Updated 17/03/2026

APLS Algorithm

COACHED for Defibrillation in Cardiac Arrest

Monash Children's Medication Book - printable version

ANZCOR Guidelines - Paediatric

ANZCOR Guidelines - Newborn

Updated 27/02/2025

Here are some fantastic resources to develop your understanding of airway management in infants and children.

RCH CPG

How children are different

Positioning infants and children in airway management

Apnoeic oxygenation during paediatric intubation

Intubation checklist

And finally (and most importantly):

Fixation bias in healthcare

Cognitive biases can risk patient safety as much as anatomically or physiologically difficult airways.

Key points based off a survey sent to >22,000 medical practitioners:

Main contributing factors to fixation bias:

• stress
• poor communication
• unexpected complications

Barriers they thought helped prevent re-occurrence:

• simulation
• improved teamwork
• asking for help or other opinions from colleagues
• taking breaks

Four other cognitive biases to be aware of:

• anchoring
• cognitive miserliness
• confirmation bias
• overconfidence bias

Updated 20/04/2026

Rapid assessment

Do a structured ABCDE assessment to help you work out if it is anaphylaxis or not and how severe it might be.

Anaphylaxis KITS

We have kits in the department to make it super quick and easy to get it drawn up and given.

The box can be found at triage, Green Pod, AC and Resus.

It has all the kit you need to draw it up and the ASCIA simplified dose in table form (see below).

Also : never anything smaller than a blue needle - yes - even for babies, you are saving lives not being nice (keep telling yourself that).

About the dose and how many ml’s of what adrenaline

Due to the recurrent situation of dosing errors with adrenaline due to the fact that it is a stressful situation with cognitive load and a very tiny small dose of a very concentrated drug, it is not uncommon to have frequent drug errors, particularly in our paediatric group and especially the under 1 year age group it is very easy to make a x10 error!

To simplify things, the coroner and ASCIA have decided to advise as follows:

• Only ever use the 1:1000 ampoule (the small one)
• Only ever dose ml’s (take the mcg/kg math and then converting it to ml stress away)
• It is only ever dosed in 0.1ml increments
• i.e. if they look roughly 2 years or under: JUST DOSE 0.1 ml STAT -  no need to do the math = just get the drug in STAT at a safe dose.

Check the lid of the box of the anaphylaxis kit.

Do not do the math of 7.5kg = 10mcg/kg = 75mcg = 0.075ml

This is an incredibly difficult dose to draw up in the heat of the moment.

Updated 25/03/2026

Infographic

Intranasal Adrenaline devices are now available in Australia for those > 4 years of age and > 15kg (the research was based on this cut-off, may change in the future).

It comes in two doses: 1mg for 15-30kg (green) or 2mg for >30kg (blue). It comes in a foil-packaged two pack. Each spray contains only one dose.

Importantly, it is not yet on the PBS nor available over the counter; it is the most expensive option by far for Adrenaline devices ~$194 (compared to $25 for Epipen with PBS script).

The IM Epipen device remains the standard of care: keep using it.

The advantages of the IN device:

• no needle - less hesitation to use it
• very small and easy to carry around - can buy a little carry case to clip onto a keyring or bag
• super easy to use - simply put the nozzle in the nose, push the plunger, done

The IN device may be considered for:

• needle phobic users
• novice or infrequent users
• neurodivergent users
• special request from a patient willing to wear the out of pocket cost

Administration:

• the spray should be inserted into a nostril with the nozzle pointed straight toward the forehead
• patients should not sniff during or immediately after dosing
• if any liquid drips out of the nose, a second dose may be needed
• if symptoms don't improve within 5 minutes after the initial dose, a second dose should be administered using a new nasal spray, ideally in the same nostril

Not all pharmacies will stock it, so the patient should call around first.

The ASCIA action plans have been updated in accordance with the new device.

For more information, see Allergy & Anaphylaxis Australia - neffy and Australian Prescriber.

Updated 14/10/2025

Infographic

First line: Midazolam 

Midazolam can be given many different ways (0.15mg/kg IV, IM, IO; 0.3mg/kg IN, Buccal, oral - max 10mg)

Remember: you repeat the dose at 5min if ongoing seizure / status

Diazepam: okay if that is all you have access to (IV/IO only)

Lorazepam tends not to be used in Aus

Second line: Just go Levetiracetam

Dose 40-60mg/kg IV/IO - max 4.5g

As proven by ConSEPT and EcLiPSE trials: Keppra and phenytoin kind of equivocal in many ways

EXCEPT…Keppra is quicker to draw up (no infusion), quicker to administer (5 min vs 20-30 min), needs no CVS monitoring, does not cause nasty side effects, doesn’t need an infusion pump or q5min obs, not nursing care intensive, etc

Keppra is now cheaper too (only $2 a vial!)

Maintenance Rx:

If your patient is already on Keppra maintenance Rx (and compliant/good absorption assumed): pick phenytoin as your second line

NB: Avoid phenytoin use where able for Indigenous Australians due to risk of DRESS.

If they are already on phenytoin maintenance: pick Keppra as your second line

If they are on both: reload your Keppra dose as per algorithm, but make Sodium Valproate your 3rd line agent (or Phenobarbitone if baby < 1 yr age) - if you can avoid < 3yr age then do, but if you need to give it - give it - small risk hepatoxicity if undiagnosed metabolic disease present

About Phenobarbital: 

Consider in babies (up to 1 year) but remember can cause resp depression

Remember: you can STOP the infusion when the seizure stops

About Pyridoxine: 

Rarely need to give: only for a type of developmental/ encephalopathic epilepsy type or if you SUSPECT metabolic (eg hypoglycaemia + lactic acidosis + have not stopped seizing and you have no clear etiology – usually in the peri-neonatal period)

So: little baby seizing, they are not stopping despite everything you have given, you are at the end of seizure algorithm and intubating for that reason in anyway AND the blood gas is wonky and you are suspicious for metabolic cause --> ask the question to  PIPER/neurology for opinion

Difficult to get hands on anyway: NONE in our hospital, will be in some but not all hospitals (eg Ballarat, some metro, all children's hospitals, etc)

Needs special SAS form to be done

Causes rubbish side effects: risk CVS collapse / apnoea

Should only be specialist initiated

You will be intubating this baby and PIPER will bring it with them or take the baby to it ie transfer

If you have a baby in your catchment area with known pyridoxine-deficient seizures: might be worthwhile to have a vial in your hospital available

You can technically give 25mg tab x4 via NGT/PEG but in this scenario IV load preferred

About Thiopentone:

Good drug that does many good things (works on many of the seizure receptors and neuroprotective ie ‘chills the brain out’ but: tricky to draw it up (2 step technique to prep infusion), almost always spills, smells like sulpha / rotten garlic, can cause hypotension and since ketamine came along it took the back seat.

It is still kept in ED, OT and ICU.

Updated 21/07/2025

In 2022, the National Asthma Guidelines and the RCH CPG for adolescents with asthma changed significantly to SMART Action Plans.

Symbicort Turbuhaler (Infographic):

• DPI
• Requires NO spacer
• Requires NO breath co-ordination (the natural breath taken will activate the particles in respiratory tract)
• More 'green' ie environmentally friendly
• At baseline start with 1 puff BD
• Then up the dose to 2 puffs bd (if needed)
• For breakthrough symptoms: take 1 puff extra prn
• If > 6 puffs extra in a day for > 2 days --- need to get medical review (GP or ED)
• if > 12 puffs extra in a day -- need to get medical review same day
• If having acute severe or critical attack: keep using as many puffs as needed till help arrives or pt arrives in ED
• On arrival to ED: switch to severe/critical/life threatening CPG as indicated
• Remember to educate about 'mouth rinse straight after use' to avoid oral thrush - important to do with the DPI
• Remind pt to refill when arrow reaches 'red' on the counter dial (20 doses left)

Symbicort Rapihaler (Infographic):

• The 'puffer' MDI
• Ideally must use spacer - unless they can co-ordinate breath in well (and even then, less effective without spacer use)
• Less 'green' ie contributes to environment carbon gasses
• At baseline start with 2 puffs bd
• Then up to 4 puffs bd if needed
• For breakthrough symptoms: take 2 extra puffs prn 
• If >12 puffs extra needed in a day for > 2 days --- need to get medical review (GP or ED)
• if > 24 puffs extra in a day -- need to get medical review same day
• If having acute severe or critical attack: keep using as many puffs as needed till help arrives or pt arrives in ED
• On arrival ED switch to severe/critical/life threatening CPG as indicated
• Remind pt to refill when arrow reaches 'yellow' zone on the counter dial (20 doses left)

The plans can be found here to print.

Remember:

1. To print in COLOUR: more likely to be a visual reminder, not get lost and more likely to be memorised better. Some schools or care centres require the plan to be printed in colour.
2. To print on BOTH SIDES = one piece of paper (less bits to lose, more environmentally friendly)
3. The back part of the action plan are the individual instructions for 'how to use' , hygiene, etc - all important stuff
4. To print at least 3 COPIES: one for patient (suggest sticking on inside of bathroom mirror or inside cupboard door), one for parent / care giver (suggest sticking on fridge or on inside of pantry door), one for school
5. If parents are separated: you need to print one extra copy (often exacerbations happen on the end of the weekend with the 'less-frequent-caregiver' or the 'weekend-mum or -dad')
6. Ask the patient and/or caregiver to take a photo of the action plan on their phone and keep it there (if paper is lost they will likely always have access to their phones still)
7. If they are going away to school camp, etc to take a copy for the appointed caregiver of event

Updated 14/07/2025

Infographic

In 2022, the National Asthma Guidelines and the RCH CPG for adolescents with asthma changed significantly to SMART Action Plans.

Major changes summary:

• NO salbutamol (SABA) on the action plan – only LABA! No short acting bronchodilators
• With acute presentations to ED with asthma exacerbations: please still follow the Acute Exacerbation Management as per usual (i.e. Salbutamol / Atrovent etc)
• Did you know?: you can just ask to them to use the Seretide or Symbicort puffer they have in their hand and start a mini burst with 2-4 puffs with that, while you go get the salbutamol/ipratropium
• When ready for discharge: follow the SMART action plans
• They ALL need to be on an ICS for maintenance: everyone goes home on a steroid
• They can (in consultation with their regular care provider) take ‘breaks’ over ‘well periods’ eg if winter + spring is their ‘trigger period’, be on it for 6 months then medical review with them and take a break for 6 months until next year etc
• Dry powder inhalers are now in vogue: much greener on the environment (i.e. Symbicort Turbuhaler), cheaper and do not require a spacer (less bits = better compliance plus also much cooler if you’re a teenager to not carry a big bit of plastic around)

Why the changes?

• By age 12 years old = they are the group of true asthmatics, ie proper bronchospasm (as opposed to younger groups where it might be often exclusively viral induced / seasonal / outgrown eventually)
• Of the paediatric fatalities due to asthma = this is the biggest age group
• Likely due to non-compliance which is multifactorial:
  • less dependence on and oversight by parents (trusting mature child to be compliant)
  • body image and peer acceptance are important and carrying an inhaler might not be deemed ‘cool’ or even lead to bullying risk
  • non disclosure to care givers e.g. going to camp and not notifying in charge caregiver or providing asthma plan / sleep overs at friends and not admitting to symptoms / separated parents etc
  • spending longer periods away from home e.g. extracurricular activities, camp, work etc and losing routine for maintenance treatment e.g. : before brushing my teeth-regime and losing parent/caregiver oversight on this
  • medical independence in regards to ‘rights’ seeing GP independent from parent / care giver and parent losing the oversight / enforcement of action plan as such due to not being aware
• Anaphylaxis co-existing in this group of asthmatics are common and subsequently higher risk of mortality
• mental health / depression
• vaping habit

As such the thoughts from coroner and the investigation bodies were as follows:

1. maintenance regime with inhaled corticosteroid is a MUST because = baseline anti-inflammatory effect in this group is of great importance for major prevention of mortality
2. a long acting instead of a short acting beta agonist is better value i.e. if a dose missed here or there not as critical (a little bit that lasts longer is better than a little bit that does not last long)
3. the combination inhalers will make compliance better = less puffers + less instructions = easier to use + better compliance overall

• You want to send them home on number 1 or number 2 ideally
• Can add in oral prednisolone or tiotropium if long flare
• Consider Montelukast (remember to discuss side effects)

Updated 25/06/2025

Infographic

RCH CPG

Pre-school asthma

• Viral Induced wheeze is now out of vogue, ie we do not call it that anymore
• It is now called: PSA
• Age 1-5 years
• Majority will outgrow by school going age
• Triggers remain mainly viral / seasonal
• SABA with ASTHMA action plan as per usual
• Low threshold to commence ICS
• Can consider Montelukast in lieu of ICS if risk of S/E accepted by parents
• This might be better for non compliant child (eg neurodivergent who does not like inhaler or repeated poor parent compliance due to the challenges to administer etc)
• Oral Prednisolone reserved for mod-severe exacerbation requiring ED/hospital stay only
• Dose is now standard 1mg/kg (not 2mg/kg stat then 1mg/kg) then consider for another 2 days
• Can also give single Dexa 0.3mg/kg in lieu of Prednisolone (again consider in poor compliance situation)

And lastly, remember:

Broncho-constriction can be wheeze, but can also present as:

• periods of sudden, persistent cough (especially night time)
• periods of feeling SOB limiting activities (often exercise or activity induced)
• periods of sudden persistent change in WOB
• changes in breathing effort and perception of breathing limiting normal activities or sleep

Updated 07/10/2025

Infographic

The 2016 Melbourne Thunderstorm Event event was the biggest, most catastrophic Thunderstorm Asthma event on record in the world, with the highest mortality rate to date. In 2010 there was a smaller scaled event too. To our knowledge Melbourne has now had 4 Thunderstorm events on record (dated from 1987). Recurrence is possible, so we need to be vigilant.

Many will remember the day and some of us would have worked on the day as well.

For those who are not aware, here are some amazing facts to remember:

It was the culmination of a 'perfect storm'

A wet spring (lots of grass pollen growth) + a couple of stinking hot November days (temps up to 40 - 44 degrees) + thunderstorm rolling in with humidity releasing pollen + strong wind gusts due to the storm and a sudden drop in temperature – triggering a massive pollen release over a large geographical area.

A major disaster

Between 7pm and 7:15pm, 000 calls were overwhelmed with 201 calls in just those 15 min: of those calls, 150 were waiting for an ambulance to dispatch (with none to dispatch) and of those, 100 were CODE 1 calls.

Over the next 5 hours the Code 1 calls blew out to 643.

By 7:30pm, Vic Pol and the fire brigade where asked to attend where ambulances could not get to (together they attended about 20 calls in those first minutes of the event).

Only one hospital confidently called a Code Brown situation within hours.

• 5 hospitals were on ‘Code Brown standby’
• Several were in a Code Yellow (admin overload with triages etc)
• None of the private hospitals activated any code

A health emergency was only declared at 11AM the next day.

Severity of illness

There was a 672% increase in Respiratory presentations over those two days (compared to the average for the previous 3 years).

• 27% were children < 14 years of age.

ICU had a 3000% increase in admissions over day 1 of the event.

There were 17 cardiac arrests: 7 died on scene, 2 made it to hospital on mechanical CPR, 8 had ROSC on scene.

The coroner had a massive 186 more referrals for deaths that week but in the end only officially declared 10 cases due to the event, partly also because of limited info for some as standard documentation admin systems were overwhelmed.

Lessons

After a massive inquest and multiple interviews with responders and staff who worked on the day, these were the take home points:

Always be vigilant with symptoms like SOB, wheeze or 'can't breathe' triages: even when there is no asthma history

• Almost 50% of those affected had never been formally diagnosed with Asthma, had no preventers or asthma plan
• About 50% of those affected with this event were Asian and Indian heritage / immigrants: again a cohort we don’t often see with asthma issues: be vigilant even if no asthma history
• A vast majority of those affected had a history of hay fever, allergic rhinitis or spring allergies

Have a low threshold to give a stat dose of antihistamine to the ‘spring /summer’ asthma patients or if there is no clear trigger for their asthma exacerbation, eg not a viral illness

• Of those who worked on the day: felt the patients they gave antihistamine to at the start rallied much quicker and recovered better
• also consider recommending steroid or antihistamine nasal spray

Make sure you check your hospital's Code Brown protocol

• Code Brown protocols have now been developed at all hospitals and there is more awareness around this
• BH protocol

Check your hospital's thunderstorm asthma policy

• Thunderstorm Asthma protocols now exist EVRYWHERE: at pharmacies, at UCCs, in EDs etc
• There is a thunderstorm asthma box in our drug room containing:
  • 200 Salbutamol inhalers
  • 80 spacer devices and attaching adult and child masks
  • 10 boxes Salbutamol nebs
  • 40 bottles Prednisolone tablets
  • 15 bottles Prednisolone (Redipred) oral solution
  • 200 Adrenaline amps
  • pre-printed labels, blank labetls and small plastic bags for any take home medications
• BH policy

Pollen counts matter

• have some awareness: many resources eg Vic Emergency app, Air Rater app, Pollen forecast website etc

Other useful resources to check out

• Vic DOH page
• National Asthma Council
• Asthma Australia
• ASCIA

Updated 13/05/2025

A multidisciplinary simulation session with the ED, Paediatric, ICU and Anaesthetic teams at Bendigo Health covered the presentation of a previously well child with sudden unexplained collapse and out of hospital cardiac arrest.

Here are some resources from that simulation session that can assist clinicians with the very difficult task of delivering bad news and managing an end of resuscitation decision.

Ongoing education to fill this role is super important: your words and actions will forever form part of the families' deepest memories.

Delivering Bad or Life-Altering News

These protocols and mnemonics can help to guide the delivery of bad or serious news to either patients and family members. See the article by Berkey et al for more detail.

ABCDE

1. Advanced preparation
2. Build a therapeutic environment/relationship
3. Communicate well
4. Deal with patient and family reactions
5. Encourage and validate emotions

SPIKES

1. Setting
2. Perception
3. Invitation
4. Knowledge
5. Emotions
6. Strategy & summary

BREAKS

1. Background
2. Rapport
3. Explore
4. Announce
5. Kindle
6. Summarise

NURSE

1. Naming
2. Understanding
3. Respecting
4. Supporting
5. Exploring

The 4Ls of Breaking Bad News

1. Listen
   • Actively listen to the patient's/family's concerns, questions and emotional reactions.
   • Don't interrupt, but rather allow them to express their feelings and ask for clarification.
2. Let
   • Allow them time to process the information and react to the news.
   • Acknowledge their emotions and validate their feelings.
   • Avoid rushing or trying to force them to move forward before they're ready.
3. Link
   • Provide resources and support that can help them cope with the news.
   • This might include information about treatment options, support groups or counselling services.
4. Leave
   • Respect their need for time and space to process the news.
   • Don't force them to discuss further if they're not ready.
   • Offer to follow up with them at a later time.

The experiences of parents

Evidence supports parents and carers being in the resuscitation room:

• the majority want to be there
• they feel their child is advocated for
• they are there for them in their moment of need (they did not abandon them)
• they feel and see how everything possible is being done
• they feel and see the emotions in the room
• they understand better how sick their child was
• at three months post event, they suffer less PTSD and more acceptance
• the need for healthcare workers to be able to fill the role of this support person is a pivotal role in any major paediatric resuscitation

Social Work

Social workers can play a critical role in supporting a family during and after a resuscitation event, no matter the outcome. They can be contacted to attend the ED during their available hours.

Here are some very valuable resources that the ED social worker has provided:

• RCH Resource for bereaved parents
• Always Your Child
• Planning a funeral for your Child

Other links for further reading:

• Grief Link
• Ladybird Care Foundation
• Bears of Hope
• Red Nose
• Heart Kids
• Amber Community
• Feel the Magic

Health professionals - our experience of grief

As a healthcare provider (doctor, team leader, nurse), am I allowed to show emotion? Is it unprofessional? Can I cry? Is it acceptable?

On a Don't Forget the Bubbles post, Andy Tagg reflects on his own experiences as an Emergency Doctor on this topic.

At the end, he shares his very own personal experience where he was on the unfortunate receiving end of experiencing his own child's death and his thoughts on the treating doctor sitting down to cry with him.

Updated 07/07/2025

Infographic

Triage: ‘Baby funny breathing’

• It’s either a very normal baby complaint ie : periodic breathing

or

• It’s pretty serious until proven otherwise ie: apnoea 

Just about zero to 180 degrees of separation…tricky...

If they are < 6 weeks corrected age: the triage is a category 2 until medically assessed

If they are > 6 weeks corrected age with normal obs at triage and screening questions suggestive of periodic breathing: can be a category 3, if all reassuring

Definitions

Apnoea:

• absence of breathing for a period of >15 seconds often associated with a bradycardia and/or desaturation.
• common occurrence in preterm neonates that is often due to idiopathic apnoea of prematurity
• Both preterm and term neonates may have apnoea related to underlying illness or pain.

Periodic breathing:

• a normal neonatal breathing pattern
• characterised by alternating cycles of five to ten seconds of breathing and pauses in breathing
• is not associated with bradycardia or cyanosis.
• increases in frequency between two and four weeks of age and resolves by six months of age
• Babies have an immature respiratory centre. When they breathe normally, they blow off their carbon dioxide. This causes them to become hypocapnic and they stop breathing in response. This causes their carbon dioxide to increase and they then become tachypnoeic to blow off their increased carbon dioxide and they subsequently become hypocapnic and the cycle starts again.

Assessment

A simple approach to history taking:

• Ask your questions around trying to understand if it was periodic breathing event vs a suspected apnoea event?
• If it sounds like an apnoea event or not sure:
  • Ask your questions around physiological compromise, how long it lasted, how it ended (needed stimulation etc)
  • ?more than one or isolated event
• Try to understand the events immediately pre and post apnoea event: feed / fever / well / unwell/ sleeping / pain / minimal handling / etc
• Progress your questioning to try and understand possible causes
• Proceed to your standard history for babies: perinatal / birth growth and development / immunisations / social hx

Examination:

• Settle in a cubicle or a space in ED
• Expose and examine
• Set of full obs
• Observe a feed (no need to do a direct observe - as long as feed is in an area while on a sats probe, parent can press buzzer if help required, etc)
• Do a set of obs post the feed (no BP this time - just sats and HR is fine)
• Re-examine (not thorough - just cursory this time) and particularly handle the baby (pick up, hold, cuddle, leopard or tiger hold, dress / undress : while talking to parents about discharge stuff etc etc)

Management

If after:

• 2 set of obs
• a feed
• a period of observation leading up to / post feed
• 2 examinations (1 pre and 1 post feed)
• handling well after a feed
• -> screen social situation / gauge safety netting situation and discharge home
• -> GP F/U within 48 hrs

If still unsure at that stage: ask for second opinion:a senior in ED, another consultant to review for second opinion or ask paeds to review

This can all be done within 4 hrs if pt was seen within triage category time

Management of an ‘observed’ breathing event in ED:

• Wait 10 seconds
• If does not self-resolve --- tactile stimulation by good rubbing of feed or gentle rubbing chest wall or back
• If baby has NGT/OGT in situ --- give gentle tuck on NGT/OGT or if suction close by --- gentle nasal/oral suction (not deep in the oropharynx)
• Make sure nose is decongested

If at any point:

• desaturates <90%
• HR < 100bpm
• cyanosis clinically
• floppy
• -> start BVM or Neopuff PPV support until recovered
• If the event was significant or repetitive episodes then start CPAP (nasal preferred, with or without cut down tube)
• If ongoing: trial prone position with a safe position ensuring non-obstructed airway

Treat the cause: so --> continue to look for cause and manage as appropriate

Remember:

• Always decompress the stomach and decrease or stop feeds
• Ensure baby not too warm: better to keep around lower normothermic range (ie don’t overheat)
• Ensure BSL is normal
• Ensure hydration status is normal
• Manage any pain / irritation (dry nappy / loud noises or alarms / cords / strapping / analgesia)
• Minimise handling (even mum cuddles if you are worried)

Disposition

• If in neonatal period: discuss with paediatric team re ?caffeine loading
• If significant or frequent apnoeas persist --- intubate, ventilate + transfer

Updated 11/12/2025

Infographic

An interesting case:

A child presented with excruciating eye pain with a red eye, clutching at the eye, not wanting anyone or anything close to the eye.

• Perfectly well and healthy and happy after a fun day out in the sun enjoying a summer day and then in the evening suddenly out of the blue just screaming with eye pain.
• No history of trauma
• No history of foreign body
• No medical history

The culprit - affecting both children and adults alike - was a tiny beetle.

Since the 1970s, there was a seasonal epidemic of acute, extremely painful red eye in the summer months in North East Victoria.

It remained a mystery for many years until the 1990s when a local ophthalmologist figured out the mystery and gave it a name:

Christmas Eye due to overlap with the Christmas season

Caused by a tiny, tiny beetle present around the harvest season (summer)

Its presence in the eye is very innocuous and you might not even be aware of it at all as you are playing outside in the grass or going for an evening walk.

You might inadvertently rub at your eye, so minor you might not even have a memory of it.

And then a couple of hours later you will be woken up with excruciating eye pain.

It is thought that:

• The rubbing of the eye causes you to crush the little beetle
• A delayed inflammatory response happens
• A substance called ‘pederin’ gets released and causes a local blistering reaction and it is not uncommon to see up to 90% of the corneal surface as one big blob of abrasion when you get the fluorescein stain done, almost all of the eye surface will have fluorescein take up and just look like one big green angry eye

Management

It gets managed with a washout, chlorsig drops and the eye doctor will pop a silicone hydrogel contact lens on and monitor it every couple of days

Due to high turnover of epithelial cells it heals in about 7-10 days and long term complications are rare

Patients will often arrive to ED in extremis of pain and require strong analgesia and topical lignocaine drops ASAP

It is now thought to have spread somewhat to include geographical areas of North East Victoria, Western Victoria, Gippsland and South and Central NSW

Differential of painful red eye to remember:

• Acute glaucoma
• Anything with a ‘-itis’:
  • Keratitis of any kind
  • Uveitis
  • Endophthalmitis
  • Conjunctivitis of any kind
• Foreign body +/- corneal abrasion
• eye injury (in kids can be undisclosed history):
  • Penetrating trauma
  • chemical

Updated 06/08/2025

Infographic

Paediatric CXR

• By far the most requested imaging in kids
• By far also the most unnecessary imaging request across the board (DFTB and Choosing Wisely)

One of the most important reasons not to do a paediatric CXR is that they have features and findings for certain age groups that will be very normal for that level of development but if you compare it to an adult CXR it would be an 'abnormal' finding.

• Thymus
• Big heart
• Tracheal buckling
• Ribs
• Vascular markings

• More cost
• More lifetime radiation
• Longer stays in ED
• Hospital admission
  • Eg that bronchiolitis baby that you could have send home, now had a CXR with some mucus plugging / peri bronchial cuffing and atelectasis and now you are calling it a CAP and suddenly sending home now doesn't look so reassuring anymore...
  • or, you do send them home with antibiotics but in 3 days you see them again, this time for diarrhoea and dehydration...
  • or, the 1 year old with the 'full mediastinum' or 'right upper lobe' consolidation gets and alternative diagnosis than just 'hey this is his thymus, this is perfectly normal'

• bronchiolitis
• asthma
• first wheeze
• croup
• external request

• Just ask yourself: what is the specific question I have here?

• You don't need a CXR to help you
• It's perfectly fine to diagnose without a CXR, it's old school, but it is still cool

• eg if they already had antibiotics and is in with a (probably subsequent / back-to-back) viral illness but you are unsure if it is non-resolved CAP vs now new viral illness?
• or, maybe they are already on antibiotics and you are screening for: complication (eg parapneumonic effusion), atypical infection or else (eg lymphadenopathy if you are broadening your differential list)

• Infection - PUO, sepsis, complications
• Cardiac - heart failure?
• Foreign body
• equipment - ETT, NGT (not routine), etc
• Trauma

Updated 03/12/2025

Infographic

BH Prompt Guideline

About Dexmedetomidine

Been around since 1999 and of recent times have gained real popularity in paediatric population due to safe side effect profile

The best aspect: NO NEEDLES as it is given intranasal!

Next best thing: minimal side effects almost zero serious (meaning needing medical intervention to correct) side effects!

• The most common side effect is asymptomatic bradycardia (mainly thought to be a sleep bradycardia as the drug simulates a deep sleep or a good nap but could also be because it increases the blood pressure a little bit which sends your physiology to decrease heart rate)
  • For those who looked at this in studies or in their respective departments via audits they found just stimulating the patient ‘fixed the number’ and almost all where asymptomatic and none required medical intervention
• For those who actually had hypotension it was due to re-dosing, underlying cardiac condition or medications (eg beta blockers) or those running on infusions eg in PICU

Short of the long : it is SAFE

Dosing

• Make sure you dose effectively using the mucosal atomization device (MAD) steps highlighted in the guideline and infogram
• Dose 30 min before your planned procedure or imaging: but check in at 15 min, 30 min and 45 min
• At 45-60 min if you have no joy: time to proceed adding an adjunct, re-dose or go to plan B sedation (eg IM /IV ketamine) or abort / reschedule procedure

Procedure

• It’s a ‘low fuss sedation’ in terms of set up, monitoring etc:
• A set of obs pre procedure for baseline (the triage set of obs is fine)
• Then dose them (no need to be on monitoring at time of dosing if it is just upsetting them)
• Once it starts taking effect pop a sats probe on and there you go – await the nap
• No need to be one-on-one monitoring like our other procedural sedation: as long at they are hooked up to monitor and carer in room with them and staff member checking in at 15, 30, 45 and 60 min time intervals post dosing (and of course responding to monitor alarms)

Sedation wears off like a ‘good nap’ ie 60+ minutes or so

Parental consent

Queensland kids have this year developed a parent factsheet which also explains expectations in a nice simple language.

Adjuncts

Dexmed can be used as adjunctive to other sedatives. See this table for options.

My top 10 tips on this:

1. Don’t use Dexmed and Clondine together : it is either / or
   • They are both alpha agonists: Dex is 8 times more selective so less side effects but if you add in Clonidine you will likely have higher chance of brady, hypotension and oversedation, dizziness etc
2. Don’t dismiss Clonidine altogether! If it is a behavioural situation and you need safe situational control and you really need this kid to have a longer nap than definitely go for the Clondine (oral dosing also fine but tastes like yuck)
3. If it is expected to be painful: dose the Dex and 15 min later dose fentanyl and at the 30 min mark post the dex dose (15 min after fent in) you will likely be good to go (+/- 15 min)
4. If it is a neurodivergent kid, super anxious or even a re-attempt after a previous bad experience: dose intranasal ketamine and then Dexmed, check in at 15 min and hopefully you are good to go
   • There are some positives coming in research for intranasal ketamine but not yet published in hospital guidelines, some pre-hospital use is happening though! Short of long: it is safe to use, but it’s the fine tuning of the dose (mg/kg) that is still up for debate (main issue being underdosing not overdosing)
5. You can also dose Midazolam for this worried cohort ie oral dose midaz with a little apple juice then dose IN Dex 15 min later
   • OR dose Dexmed, check in at 15 min then dose IN midazolam and recheck in 15 min
6. For very quick procedures, nitrous can be used to rescue the situation, small chance of post procedure vomit but there is no harm in this (I routinely advise parents if any nitrous given there will be a vomit)
7. If you dosed and you are almost in a sweet spot but not quite and they need to be really still for a scan etc: consider a re-dose up to max 4mcg/kg or 200mcg
8. If you dosed and you are losing faith: go plan B ie IM ketamine or just get your IV in and proceed to full procedural sedation
   • Be mindful your space and staff and monitoring situation changes when you proceed to this step
9. You can also abort mission and plan better in a different space ie theatre or the next day (if late in evening + ED busy and everyone is tired)
10. Remember the synergistic analgesic effect of Dex: so if you can EMLA skin or pink viscous lignocaine gel a lip / tongue or get your needle local anaesthetic regional block in with a little bit of Dex on board you will likely be good once the LA effects kicks in in about 5 min

Rule of thumb: only use ONE adjunct, if it doesn't work, go to plan B

For anything more than a really quick procedure, Dexmed and Ketamine is the best combo.

Note that the Monash Kids drug book now has a SEDATION SECTION with the intranasal doses. Use it please.

Updated 05/01/2026

Infographic

See the infographic for:

• What is the difference between heat exhaustion and heat stroke? (tip: the core temperature and the CNS status are what helps you differentiate this)
• For heat stroke : what is the very simple basics of the physiology and how it affects the organs (and hence the clinical presentation you will be dealing with)
• The very simplified management steps for heat stroke emergency

Note:

• It can be quick onset: it is estimated kids can warm up 3-5 times faster than adults, especially in a car on a hot day where the temperature can be 20-30 degrees more than the outside temperature
• It can be really bad real quick: they vasodilate quicker and more so than adults and their CVS ability to adapt is less so than in adults
• The metabolic stress on their little bodies quickly overwhelms their regulation systems: kids tend to become hypoglycaemic much quicker etc

It is estimated that Ambulance Victoria get about 1200 call-outs a year for entrapment (in hot car) - note: this does not count for all heat illness callouts eg heatstroke in shed or externally.

• Of this about 87% are kids < age 13 years
• Of this the majority are aged 1-3 years and by far the most susceptible group for rapid deterioration and long term effects or death

Hospital data seems a bit under reported (it hinges on how we do our 'injury surveillance' data) and our diagnosis is often input as 'dehydration' or 'syncope' and in adults 'decompensated heart failure', etc instead of heat exhaustion.

Based on this KPMG looked at weather trends, hospital admission rates and the differences in expected annual mortality numbers during these heatwave periods and made a projected estimation that heat related deaths for Australia are probably around the 36,000 mark for the period 2006 - 2017 (this averages to abut 3270 deaths per year due to heat).

A reminder that 'kid in a hot car' is seen as neglect and a serious offence - social work and CPS need to be notified.

Updated 04/02/2026

Infographic

Apart from HIE related cooling for neonates, no active cooling clinical practise guidelines exist in Australia for paediatrics, so most information is derived from adult guidelines.

The important things to know:

1. You need to monitor CORE temperature when cooling (rectal / oesophagus / bladder)
2. RAPID cooling: as quick as you can - strip clothing, cool the environment, get a spray bottle with tepid / room temperature water and spray, get fans on, get icepacks on, consider cool IV fluid (fridge in resus drug room) but do not fluid overload ie 10ml/kg bolus and review
3. STOP active cooling once you reach 38'5 -38 degrees celsius: this is so that you do not cause inadvertent shivering (high metabolic demands, makes monitoring difficult, might miss arrhythmias on telemetry, might have fussy crying child, etc etc)
4. If they ARE shivering you need to manage it actively (topic on its own: but diazepam, sedation and intubation is the short gist of it)
5. Drugs like antipyretics will NOT help

Best to avoid immersive cooling in babies and small children:

• Again not studied well
• Plus theoretical 'diving reflex' or bradycardia if you inadvertently splash face
• Plus theoretical chance of 'autonomic conflict' ie simultaneous sympathetic 'cold shock' and parasympathetic 'diving response' which is thought to hav increased risks for ectopic / arrhythmia
• Plus a little body in tubs of cold water will make monitoring difficult and you have to ensure face stays out of water
• Plus risk of overcooling: their little body surface to environment are bigger and less body fat so will cool rapidly

Basic general consensus:

• If it is exertional heatstroke
• AND it is a bigger kid/adolescent
• AND who is stable and co-operative (not agitated or too confused)

-> You might consider immersive cooling

Last things:

• IV cooling catheters not well researched and we don't have it in anyway
• Respiratory cooling not well researched and not thought to make huge impact, but in a low resource setting it will not do harm to try a bit of dry air / non humidified air with high flow to facilitate evaporative cooling

BH - Heatstroke Supplies

We have a 'hyperthermia box' in resus with instructions and the basic equipment in there.

Just of note: remember to pick a trolley with an 'end of bed' pull up part at the feet so that you can clip the bull dog clips and tarp / body sheet to it so that the ice and water is contained in a shell.

Continuous Core Temp Monitoring

• Initially foley IDC with temp probe, attached to monitor
  • Bladder temp preferred but if time-critical can insert rectally (with lube) to depth of at least 7cm (consider marking 7cm line with permanent marker before inserting).
• When time allows, use oesophageal or IDC temp probe.

Immersion Cooling - AVOID in babies and small children

Ice:

• Benchtop ice dispensers in kitchenettes.
• Located in Resus corridor, Green pod and Radiology ward.
• Each dispenser can deliver 5kg of ice in 3 mins before empty.  They replenish at a rate of 120kg per 24 hours.   
• Use basins/disposable bedpans to collect. Do not use plaster bucket.

Body bags (“Ice taco”):

• In the storeroom opposite the BAR cubicle.
• One person at each end of the tarp to keep the water/ice inside.

IV Midazolam

• PRN for control of shivering.

Towels

• Multiple, for patient, floor, etc.

Dry trolley

• Once the temp target to cease rapid cooling is met, dry the patient and transfer them onto a dry trolley.

Evaporative Cooling

Fans:

• A small clip on fan is in the heat box in resus 1
• All hospital fans were discarded during COVID.  They get contaminated quickly.
• Contraindicated where resp/droplet precautions are needed (e.g. COVID)

Spray bottles/misters:

• In Heat box in resus 1.

Iced bedsheets/towels:

• Pre-soak these in a slurry of water and ice.
• Apply to patient’s skin, changing regularly.

Respiratory evaporative cooling:

• High flow dry medical air 20-40L/min via nasal prongs
• Ideally use high-capacity flowmeter.  If not available open standard flowmeter to max.
• Can still use in intubated patients.

Invasive Cooling

Cooled saline (4°C), if hypovolaemic:

• Resus drug room fridge.
• If you take one out, replace it.
• Each litre will drop the temp approx 1°C.

3-way Foley catheter bladder irrigation:

• IDC trolley.
• Irrigation fluid will be room temp which will reduce rapid cooling benefit.

Ice Taco/Ice Burrito (Body bag cooling - BBC) - AVOID in babies and small children

Requires proper assessment of the patient’s condition and clinical judgement. BBC allows placement of monitoring equipments/ resuscitation, if needed, as the patient’s chest can be kept dry while the body is surrounded by ice/cold water.

• May not be suitable for children / elderly

Recommended equipment list for Body Bag Cooling:

• • Disposable Body bag/Cadaver sheet – white plastic sheet (storage room next to BAR)
  • Cold water source - tap
  • Ice: 3-4 bags – ice machines
  • Rectal thermometer + lubricating gel
  • Towels: 3-4

Cold water immersive cooling using a body bag in emergency department for a patient with classic heat stroke

• Prepare a disposable body bag on a bed with buckets of ice.
• The patient is placed directly into the body bag with monitors including core body temperature monitor.
• Buckets of ice and tap water are poured into the body bag to initiate cooling.

Updated 03/09/2025

Some interesting data that is collected by the Australian Institute of Health and Welfare that comes from the 'injury surveillance data' that we input when we discharge a patient who has presented with an injury.

From their yearly report for 2023-2024 (both adult and paediatric data):

1. Injuries/trauma are only about 8% of total burden of disease in Australia
2. For kids:  >50% of the injuries we see are the under 4 year age group (falls, lumps, bumps, cuts)
3. 1 out of 4 of injury presentations is a kid (ie <14 years age)
4. Unsurprisingly: falls are the major injury mechanism requiring admission
5. Falls and mental health are the top reasons for deaths (and only then is it traffic accidents! Speaks a lot for road traffic safety in Australia) (nice to know fire arm laws and regulation about sharp instruments can make a difference)
6. Surprisingly: the longest LOS for admitted patients was not due to falls! Rather burns...but: falls came in second
7. About the critical stuff: 2% of our injured patients requires ICU, 1% requires intubation
8. About the deaths: only 0.6% of our injured patients die (not bad if you keep in mind falls (so geriatric -elderly folk) is our biggest injury mechanism. So thinking about this differently: our death rate from things like traffic accidents are minuscule in the bigger picture of things!
9. Arrival: 1 out of 5 arrive by ambulance or air rescue
10. Some fun facts about injury presentations (some we already know): March is our busiest month, Jan 1st is our busiest day, Sat and Sun are our busiest days of the week, 4PM is our busiest hour of the day.

RCH (Preventing falls and Safety around the home)and Kidsafe have injury prevention info that you can share with parents, particularly of the 0-4 year old cohort.

Updated 27/10/2025

Infographic

Is measles even still around?

One of the oldest documented illnesses and despite having a vaccine available since 1963 and some countries having eliminated it, it is showing an increase in outbreaks recently.

Australia

It was officially eliminated in 2014 (ie endemic transmission was thought to be zero) BUT even just in 2025 between Jan and May there were already 77 confirmed cases:

• all were between the ages of 20-50
• all were either unimmunised or only partially immunised
• most were traced back to overseas travel for transmission

America

Declared themselves measles free in 2020 but in 2025 Jan to July alone had multiple outbreaks in 42 states with a staggering 500% increase in confirmed numbers.

Why does urgent contact tracing matter so much?

You can see by the timeline that after the virus is contracted it can be up to 14 days before the prodrome and infectious period starts. This is a very valuable window where contact tracing can occur, so that individuals might be very vigilant at early onset symptoms to isolate themselves.

It also means that the un-immunised + partially immunised have a valuable window of 72hrs post confirmed contact to either get vaccinated or get immunoglobulin.

For individual choosing to remain un-immunised it means complete exclusion from childcare, school and work for a total of 14 days after onset of the rash.

Infectious period

Most infectious 24hrs after onset prodrome until 4 days after onset of rash.

It's airborne and anyone in the same area / room for 30 min or longer are considered exposed.

On arrival to ED, suspected cases need to be placed into an isolation room or into a single room with airborne precautions in place ASAP.

Testing

The most sensitive test is the nose and throat swab PCR up to 3 weeks post the onset of rash.

Who are our vulnerable groups?

<12 months: not immunised yet as MMR 1^st dose is at 12 months

<18 months: only partially immunised as 2^nd dose MMR is only at 18 months

Pregnant: Avoid contact!

• Maternal risk of pneumonia, hepatitis and ten-fold increase risk of death.
• Fetus: risk preterm labour, still birth, death.
• Advise not getting pregnant 28 days after measles or vaccination.

Updated 19/02/2026

Infographic

A questionnaire survey was given to family and patients and primary care doctors of 448 confirmed meningococcal cases.

By far these where the top three very specific first clinical signs they found:

1. Leg pain (31-63%) ie be weary of the unexplained limb pain
2. Cold hands and feet (35-47%) ie be vigilant of the worried parent complaining about this at triage
3. Abnormal skin colour pallor or mottling (17-21%) ie always have a look at the skin

Note: the non-blanching rash is NOT on the list because it is a late sign.

There are three syndromes as part of the spectrum of meningococcal disease:

1. 'Just' Meningitis
   • the classic headache, photophobia, meningism, confusion, altered conscious state (seizure – less common)
   • normal haemodynamics and not requiring vasopressor or organ support, i.e. can be managed in a standard ward potentially
2. Sepsis but no Meningitis
   • non specific flu like symptoms or febrile illness and then suddenly more unwell with sepsis type symptoms and organ dysfunction
3. Both
   • like a wild fire and very rapid ++
   • bad flu with bad headache
   • within hours life threateningly sick (or dead)

The four phases of this critical illness:

1. Phase 1 (Hour 1-12) : Non-specific illness
2. Phase 2 (Hour 13-24) : Systemic invasion
3. Phase 3 (Hour 18-36) : Septic shock +/- meningitis
4. Phase 4 (Fulminant) : Meningococcaemia

A systematic review of many cases found that the time line is very tight: just hours!

In particular if you look at phase 2: this is your golden window to pick that one needle in the haystack and make a big difference by identifying it early.

This might be:

• The represent same day ie might have been discharged earlier as day 1 febrile illness
• The unwell child you observed for a while but the tachycardia persisted
• The fever that now has a headache too or is now confused or more lethargic than earlier
• Be wary the ‘cold hands and feet’ (compensated shock)
• Mottling…

If you do send someone home in phase 1, this is understandable as it looks like another flu like or viral illness, as long as your safety net advice on discharge covered phase 2 and 3 signs.

Immunisation

The serogroup ACWY is funded through the National Immunisation Program for:

• all children at age 12 months
• adolescents 14-16 years
• from >2 months for people with certain medical conditions that increase their risk of invasive disease

The serogroup B is funded for:

• ATSI children aged <2 years
• from >2 months for people with certain medical conditions that increase their risk of invasive disease

Note that the meningococcal serogroup B is currently 80-90% of our incidence cases in Australia. The vaccine can be administered from the age of 6 weeks. It is not yet on the standard immunisation schedule but is available on script with out-of-pocket costs.

See the Immunisation Handbook for further details.

Updated 17/02/2025

A febrile child with 'just the flu' can become seriously unwell with the following complications:

• pneumonia
• myocarditis
• meningitis

Myocarditis (Infographics 1 and 2) should be considered if there is resistant shock.

RSI Considerations (Infographics 1 and 2).

References:

• Advances in Shock Management and Fluid Resuscitation in Children
• Diagnosis and Management of Myocarditis in Children
• Diagnosis and Treatment of Myocarditis
• Diagnostic and Clinical Approach to Paediatric Myocarditis
• Influenza RCH CPG
• Intubation of the Critically Unwell Child in the Emergency Department (Currie, 2021, Don't Forget the Bubbles)
• Monash Children's Medication Book
• Ten Not To Be Missed Paediatric ECGs

Updated 01/10/2025

Infographic

Up to 1/3rd  of children presenting with nasal trauma could have nasal fracture

Luckily majority of them are uncomplicated and does not need much intervention

Less common in the  < 5 yr age group (anatomy of face is still developing: forehead and orbital rims projects more than nose, so head will take the impact with eg falls

plus direct trauma mechanism injuries less likely in this age group)

Nasal development has two growth spurts:

• one at age 3-5 (projects more at this stage and can then have increased exposure to injury)
• and again at puberty until it reaches adult size at age 18-20 years

Injury mechanisms:

• <5 yr
  • mainly falls
  • if any 'direct trauma' or 'odd mechanisms' you should be suspicious for NAI
• School aged children:
  • mainly sports and falls
• Teenagers
  • sports, direct trauma (assaults) and MVA's

In younger children they have mainly cartilage and still have unfused sutures so more prone to greenstick fractures which can be missed initially and become more evident as they grow older ie deviated septum / breathing problems

Younger kids who have true high impact trauma to face eg MVA are at higher risk of complicated facial bone fractures such as naso-orbito-ethmoid fractures ie 'open book fracture of face'.

So best to have a little 'screening check list' of areas on the face to check apart from the nose to help you decide of imaging required (see 'D' for Disability on infogram of this info)

• raccoon eyes, battle sign, haemotympanum, watery rhinorrhoea: ?BOS fracture
• midface mobility or crepitus: ?Le Forte fracture
• facial numbness: ?maxilla or orbital fracture
• double or funny vision: ?orbital fracture
• dental malocclusion: ?maxilla or mandible fractures

Four last things to note:

1. Facial XR are outdated and from the previous century
2. So it's either observe with a follow up review or OPG XR (if jaw fracture suspected) or CT facial bones if your screening check or mechanism leaves you suspicious
3. If ENT not readily available, remember that plastics and maxfac are pretty fond of 'nose jobs' too!
4. Septal haematoma is the big acute complication you should not miss (knock on effects of septal abscess, septal necrosis, saddle nose deformity and life long cosmetic effects)

Updated 07/05/2026

Infographic

It is uncommon but sometimes indicated to do a soft tissue neck XR. (This does not cover C spine or trauma.)

Indications include:

• stridor not responding like a classic croup or very recurrent in a short period or biphasic+non resolving---particularly if they are in the 'foreign-body-to-mouth-non-verbal' age group
• drooling and dysphagia (?epiglottitis ?button battery ?other FB ?deep neck infection)
• torticollis with no obvious cause or with other red flags
• the 'serious sore throat': not responding to analgesia or representing for care or immunosuppressed or the unvaccinated kiddo as they are at risk of serious bacterial infection / deep neck infection
• refusal to move neck with no clear cause especially if not improving with simple analgesia
• the tripod / toxic / septic looking child

Remember to only request it if you have a clinical situation to correlate it with, especially because there can be false positives

• Neck flexion
• Crying at time of XR being taken
• Swallowing just at the right time can all make the pre-vertebral tissue look a bit thicker

So make sure the child is very well settled with analgesia, consider a small feed for settling or a parent cuddle before you get that XR.

Updated 30/07/2025

Infographic

How to correct age for prem babies

If you know all of this you can skip and maybe just remind yourself why it is important (look at 'why it matters').

If you are very unsure about it all:

Read the info-gram and then look at the two examples below.

In general my tips are:

I ask 3 specific questions

1. What is their DOB?
2. What was the expected date of delivery? (EDD)
3. How far along was your pregnancy on the date your baby was born? (gestational age) or work it out for yourself

And in general I personally look at a calendar (use the one on your computer desktop) and just 'count it out' by marking the DOB and the EDD and counting the weeks in between those.

Once you know the 'weeks of prematurity' you can work out the corrected gestational age.

Examples

Updated 23/01/2026

Infographic

Checking the signs of dehydration helps you to decide how to rehydrate eg trial oral fluids first (mild/moderate) vs go straight for IV rehydration (severe) or a fluid bolus pre rehydration (shocked).

Checking weight change to assess dehydration in children is more accurate (especially < 2 years of age) because it's the closest practical measure of total body water loss, whereas “clinical signs” are indirect and easily distorted by other factors.

• ALWAYS check a (bare) weight on arrival ED today as they might very well represent tomorrow or the next with a failed trial of fluids at home.

A hydration check is as easy as 1,2,3 (4,5)

1,2,3

• You need to check 3 areas on your patient
• And check 3 things in each area

Then 4,5

• Check their file for observations and weight

Check

1. Head
   1. Fontanelle
   2. Eyes & Tears
   3. Mucous Membranes & Lips
2. Chest
   1. Central Cap refill time
   2. Skin colour
   3. Breathing
3. Limb
   1. Temp to touch
   2. Skin turgor
   3. Peripheral pulse
4. Obs chart
5. Weight

Dehydration = fluid loss → shows up as weight loss

1 kg weight loss ≈ 1 litre fluid loss

Weight gives a % dehydration estimate

Updated 09/09/2025

Infographic

How much (calculations)

and

What type of fluid

Of note: we are not covering neonates, special medical conditions (eg metabolic babies, liver or renal failure), fluid restriction (eg Na+ or electrolyte abnormalities) or trauma (acute blood loss).

We are just talking about: dehydration in a previous well child due to acute GI losses or poor oral intake due to various reasons (eg mouth ulcers or sore throat). This is to say: the majority of kids we see.

Six Points to Highlight:

1. Always, always check a weight
   • On first AND subsequent presentations, please
   • If they represent in a couple of days, the weight on the initial presentation is incredibly valuable to help calculate the %-dehydration accurately (way more accurate than clinical guess-timation)
   • <12 months no nappy on, most or all clothing off
   • 1-3 years light clothing only (shoes, jackets, nappies off)
2. Only give IVF if enteral route not possible (eg contra-indication or failed oral/NGT routes)
   • Just having an IV in situ (eg for IV antibiotics) does not mean IVF are needed
3. Regarding replacing deficit: we only ever replace 5% deficit in the first 24 hours
   • meaning if it is 10% dehydration, you would still only replace 5% deficit in the first 24 hours and then re-assess at that point. Then replace remaining deficit over the next 24 hrs if needed.
4. Bolus fluid for shock is : 0.9% Saline
   • Maintenance and rehydration fluid is: 0.9%Saline + 5% glucose
   • You can use premixed bags with the K+ included if renal function and K is normal/borderline low
5. Remember to be guided by your hydration checks/fluid assessments to gauge if ongoing fluid is needed
   • you can also stop it sooner if they are rehydrated, and especially if starting to take fluids orally.
   • Oral is always best
6. If they remain unwell for a medical condition after dehydration period completed: drop the fluid rate and switch to 2/3rd maintenance ASAP. This is important.
   • They almost always get a degree of SIADH, fluid retention and/or electrolyte imbalance. So switch to 2/3rd maintenance ASAP please.

Updated 24/09/2025

Infographic

NGT fluids and kids - who and how much and how quick and when to say 'NGT failed'.

Choose your customer well

• Best for <2 years age
• The 2-3 year group is still possible if they are 'flat/subdued' enough, ie that dehydrated little tucker who is listless, will cry a bit when you fuss but doesn't have their usual toddler energy -> give it a go with rapid rehydration regime - often they perk up half way through rapid rehydration and pull the tube out  -> which is a good prompt for you to do a review  and try to get them home anyway!
• Above 3 yrs they generally will not tolerate, have dexterity to pull it out etc
• If it is a special needs child eg CP or ABI: you can still consider as they very well might tolerate NGT better than multiple IV attempts: chat to the parent and make a shared decision

When to do

This is for the failed TOF but no special acute indication for IVF (eg hypoglycaemic, NPO etc).

Especially good if you are not wanting to admit, but do want to do some rapid rehydration and then get them home from ED.

Top tips

1. ALWAYS pre-dose with Ondansetron (if > 8kg)
2. Almost always dose some paracetamol down the NGT if it is a febrile or mouth ulcer / sore throat / miserable kid situation
3. If it is a sore mouth / sore throat situation, be conscious of that and pre dose with topical lignocaine gel (the pink stuff from a 'pink lady') - it will be painful when tube is inserted, have a heart. Dose is 0.15ml/kg
4. Strap the NGT in securely and do it quickly, don't fuss and hold down too long, it just escalates the attempts at trying to pull it out and works the parents up too. Have all you need ready to go and have a pair of hands to help you do it quickly.
5. No CXR required unless you are absolutely unsure clinically if it is in situ, ask a Dr or another colleague to help you check before you decide to do CXR.
6. Rapid regime is only for dehydration due to acute losses or poor oral intake eg gastro or gingivostomatitis, etc.
7. Slow regime for all respiratory (eg bronchiolitis) or medically unwell due to other reasons (they do not do well with full tummies, rather go slow). If they are being admitted in anyway for whatever reason, just go with slow regime.
8. We only ever rehydrate 5% dehydration volume with NGT regime. If they are dehydrated more than this, consider if they need IV regime rather or just start with 5% volume and then re-assess hydration status at the end of 6 hours and adjust as needed, ie continue rehydration regime vs switch to just maintenance regime.

For rapid rehydration:

• start 25ml/kg per hour (for 4 hours, stop sooner if keen and able to tolerate orally)
• if they vomit (despite Ondansetron) -> pause 30 min -> then drop rate (half rate or drop to 10ml/kg)
• if they vomit despite all above proceed to slow NGT rate

Slow rehydration:

• start at 50ml/kg volume over 6 hrs (ie 8.3ml/hr)
• at end of 6 hrs: review them
• if ongoing losses: calculate that in to your ongoing hydration (drop to full maintenance rate + add in losses in preceding 6 hrs rate and then re-review patient in 6 hours)

however

• at this 6hr review time: also have a think if they can actually try TOF now? They might very well be good to go back to enteral route at this point?

Final tips

Updated 18/09/2025

Infographic

Trial of fluids vs oral rehydration

What is the difference?

For TOF: we are only doing a short focussed attempt to see if 'what we put in goes in and stays down' ie they don't vomit or flat out refuse any fluids.

This is so that we know we can then send them home as they do have THE ABILITY, we give the education to the parents (what, how much, when) so they have THE KNOWLEDGE and we screen the social history so we know they have THE MEANS.

It is not the actual rehydration process, this takes time, ie hours to days.

For oral rehydration: this is where they continue oral fluid intake in increments at home and progress onwards as tolerated, eg clear fluids to formula to bland solids to normal intake options or regular favourites etc.

When to do?

Don't do if they are 'too well' : just explain how to and they can go and attempt at home themselves.

Don't do if too unwell: just proceed to NGT or IVT (too flat /lethargic or moderate severe hyperketotic-hypoglacaemia).

They need to be: just the right type of patient

How much?

10ml/kg

Over 1 hour

Aim for 80% or more of this to say : yip success or 'passed TOF'

What fluid?

ORS / hydralyte / Apple juice 50% diluted / breastmilk

Can progress to formula / gentle solids if tolerating and keen to try

Updated 01/07/2025

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RSV is one of the commonest causes of acute respiratory illness in young children

• Australia had 175,786 RSV cases in 2024 (off those who were swabbed - in reality more)
• 86,205 cases (49%) were children under four years old
• 4054 admissions across the 8 major paediatric hospitals during that time (no regional rural data included)
• A notifiable disease since 2021

There is now a vaccine!

It has been available on the National Immunisation Program free on the RSV Mother and Infant Protection Program since Feb 2025 and now for older adults.

Which means many children are not yet all protected and we are still 'catching up'

Who gets it?

Pregnant women

• In each pregnancy from 28/40

Infants - at birth

• If mum didn't receive vaccine during pregnancy
• If born <2/52 since mum was vaccinated
  • antibody transfer increases progressively from the time of vaccination; however protection is significantly reduced if the infant was born less than 2 weeks after the mother receives the vaccine
  • maternal vaccination provides passive protection to newborns for up to 6 months
• High risk babies get a repeat dose before discharge, irrespective of mum's vaccination status (heart/lung disease/prem/immunosuppressed)

All babies <8/12 with the above criteria and missed a birth dose

8 months to 2 years of age

• ATSI children
• High risk babies

Some adults qualify too!

• everyone >75 yrs
• special risk groups >60yrs
• adults 60-74 yrs and special risk groups >50 yrs - may consider privately purchasing

What do they get?

Mums and older adults get a recombinant vaccine (different one for the two groups)

Babies get monoclonal antibodies vaccine

Why?

It is estimated that babies <6 months will have up to 70% less chance of becoming seriously unwell (ie admitted) with RSV if mum is vaccinated during pregnancy.

The current focus is on the <2 year group, as it is perceived that >2 yrs there is less likelihood of serious illness.

Bottom line:

Make questioning about RSV vaccine a routine part of your history taking when you are assessing a baby with LRTI that could be bronchiolitis

You can encourage parents to consider or receive it, since it is relatively new (ie create awareness / health advocacy)

Updated 23/04/2026

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Sore throat is one of the most common paediatric presentations. It is often difficult to determine if it just a simple/uncomplicated sore throat situation or if you should think about it a bit more and consider other differentials than just 'viral'infections.

Of those that do have bacterial infection, the majority will do fine without antibiotics, as studies have shown giving antibiotics only shortens the 'unwell' period by average 16 hours, so instead of being unwell 3 days they are unwell for 4 days.

Plenty of factsheets around to help you navigate that conversation with parents (see links below).

The most important bits to try and unpack with your history taking are:

• Are there special risk factors?
• Are there any red flags?
• How are feeds and fluids going? (dehydration/oral intake)
• Do they need special follow up? (ENT/growth and development etc)

If antibiotics are indicated, see the RCH guideline.

Tips for analgesia in the ED:

If it's a particularly red raw sore throat (strep or tonsillitis) you can consider:

Dexamethasone 

• 0.15mg/kg as a stat dose only
• It has shown to decrease the pain period by 6-12 hours and this enables little ones to start taking orally sooner
• If we are treating as bacterial tonsillitis severe enough to admit (rare in younger kids, more common in adolescents) then you can bump the dose up to 0.6mg/kg
• No discharge medication option

Topical lignocaine gel

• The 'pink stuff' from a 'pink lady/mix'
• Xylocaine viscous
• The dose is 0.2ml/kg
• Important to aim for the back of the throat or the 'sore bits' when administering as it will numb the tongue and likely affect TOF attempts
• No discharge medication option
• Can be repeated q3hrly if admitted

Helpful factsheets for 'simple sore throats'

https://www.safetyandquality.gov.au/publications-and-resources/resource-library/sore-throat-should-i-take-antibiotics

https://ccmsfiles.tg.org.au/s3/PDFs/ABG16_NPS_2017_What-every-parent-should-know-fact-sheet.pdf

https://www.rch.org.au/kidsinfo/fact_sheets/Tonsillitis/

https://www.rch.org.au/kidsinfo/fact_sheets/Tonsillitis/

https://raisingchildren.net.au/guides/a-z-health-reference/sore-throat