If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
It is proposed that the following conditions should be sent directly to emergency. This is not a list of all conditions that should be sent to the emergency department, it is intended as guidance for presentations that may otherwise have been directed to general paediatric outpatients:
Brain & Nervous System
- Headaches
- that wake at night or headaches immediately on wakening
- new and severe headaches
- associated with significant persisting change of personality or cognitive ability or deterioration in school performance
- recent head injury or head trauma
- any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
- sudden onset headache reaching maximum intensity within 5 minutes ( = explosive onset)
- presence of an intracranial csf shunt
- hypertension above 95th centile by age for systolic or diastolic
- Seizures
- all children with new onset of clinically obvious epileptic seizures should be referred to emergency for initial assessment, observation and consideration of emergency investigation or management.
- any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
- significant change in seizures for established epilepsy:
- new onset of focal seizures or
- a dramatic change in seizure frequency or duration
- Faints syncope and funny turns
- loss of consciousness in association with palpitations
- sudden loss of consciousness during exercise
- possible infantile spasms. this may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old
Respiratory
- Asthma, stridor and wheeze
- infants who have apnoea or cyanosis during paroxysms of coughing
- children with recurrent or persistent respiratory symptoms who have had an episode of choking suggestive of a possible inhaled foreign body
- recent onset or escalating stridor and respiratory distress
- acute respiratory distress not responding to home management
- acute respiratory symptoms causing inability to feed or sleep in an infant
- Persistent and chronic cough
- infants who have apnoea or cyanosis during paroxysms of coughing
- children with recurrent or persistent respiratory symptoms who have had an episode of choking suggestive of a possible inhaled foreign body
- prominent dyspnoea, especially at rest or at night
- cough causing inability to feed or sleep in an infant
Gastroenterology
- Jaundice
- Jaundice in infants with elevated liver transaminases or conjugated (direct) bilirubin > 20 microMol per litre or >15% of total bilirubin.
- Jaundice in ≥38 week infant ≥ 330 UMol/L
- Jaundice in 35-37 week infant ≥ 280 UMol/L
- Jaundice in <35 week infant ≥ 230 UMol/L
- Chronic & Recurrent Abdominal Pain
- severe pain not able to be managed at home with simple analgesia
- significant change in location or intensity of chronic abdominal pain suggestive of a new pathology
- pain associated with vomiting where this has not occurred before
- bile stained vomiting
- Chronic Diarrhoea and/or Vomiting
- vomiting or diarrhoea with weight loss in an infant <1 year
- suspected pyloric stenosis
- bile stained vomiting
- acute onset abdominal distention
- weight loss with cardiovascular instability, e.g. postural heart rate changes
- new onset of blood in diarrhoea or vomitus
- Constipation with or without soiling
- severe abdominal pain or vomiting with pain
Urinary
- Urinary Incontinence and enuresis.
- recent onset of polyuria/polydipsia that might suggest diabetes (mellitus or insipidus)
- Recurrent Urinary Tract Infections (UTI)
- acute infant urinary tract infection presenting septicaemia or acutely unwell
Musculoskeletal
- Acute joint pain with fever
- Acute joint pain unable to weight bear.
Cardiac
- Chest pain with haemodynamic compromise or history of cardiac disease
- Infant <3 months with newly noted murmur and any of the following:
- poor feeding
- slow weight gain
- weak or absent femoral pulses
- post ductal (foot) oxygen saturation < 95%
- respiratory signs (wheeze, recession or tachypnoea)
Allergies
- Anaphylaxis
- Allergic reaction where there are any respiratory or cardiovascular symptoms or signs
- Reaction to peanut or other nut should be referred to Emergency as these reactions can progress rapidly and should be observed and assessed in Emergency
- Exposure to a known allergen with a previously identified potential for anaphylaxis in this patient even if the reaction appears currently mild
- Severe angioedema of face
Growth concerns
- Faltering growth (failure to thrive in children < 6 years)
- severe malnutrition
- temperature instability
- cardiovascular instability – postural heart rate change
- Short stature
- possible CNS signs (visual disturbance, morning headaches)
Developmental concerns
- Non verbal child with acute distress and unable to examine adequately for medical conditions causing pain eg tooth abscess, bone infections or osteopaenic fractures
Behavioural concerns
- Suicidal or immediate danger of self-harm
- Aggressive behaviour with immediate threatening risk to vulnerable family members
Irritable Infant
- Fluctuating or altered conscious level – weak cry, not waking appropriately for feeds, lethargy, maternal concern of failure of normal interaction
- Suspicion of harm or any unexplained bruising, especially in infant <3 months
- Significant escalation in frequency or volume of vomiting
- New onset of blood mixed in stool
- Fever
- Increased respiratory effort
- Weak or absent femoral pulses in infant <3 months
- Presence of newly noted heart murmur in infant <3 months
Physical findings of concern in an infant <1 year
- Inguinal hernia that cannot be reduced.
- Painless firm neck swelling that is increasing in size.
- White pupil or white instead of red reflex on eye examination.
- Previously unrecognised intersex genitals (ambiguous as either virilised female or incomplete formation male eg bilateral absent testes).
- Possible Infantile Spasms. This may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old.
- Absent femoral pulses.
- Infant <3 months with newly noted murmur and any of the following:
- poor feeding
- slow weight gain
- weak or absent femoral pulses
- post ductal (foot) oxygen saturation < 95%
- respiratory signs (wheeze, recession or tachypnoea)
Diabetes
- New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
- Ketoacidosis in a known diabetic with any of the following:
- systemic symptoms (fever, lethargy)
- vomiting
- inability to eat (even if not vomiting)
- abdominal pain
- headache