Paediatric Patients PDF

Paediatric Patients John Craven OVERVIEW Paediatric patients can be challenging for paramedics as they may respond to illness and injury differently to adults. Parents and carers need to be engaged in the assessment and treatment of children as they can reference what is normal for the child and prov...

Paediatric Patients John Craven OVERVIEW Paediatric patients can be challenging for paramedics as they may respond to illness and injury differently to adults. Parents and carers need to be engaged in the assessment and treatment of children as they can reference what is normal for the child and provide emotional support. Respiratory distress is one of the most common acute paediatric issues and respiratory failure is a leading cause of cardiac arrest in children. Introduction Paediatric patients represent a challenge to paramedics. Research suggests that cases involving children evoke anxiety and discomfort, and lack of confidence leads to a reluctance to initiate timely and appropriate treatment, possibly contributing to patient morbidity and mortality (Fowler et al., 2017). Training is often sparse and paramedics often feel underprepared and stressed. This is exacerbated by the fact that paediatric interactions are relatively infrequent, making up an estimated 4–8% of call outs (Miller et al., 2014). Although only a small proportion of paediatric cases require emergency intervention due to a life-threatening condition (Drayna et al., 2015), children still present unique challenges as they are anatomically, physiologically and developmentally different to adults. They suffer from a range of conditions that are either not found in adults or present in different ways. The infrequency of interaction may impede the development of familiarity with both conditions and children themselves. One of the common fallacies with children is that they sicken and die quickly. The reality is that children have a more responsive and compensative physiology than older people, in particular a dynamic cardiovascular system, and can compensate from disease insult more effectively. Accordingly, children will often not overtly appear unwell until the later stages of a critical illness, or they may display more subtle signs than adults. What is notable is that once a child's ability to compensate is overcome, they may rapidly deteriorate to deleterious result, hence the emphasis in paediatrics on the early detection of severe illness. The ability to recognise that a child is seriously unwell is a key skill in the field of acute paediatrics; one of the major tasks of clinicians dealing with children is to identify the 'sick child’ from a large undifferentiated group of children who may be potentially sick. Many children who have suffered poor outcomes in the healthcare system have long periods where the severity of their condition has not been recognised or has been significantly underestimated. Observation charts with normal reference ranges are now in common use and have been successful in aiding healthcare practitioners (see Fig 56.1). FIGURE 56.1 Early warning observation chart from SAAS MedSTAR. When approaching all children, a rapid assessment can help differentiate the critically unwell child who needs immediate resuscitation and/or treatment from the less unwell child who can be assessed using the patient-centred interview. In addition to identifying potential diagnoses, the severity of illness should be assessed. Differentiating illness severity using terms such as 'mild’, 'moderate’, 'severe’ and 'life-threatening’ is a more sophisticated form of clinical assessment: an evaluation of the risk, clinical needs and extent of required intervention is made in addition to disease diagnosis. This aids treatment of the condition and aids communication of clinical urgency to other treating clinicians. There is a significant difference between the management of mild asthma and lifethreatening asthma, for example. While there are numerous diseases that may cause a child to become critically unwell, all fulminant pathological processes if untreated eventually result in either respiratory failure or circulatory collapse, which will progress to cardiac arrest (see Fig 56.2). Respiratory failure is generally due to obstruction of the respiratory system or failure of respiratory drive. Respiratory obstruction can occur in the upper or lower airways at the level of alveolar gas exchange. Shock, or circulatory collapse, is due to failure of the cardiac pump or intravascular depletion, either through fluid volume loss or maldistribution of fluid outside the central circulation. FIGURE 56.2 Progression of serious illness. Identifying these underlying pathophysiological processes allows paramedics to treat severe illness urgently, effectively and somewhat empirically without necessarily identifying the specific underlying cause, which may take time and further diagnostic tests to ascertain. Important differences in children Children represent a diverse group of patients. In addition to having a unique range of diseases, they vary enormously in size, shape, weight, emotional response, intelligence and ability to socially interact. Knowledge of anatomical and physiological differences is required across this range to allow paramedics to competently manage a seriously ill or injured child. Weight The most rapid change in weight occurs in the first year of life. Term newborn babies have an average weight of 3.5 kg which increases to 10–12 kg by 1 year of age. Weight then increases by approximately 2 kg per year until the pubertal growth spurt begins at 10–12 years of age. As most medications and IV fluids are dosed per kilogram of body weight, it is important to establish a child's weight as soon as possible. A parent or carer will often be aware of a recent weight, especially with infants. As a guide, most medication dosing is calculated using 40 kg as a base for maximal adult dosing. This can often be used as a quick method of double-checking drug doses to prevent errors of overdosing. Airway The size, shape and proportions of the body change with growth. A number of these are clinically important in managing an acutely ill child. The airway is influenced by the shape of the mouth and neck. In a baby, the head is proportionally large, the neck short and the shoulders thin, which influences a more flexed neck position when lying supine, resulting in airway narrowing. The tongue is relatively large, the floor of the mouth easily compressible and the larynx more acutely angled, all of which may impede the view during laryngoscopy. Infants are primarily nasal breathers up to approximately 6 months of age, and while a child below this age can breathe through their mouth when there is nasal obstruction, they do so only under duress and with increased effort. Breathing At birth, the lungs are developmentally immature. Over the first 2 years of life, there is a significant growth and development of the small airways and expansion of the surface area available for oxygen exchange. The result of this is that small children have less respiratory reserve and an increased likelihood of developing severe respiratory illness. The smaller size of the upper and lower airways increases the chance of airway obstruction from mucus production and airway inflammation, partly explaining the propensity of children in developing wheeze, stridor or respiratory distress in conditions such as croup, bronchiolitis and asthma. The immature lung is more vulnerable to insult and infants may take a long time to recover from periods of respiratory support or even simple chest infections. The compliant chest wall and weaker muscles mean that infants rely on the diaphragm for respiratory effort, and in trauma this means that force may be transmi ed easily to deeper organs such as heart and lungs with li le chest wall damage. Infants have a relatively greater metabolic rate and oxygen consumption; however, tidal volume remains proportionally constant across all ages at 5–7 mL/kg to adulthood. The combination of higher oxygen consumption with small lung volumes and limited respiratory reserve means that small children will desaturate more rapidly than adults. Circulation A newborn's circulating blood volume is estimated at 80 mL/kg, which is higher than in adults, although the actual volume is tiny. Relatively small blood losses can be critical. In utero and at birth the ventricles of the heart are roughly equal. By 6 months of age, the altered pressures of the systemic and pulmonary circulations have caused the left ventricle to dynamically hypertrophy and become dominant. The rise in systemic vascular resistance from low levels as a newborn is reflected in the changing normal values of blood pressure until maturity. Despite the small stroke volume of the newborn heart (approx. 1.5 mL/kg), the cardiac index is at the highest point of any stage of life. However, the relatively fixed stroke volume means that cardiac output is mostly related to heart rate. The infant vascular system is also more dynamic and the peripheral vascular system can quickly constrict to divert blood flow into the central circulation, resulting in improved circulation and reduced heat loss. This clinically appears as mo ling of the skin and cool peripheries. PRACTICE TIP For a rapid cardiovascular assessment: heart rate pulse volume central capillary refill time blood pressure Infants have very high body surface area to weight ratios, which decrease as they grow. As such, they are prone to rapid heat loss and struggle to regulate their body temperature. Hypothermia is a significant issue if infants are stripped and exposed, such as in a resuscitation situation. Fever The human body actively regulates its own temperature. Cooling is achieved by perspiration, increased peripheral and superficial blood flow (causing a flushed appearance and warming thermoreceptors in the skin to give a sensation of ‘hot’), and behavioural changes such as to remove layers of clothing. An increase in body temperature is achieved through vasoconstriction of superficial blood vessels (causing a pale or mo led appearance and thermoreceptors in the skin will give a sensation of ‘cold’), piloerection of hair, shivering or rigors to create heat through muscle activity, and behavioural changes, such as wanting to rug up. This is regulated by the hypothalamus which lies adjacent to the pituitary in the limbic system of the brain. Fever is a regulated part of the immune response and should be distinguished from heat stroke and malignant hyperthermia, which are unregulated and dangerous conditions. The process of developing a fever begins with white blood cells activating in the face of an infection and releasing endogenous pyrogens, which include cytokines such as interleukin 1 (IL-1), interleukin 6 (IL-6) and tumour necrosis factor (ElRadhi, 2012). These cytokines stimulate the hypothalamus to raise the body temperature set point and set in motion the process by which the body increases temperature. Fever is theorised to aid the immune system by improving blood flow and immune system activity, and inhibiting the activity or replication of many viruses and bacteria. A fever is generally considered when the temperature is greater than 38°C and is believed to not naturally exceed 42°C. Babies (0–3 months old) and immunosuppressed children may become hypothermic in response to infection instead of developing a fever. In these situations a temperature of less than 36°C is considered a sign of potential sepsis. 'Fever phobia’ is a term coined during research in the 1980s when it was identified that health professionals and lay people had unreasonable fears that fever was an illness or could damage a person (Schmi , 1980). While fever makes a child uncomfortable and the underlying cytokine release is associated with febrile convulsions, there are few other ill effects. Trying to cool a febrile child externally will cause them significant discomfort and is likely to induce shivering and rigors as the body a empts to maintain warmth. Medications with antipyretic actions, such as paracetamol and ibuprofen, are more successful and act directly upon cytokine production and will generally reduce a fever by approximately 1°C. However, the question needs to be asked as to why there is a need to bring down a fever. If temperature is regulated by the body with fever an active part of the immune response and there is li le consequence of fever, it would seem counterproductive to the activity of the immune system to a empt this, other than to bring comfort to a patient. Thus, current recommendations are to not externally cool children with tepid baths or sponging, to keep them dressed comfortably and to use ibuprofen and paracetamol for their analgesic effect rather than as antipyretics (Chiappini et al., 2009). Dehydration Evaluation of dehydration (or hydration status) is a key element of paediatric assessment. Severe dehydration is far less common in developed countries such as New Zealand and Australia but does occur and can lead to death if unrecognised or untreated. Children can become rapidly dehydrated through acute vomiting or diarrhoeal disease or more insidiously with conditions such as diabetic ketoacidosis, and hydration status is an important clinical assessment in respiratory illnesses, such as bronchiolitis, where respiratory distress compromises the ability to feed or drink. A head-down examination for signs of dehydration is the best approach (see Box 56.1), starting with the anterior fontanelle, which should be palpable in most children up to 12 months of age. While decreased urine output is a good marker of dehydration when accurately measured, it is extremely hard to estimate in an acute se ing as it progressively occurs from an early stage due to release of antidiuretic hormone (ADH). A clinical judgment of the severity of dehydration should be made which correlates roughly with a concept of the amount of body water that has been lost as a percentage of the total body weight, with mild dehydration being 1–2%, moderate being 5% and severe 10% or greater (see Fig 56.3). This allows for a rough estimate of fluid replacement that needs to occur. Rehydration may occur with oral fluids, via nasogastric route or intravenous (IV) (including intraosseous [IO]) route. Isotonic fluids (such as normal [0.9%] saline) should always be used for IV rehydration (Santillanes & Rose, 2018). BOX 56.1 Systematic dehydration assessment Anterior fontanelle (if present) Mental state Eyes > Sunken > Tears Mouth > Dry cracked lips > Dry mouth/decreased salivation Pulse and respiratory rate Blood pressure Skin turgor FIGURE 56.3 Severity of dehydration, with clinical signs. Cognition, behaviour and development Children vary enormously in their development, which dictates their degree of responsiveness, interaction with strangers, intellectual ability and emotional response. The assessment of children in an acute se ing can be challenging but success is rewarding. The challenge is to modify the clinical approach appropriately for each child's development and emotional needs. No single technique is universally effective, and the experienced clinician employs a multitude of different approaches depending on the age and responses of the child. In general, an unrushed and gentle manner will be effective, particularly when parents are engaged and distraction techniques employed. Despite best efforts, however, some children will always remain difficult. With critically unwell children, a slow approach may need to be sacrificed to timely intervention. The degree of activity and interaction of a child varies enormously with age, particularly in the first few years of life. The normal behaviour of an infant mostly consists of sleeping, waking, crying to feed, feeding and then sleeping again. Disruption or variation in this process may be the initial indicator of significant illness, as is a child who is not a entive and interested in their environment. Parents and carers Health professionals often misguidedly complain about how parents and carers complicate the paediatric interaction. In fact, they are the greatest ally in approaching a child. Parents and carers need to be engaged in the assessment and treatment process, and generally should be encouraged to remain by the child to provide emotional, and sometimes physical, support. Parents should always be allowed the opportunity to remain by the bedside of or next to a critically ill child, particularly if undergoing resuscitation. This situation is greatly aided by having a dedicated support person allocated to the parents. PRACTICE TIP Unwell children are often described as being 'flat’. This can be more objectively broken down into: level of alertness degree of spontaneous activity resting muscle tone/floppiness. Provision should be allowed for the effect a child's illness may have on parents or carers. They are often affected by anxiety and sleep deprivation, and may be unwell themselves. The term 'just a virus’ is rarely appreciated by a concerned parent. Dismissing or failing to address a parent's concerns will adversely affect the development of rapport and trust. Respiratory distress Respiratory distress is one of the most common acute paediatric issues, particularly among children under the age of 6 years. A variety of underlying causes can lead to breathing difficulty (see Box 56.2). Respiratory failure is a leading cause of cardiac arrest in children therefore ventilation is a vital part of the paediatric CPR algorithm. BOX 56.2 Causes of breathing difficulty in children Children should be evaluated as to their degree of respiratory distress (see Box 56.3). As a child develops progressively more respiratory distress, they become more lethargic, listless and non-interactive. Even if the diagnosis is unclear, effort should be made to localise the underlying pathological cause to upper respiratory tract, lower respiratory tract or an alternative cause such as cardiovascular, neurological or metabolic disease. Children who have respiratory distress due to a non-respiratory system disease tend to have effortless tachypnoea or an unexpectedly low respiratory rate. BOX 56.3 A rapid respiratory assessment Effort of breathing > Respiratory rate > Respiratory noises > Recession > Head bobbing/nasal flaring Efficacy of breathing > Air entry (chest auscultation) > Pulse oximetry Effects of respiratory inadequacy > Heart rate > Skin colour > Mental status Oxygen is the immediate primary treatment of all respiratory compromise. A mask should be applied to a self-ventilating patient, whereas assisted bag-valve-mask ventilation should be commenced should the child not be breathing or when respiration is inadequate. The delivery of oxygen takes priority until pulse oximetry is available when oxygen delivery can be titrated to achieve saturations of 94–98% in the previously normal child. Out-of-hospital advanced airway management (endotracheal intubation) in children is difficult and significantly more challenging than in the controlled environment of the hospital resuscitation room. Paramedics will not be exposed to many paediatric cases requiring intubation, making lack of practice a further complicating factor. Regardless of cause, children rarely need intubation and the risk of exacerbating the child's condition must be balanced against clinical need for an endotracheal tube in the out-of-hospital environment. Upper respiratory tract Croup, or viral laryngotracheobronchitis, is by far the most common cause of acute upper respiratory tract obstruction in young children. However, there are many other causes that need to be considered such as inhaled foreign body, epiglo itis or bacterial tracheitis. The assessment and management of paediatric patients with upper respiratory tract conditions is discussed in Section 9. Lower respiratory tract Lower respiratory tract disease is also very common in children. In children under the age of 2 years, bronchiolitis predominates. Over the age of 2, asthma and viral chest infections are extremely common. Less common are other causes such as pneumonia, pneumothorax, pleural effusion and pulmonary embolus. Bronchiolitis Bronchiolitis is a viral lower respiratory tract infection that occurs in children under 2 years of age. Most cases are due to infection with either respiratory syncytial virus (RSV) or parainfluenza or human metapneumovirus (HMPV). Significant development of the lungs occurs from the first inhalation at birth and continues for a number of years. During the first 2 years of life, there is rapid growth of alveoli (alveolarisation), development of microvasculature and proliferation of ciliated epithelial cells in the terminal airways, or bronchioles (Burri, 2006; Lewin & Hur , 2017). This last is important in bronchiolitis as it is the site of viral infection. Older children and adults regularly suffer chest infections caused by the same viruses but do not suffer the same severity of illness, apparently due to greater functional maturity of the lung. Bronchiolitis tends to run a predictable course, with the child developing progressively worsening respiratory distress, cough and wheeze, which usually peaks on the fourth or fifth night from onset of symptoms (or third night from onset of wheeze). From this point the child usually slowly and progressively recovers with improving respiratory distress, but often with worsening and moistening of the cough as ciliated epithelial cells recover and begin to move debris and mucus from the lower airways. Bronchiolitis is clinically characterised by initially dry 'wheezy’ cough, symmetrical signs of respiratory distress, generalised wheeze and crackles on auscultation of the chest with progressive decrease in air entry with increasing severity. Management is supportive: effective treatments have proven elusive (Ricci et al., 2015). Oxygen is applied to keep O2 saturations > 94% and hydration is maintained through either IV or nasogastric route. Poor feeding, due to inability to suck and breathe at the same time, is usually a good marker of moderate to severe bronchiolitis and a sign that supplemental oxygen and fluids may be needed. Children at high risk of more severe disease include those with chronic lung disease, prematurity or age under 6 weeks. Asthma Asthma is a hyperreactive inflammatory response causing airway obstruction, which leads to respiratory distress, cough and wheeze. In children under 2 years of age, a viral exacerbation of asthma can be difficult to differentiate from bronchiolitis, as both demonstrate symptoms of inflammation of the lungs. The underlying process that causes asthma only occurs as the lung matures: it is common over 2 years of age, uncommon between 1 and 2 years of age and extraordinarily rare under 12 months. The assessment and management of patients with asthma is discussed in Chapter 17. Pneumonia Pneumonia is defined as an infection of the lung parenchyma with alveolar infiltration leading to consolidation, which is where the spongy air-filled spaces of the lung becomes solid with mucus and inflammatory cells (Mackenzie, 2016). Pneumonia can be due to either bacterial or viral infection, and traditionally the most common bacterial organism isolated was Streptococcus pneumoniae, although this has become less common following development of a specific vaccine and mass vaccination of the early 2000s. Bacterial pneumonia will generally present with high fevers, breathlessness and a 'toxic’-looking child: listless, lethargic and flushed. The classic clinical signs of dull percussion, bronchial breath sounds and cough usually take several days to develop. By contrast, viral pneumonia, and that caused by Mycoplasma pneumoniae, tend to present as a severe form of viral chest infection, with breathlessness, cough and generalised chest signs of wheeze and crackles. Oxygen is the immediate primary treatment for respiratory compromise and should be delivered to keep SaO2 > 92%. Appropriate antibiotics are the treatment for bacterial pneumonia: untreated bacterial pneumonia may disseminate into sepsis. Viral infections are generally self-limiting although in rare severe cases may cause acute respiratory distress syndrome (ARDS) and respiratory arrest. Cardiovascular impairment and shock Cardiac causes of cardiovascular impairment are relatively uncommon outside the neonatal period, when most congenital cardiac abnormalities appear. The remainder of children generally have an impairment due to loss of vascular tone (sepsis, anaphylaxis) or loss of intravascular volume (haemorrhage, dehydration). PRACTICE TIP The following features suggest an underlying cardiac abnormality: cyanosis not responding to oxygen therapy unexplained tachycardia gallop rhythm (third heart sound) or murmur enlarged liver absent femoral pulses. CASE STUDY 1: Case 13885, 0920 hrs. Dispatch details A 16-day-old girl is distressed and has been feeding poorly since last night. She is now looking mo led and unwell. Initial presentation The paramedics enter the house and find the mother holding the child in her arms. The baby has a weak cry. The mother is visibly upset and has been crying. A small boy is also in the room. ASSESS Patient history Small babies can be difficult to assess. Babies primarily sleep, wake, feed, cry and fill their nappies. Uncovering symptoms specific to an illness can be difficult; however, some clues may be elicited by looking for changes in a baby's basic behaviour and appearance. The baby's mother tells you that her daughter was born at term via normal vaginal delivery and had no postnatal problems. She went home on day 2 and was breastfeeding well until the previous day when she became fussy and was less interested in her evening breastfeed. She did not wake for a feed overnight and when her mother tried to feed her this morning, she just cried irritably. She has been crying intermi ently since and refuses to se le. She is breathing faster than usual and looks pale. Initial assessment summary Problem Conscious state Position Heart rate Blood pressure Skin appearance Speech pa ern Respiratory rate Respiratory rhythm Chest auscultation Temperature Pulse oximetry History Generally unwell Alert In mother's arms 180 bpm, regular 85/40 mmHg (right arm) Cool, mo led Short, irritable cry 63 bpm, shallow panting breaths Panting breaths Bilateral air entry; no crackles or wheeze 35.8°C Unable to obtain trace Poor feeding, irritable cry, respiratory distress D: There are no dangers. A: The airway is patent. No stridor. B: There is increased respiratory rate with mild effort. C: Heart rate is 180 bpm. Colour is mottled. Capillary refill time is 3 seconds. CONFIRM The essential part of the clinical reasoning process is to seek to confirm your initial hypothesis by finding clinical signs that should occur with your provisional diagnosis. You should also seek to challenge your diagnosis by exploring findings that do not fit your hypothesis: don't just ignore them because they don't fit. This case demonstrates the difficulty of assessing a small baby. The most important assessment question—’Is this child sick?’—needs to be answered. Once this has occurred, a list of possible differentials should be composed. In the out-of-hospital se ing, it is often be er to target bodily systems initially rather than specific diagnoses; many diagnoses will require diagnostic testing that occurs in a hospital se ing but treatment may need to be empirically initiated in the meantime. Seeking out specific symptoms and signs may help refute potential diagnosis or make them more likely. What could it be? Infective cause The 'big four’ serious bacterial infections in the neonatal period are pneumonia, sepsis, meningitis and urinary tract infection. Causative organisms are mostly the organisms that newborns are becoming colonised with as a part of normal life: E. coli, Staphylococcus and Streptococcus (especially group B). It can be difficult in the out-of-hospital se ing to clinically differentiate these infections in a baby. This baby has signs of irritability, poor feeding, respiratory and cardiovascular distress, and a low temperature, all of which fit the criteria for potential serious bacterial infection. Further assessment for infection (urine screen, chest xray, blood count and culture, and lumbar puncture) needs to occur, with empirical treatment with IV antibiotics until infection is confirmed or excluded (usually at 48 hours). Cardiac cause Congenital cardiac defects occur in approximately 1% of newborns. Some of the more serious defects rely on a patent ductus arteriosus (PDA) to maintain adequate oxygenated blood flow around the body and are known as ‘duct-dependent circulations’. While most of these serious defects are detected with antenatal ultrasound, some of them, particularly coarctation of the aorta, can be difficult to diagnose. A child with a coarctation of the aorta relies on blood flow from the pulmonary arteries through the PDA to supply the left arm and lower body with blood (see Fig 56.4). In these situations, the PDA usually closes within the first month of life (rather than within the first few days) and the subsequent poor perfusion of oxygenated blood to the lower body leads to metabolic acidosis and progressive organ failure. Children appear ‘toxic’ in a similar way to children with sepsis, and it can be hard to differentiate initially. The absence of palpable femoral pulses is a diagnostic sign. Treatment is IV prostaglandin to reopen the ductus arteriosus and careful IV fluids to maintain good perfusion (Park, 2014). FIGURE 56.4 Coarctation of the aorta. Arrythmias are generally rare in the neonatal period but persistent supraventricular tachycardias (SVT) may occur. The newborn heart initially tolerates the increased cardiac work well, with heart rates 250–300 bpm, but over days to weeks the child progressively develops cardiac failure. As cardiac failure develops, poor feeding, breathlessness and poor perfusion occur. Other rare causes of cardiac failure in this age group would be infective myocarditis or congenital cardiomyopathy. Metabolic cause Congenital adrenal hyperplasia is an uncommon condition where steroidogenesis cannot occur properly in the adrenals due to an absence of mediating enzymes. The resulting excess or deficit in mineralocorticoid, glucocorticoid and sex hormones results in a group of clinical conditions. Most commonly females develop virilisation of primary or secondary sex characteristics. Salt wasting due to absence of mineralocorticoids is also a common problem. In a male child (in whom virilisation is not apparent) and salt-wasting crisis may be the initial presentation, with shock due to profound hyponatraemia and the subsequent dehydration and vomiting. Treatment is acute rehydration, normalisation of electrolytes and replacement of hormones (Trapp et al., 2011). Inflicted injury (NAI) Inflicted injury, or non-accidental injury (NAI), should be considered in all cases where the diagnosis is unclear. See below for further information. Significant abdominal or chest injuries may present with an irritable child with poor feeding and potentially respiratory or circulatory compromise. While loading the child for transport, the paramedic checks, but is unable to feel femoral pulses, making the likely diagnosis a congenital cardiac defect with a duct-dependent circulation. TREAT The patient is indeed unwell and should be transported to hospital. The child is self-ventilating and has adequate perfusion. The decision to transport the child without delay is a good one in this situation, as most of the necessary diagnostics and treatments are not accessible in the out-ofhospital se ing. A blood sugar level should be checked in all unwell children—the younger the child, the more important it becomes. Until it is demonstrated that oxygen is not required, oxygen should be provided at 4–6 L/minute via face mask. If the child had been in an unstable or compromised condition, IV/IO access should be urgently obtained, IV fluid bolus of normal saline 10–20 mL/kg (or if BSL