overload
transfusion anaphylaxis
hemolytic transfusion trial
reaction
reaction

Oxygen ,
diuretics,
Slow rate of
Refer to the protocol of sit upright,
transfusion CXR
paracetamol management of severe
frequent transfusion reaction (*)
observation
Suspect
trial if non
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 Management of Acute Asthma Exacerbation

Severe exacerbation includes

breathlessness, dyspnea, retractions, accessory muscle use,
tachypnea , cyanosis, mental status changes, a silent chest
severe airflow limitation (PEF or FEV1 value <50% of predicted

Initial treatment includes

●Supplemental oxygen,
●Close monitoring of clinical status, hydration
●Inhaled â-agonist as 2.5 mg salubutamol by nebulizer therapy
every 20 min for 1 hr, and systemic
●If necessary, corticosteroids given either orally as prednisolone
1-2 mg/kg or intravenously as methyl prednisolone
●Inhaled ipratropium may be added to the â-agonist treatment

Discharged to home if there is If nosignificant response is seen

●Sustained improvement in symptoms with the first inhaled â-agonist
●PEF more than 70 % of predicted ●An intramuscular injection of
epinephrine or other â-agonist
●Oxygen saturation >92% while the patient may be administered in severe
is breathing room air for 4 hr. cases
Discharge medications include
►Administration of an inhaled â-agonist
up to every 3-4 hr plus For patients with moderate to
►A3-7 day course of an oral corticosteroid severe exacerbations that do not
adequately improve within 1-2
hr of intensive treatment:
●Observation and/ or admission
to the hospital, at least
overnight

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 Management of Anaphylaxis

sign and • Call for help

symptoms • Remove trigger
• Check ABC

Cardiac arrest
Respiratory arrest NO
YES
Complete airways
obstruction

Basic and advanced life

Stridor /upper airway obstruction signs support
or Adrenaline IM 10 mcg/kg or
Wheeze/lower airways obstruction signs IV if in cardiac arrest
or shock

Adrenaline IM 10 mcg/kg
Repeat in 3-5 min if no response Resolution
20ml/kg 0.9 saline for shock

No resolution Observe
Monitor and ABC reassessment
Consider oral antihistamine and
Persistent upper airways obstruction: oral prednisolone
Nebulized adrenaline
Adrenaline infusion
Persistent lower airways obstruction:
Nebulized adrenaline or salbutamol
Adrenaline infusion
Aminophylline infusion
Persistent shock:
Further 0.9saline
Adrenaline infusion

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 Status Epilepticus
Time Line
Interventions for emergency department
1. Stabilize patient (ABC)
2. Monitor vital signs
0-5 minutes 3. Assess oxygenation, give oxygen, consider intubation
4. Initiate ECG monitoring
Stabilization 5. Collect finger stick blood glucose. If glucose < 60 mg/dl, give:
Phase  Children < 2 years: 4 ml/kg D12.5W intravenous
 Children ≥ 2 years: 2 ml/kg D25W intravenous
6. Attempt IV access and collect electrolytes

Does seizure continue? No Symptomatic

medical care
Yes

A benzodiazepine is the initial therapy of choice:

5-20 minutes Intravenous diazepam (0.15-0.2 mg/kg/dose) may repeat dose once
If not available, choose one of the following:
Initial therapy
 Intravenous phenobarbital (15 mg/kg/dose, single dose) OR
Phase
 Rectal diazepam (0.2-0.5 mg/kg, max:20 mg/dose, single dose) OR
 Intranasal midazolam
 Symptomatic
Does seizure continue? No
medical care

Yes

There is no evidence based preferred second therapy of choice

20-40 minutes Choose one of the following and give as a single dose:
Second therapy ● Intravenous phenytoin (20 mg/kg, max: 1500 mg/dose, single dose) OR
Phase ● Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, single dose)
If not available, then give (if not given already):
● Intravenous phenobarbital (15 mg/kg/dose)
Symptomatic
Does seizure continue? No
medical care

Yes

40-60 minutes There is no clear evidence to guide therapy in this phase. Choices include:
Third therapy  Repeat second line therapy, OR
phase  Anesthetic doses of either thiopental, midazolam, pentobarbital

American Epilepsy Society Guidelines 2016

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 Diabetic Keto-acidosis (DKA) Management Protocol
Initial Assessment:
 Flow sheet should include columns for serial electrolytes, pH, glucose, and fluid balance. Blood
testing should be 1-2 hourly for children with severe DKA and 3-4 hourly for mild to moderate DKA.
 ECG monitor for K level change
 Urinary catheter if the child unconscious
 Two I.V lines for fluid administration and blood samples draw

Potassium Bicarbonate
I.V. Fluid Insulin therapy therapy

1st hour 10- K+ should be It is only

20 mL/kg IV Start at rate 0.1 started as soon as recommended if
bolus 0.9% NaCl unit/kg/hr urine is passed. pH < 7.0
or LR Aim is gradual 20 mEq/L of K
reduction of Phosphate or K
blood glucose acetate (total 40
level by mEq/L)
2mmol/hr

2nd hr until DKA resolution If K+ is < 3 mEq/L, give 0.5 -

Then change fluid to 1.0 mEq/kg as oral K
0.45% NaCl solution OR
IV rate = increase IV K to 80 mEq/L.
85ml/kg + maintenance –
bolus
Over 23 hr

Glucose should be added as a 5% solution when the serum

glucose has decreased < 300mg/dL to avoid hypoglycemia

Any child can transition to oral intake and S.C insulin when DKA resolved i.e.
 Total CO2˃ 15mEq/L
 PH˃7.3
 Serum sodium between 135-145mEq/L
 No emesis

Nelson textbook of Pediatrics 20th edition

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 Neonatal Hyperbilirubinemia Management Guidelines

Neonatal jaundice which is caused by increased levels of bilirubin in the blood, in newborn
babies (neonates) can be harmful if not treated. This guideline helps to detect or prevent very
high levels of bilirubin.

In all newborn babies you should first:

1) Identify babies who are more likely to develop significant hyperbilirubinemia, if they
have any of the following factors:
 Gestational age under 38 weeks
 A previous sibling with neonatal jaundice requiring phototherapy or exchange
transfusion
 Jaundice that is visible in the first 24 hours of life
2) Examine the baby for jaundice frequently in the first 72 hours by:
 Checking the naked baby in bright and preferably natural light
 Examine the sclerae and gums, and press lightly on the skin to check for signs of
jaundice in 'blanched' skin.
However;
 You should not depend on visual inspection alone to estimate the bilirubin level in a
baby with suspected jaundice.
 Measurement of bilirubin levels is not indicated routinely in babies who are not visibly
jaundiced.
 Do not use umbilical cord blood bilirubin level to assess hyperbilirubinemia.

Additional care for babies with visible jaundice in the first 24 hours:

 In all babies with jaundice in the first 24 hours of life, measure and record the serum
bilirubin level urgently within 2 hours.
 Then continue to measure the serum bilirubin level every 6 hours until the level is below
the treatment threshold
 Refer the baby for urgent medical review as soon as possible and within 6 hours
 Interpret bilirubin levels according to the baby's postnatal age in hours and manage
hyperbilirubinemia according to the threshold table
How to measure the bilirubin level:
 By use serum bilirubin measurement
 Transcutaneous bilirubinometer can be used if available to measure the bilirubin level
in babies who have a gestational age of 35 weeks or more and who are over 24 hours old.
 Do not use an icterometer to measure bilirubin levels in babies.

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 Management and treatment of hyperbilirubinemia

Parents care:
Information for parents on treatment: the information should be provided
through verbal discussion. These should include:
●The fact that neonatal jaundice is common, and reassurance that it is
usually transient and harmless
●The expected duration of treatment
●Reassurance that breastfeeding, nappy-changing and cuddles can
continue.
●Encourage frequent breastfeeding and to wake the baby for feeds if
necessary.
●Provide lactation/feeding support to breastfeeding mothers.

Management of the baby:

●Use the bilirubin level to determine the management of
hyperbilirubinemia in all babies
●Use the threshold table* for choosing the treatment plan.
●Do not subtract conjugated bilirubin from total serum bilirubin when
making decisions about the management of hyperbilirubinemia.

Threshold table:* (NICE 2018)

Consensus-based bilirubin thresholds for management of babies 38weeks or more gestational
age with hyperbilirubinemia
Age (hours) Bilirubin level (micromol/L)
0 > 100 > 100
6 > 125 > 150
12 > 150 > 200
18 > 175 > 250
24 > 200 > 300
30 > 212 > 350
36 > 225 > 400
42 > 237 > 450
48 > 250 > 450
54 > 262 > 450
60 > 275 > 450
66 > 287 > 450
72 > 300 > 450
78 > 312 > 450
84 > 325 > 450
Start Perform an exchange transfusion unless the bilirubin level
Action
phototherapy falls below threshold while the treatment is being prepared

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References

 Guideline for care at first referral level in developing countries

 Guideline for the management of common childhood illness. WHO, 2nd edition 2103
 Guideline for management of sever acute malnutrition
 Nice guideline for managing acute Sickle cell disease: managing acute painful episodes in
hospital 2012
 American epilepsy society guideline 2016
 Nelson textbook of pediatrics 20th edition

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