Every paediatric emergency department should provide all the essential steps that are needed for a child. This should include initial assessment, resuscitation, stabilization and transport of the critically or injured child. Most critically ill children will first receive initial hospital care in their local emergency department for stabilization, then will be transferred to their nearest tertiary centre, depending on the availability of a bed.

A critically ill child will mostly present at a local district hospital. During a resuscitation there should be a paediatric registrar or consultant leading the team during the CPR and when stabilizing the child. Other team members include an anaesthetist consultant, paediatric junior doctor and a paediatric nurse. If the child is deteriorating, the next stage is preparation for intubation and ventilation. The nursing team will then prepare all the drugs needed for the retrieval team. The child will be retrieved by a team of specialist nurses and doctors. The Children’s Acute Transport Service (CATS) retrieval team complete the electronic drug chart (see Transportation medication chart) as a quick tool for referring a child. By adding the weight and date of birth of the child it will automatically calculate the doses and then be ready to print to use as a drug chart.

Intubation is required when the child has difficulty in maintaining their own airway, is in respiratory failure, to minimise oxygen consumption and to maximise oxygen delivery and to prevent secondary brain injury. It is important to intubate the child for a number of reasons; the patient’s airway is protected and secured, to provide positive pressure ventilation to children with respiratory failure or serious hypoxaemia, and to support the respiratory function during anaesthesia. A systematic approach to the management of the critically ill child is essential to ensure the required interventions can be delivered.

Endotracheal (ET) tubes will be used to maintain the airway; they can be cuffed or uncuffed, this will depend on the age of the child. Ensure a secured airway by good positioning of the child’s airway and with no significant leak from the ET tube. Add positive end expiratory pressure (PEEP) as soon as possible to the ventilation circuit. The gastric tube is also used to allow free drainage from the stomach in the ventilated child. Always discuss with the consultant of the transfer service about the induction agent and prepare the fluid bolus and possible dopamine infusion. A chest X-ray post intubation will be needed with a copy for the transport team.

Ensure adequate ventilation by monitoring end tidal carbon dioxide (ETCO₂). If there are ventilation problems, it is essential to rule out any ET tube-related problems urgently. These may include inadequate sedation or paralysis, large leak around the ET tube in a child who requires high ventilatory pressures. The anaesthetist will need to reassess the child and review intubation. Suctioning and physiotherapy will be considered if there is an unintended endobronchial intubation which may result in a tension pneumothorax, which must be drained. All the ventilation strategies must be discussed with the transfer consultant. There must be appropriate targets for blood gases, all depending on the clinical condition of the child.

In a life-threatening situation, two good intravenous access points are a priority. A peripheral or interosseous (IO) inotrope infusion can be used until there is a central access. The blood gases can be taken from a peripheral line until the arterial line is placed. Continuous blood pressure (BP) readings must be taken until the placement of the arterial line. Circulatory support can be discussed with the transfer consultant for the most appropriate inotrope. Early aggressive fluid resuscitation and inotropes may be required. In the circulation stage, you need to check ETCO₂ tracing to monitor any poor cardiac output and frequent BP checks until the arterial line is placed.

See chart to commence adequate sedation and paralysis of the child. Monitoring of blood glucose levels is essential along with pupil reactions and body temperature. To control temperature, a bear hugger may be used if the child is hypothermic and aim for normothermia, unless cooling is indicated. Maintaining fluids and consideration of a urinary catheter are important to monitor the output of the child or avoid fluid retention. Further tests such as CT scan or a blood film may be requested by the transfer consultant, and antibiotic infusions may be considered. Once the child is stable, all the notes must be photocopied and X-rays sent must be ready for the retrieval team.

Care of the family is important and they need to be prepared for the transportation of their child. It is not always possible for the parents to be able to accompany the child so arrangements need to be made for the parents to travel to the receiving hospital. They may not be in a fit state to drive and this should be considered. Careful documentation of discussion with the family about their child’s condition should occur.