Part of being an empowered parent is knowing when to take your child to the Emergency Department (ED). And in this post I will make it as easy as A, B, C, and D.
I have seen both ends of the spectrum: Children brought in with no emergency and children brought in with an emergency, the common bond, parents love their children and want to do the best for them. And I can relate that it can be challenging to figure out if your child’s condition warrants and ED visit or a trip to the clinic.
This post is no way a substitute for your own gut feeling or advise from a medical professional, it is purely a guideline written by a Registered Nurse who is also a mom.
ED medicine is really just making sure your patients have A, B, C, and D, if not then we intervene, but what does A, B, C, and D stand for?
A is for Airway, B is for Breathing, C is for Circulation, and lastly D for Disability or neurological functioning. It’s a simple method to ensure complex functions of the body are taking place, and if they are not, then we need to do something about it. Using the ABCD guide I will outline corresponding emergencies that would bring your child to the ED, as well as provide some tips to make your ED trip the best it can be.
But remember this is a guideline and although I have separated urgent conditions into either A, B, C, or D they all intertwine and affect other letters of the alphabet.
AIRWAY EMERGENCIES: The Airway consists of the mouth, lips, tongue, and throat. If there is any compromise to the Airway then the rest of the alphabet doesn’t matter.
- Choking: The number one reason kids have airways issues is because of swallowing a foreign object and they choke. If your child swallows a foreign object and can tell you about it, they are not choking. Talking and coughing indicate that the airway is patent (or open), however if your child is not breathing normal or drooling, their airway may be partially obstructed, and this means a trip to you local ED. If you child needs First Aid to have the foreign object removed, this too would warrant a trip to the ED to ensure all is good. It is also important to know what your child swallowed. Small things made from plastic or smooth glass are ok, jewelry and batteries however can cause damage to a child’s gastrointestinal tract or leak poisons into the body. If a battery is swallowed then come to an ED. If you are not concerned by what they swallowed and the child is having no airway issues, it can be left to naturally pass, in days or up to weeks depending on the objects. I still remember when I swallowed two marbles and my mom would “treasure hunt” in my poop until she found them, just another awesome job for a parent.
- Coughing: There are certain coughing issues that can be considered an emergency. Coughing that sounds like a bark or a whoop, can be a serious virus and your child may need supportive intervention. Coughing that induces vomiting can also be problematic and you should seek an ED physician’s assessment.
- Allergic Reactions: If you child has a known anaphylaxis (life-threatening) to a certain allergen and had to use their Epi Pen, that’s a trip to the ED and at least 6 hours of observation. If your child doesn’t have a known allergy and they have a hive-like rash, with nausea, vomiting, and or diarrhea, and or breathing/airway issues (swollen tongue or lips) that is also a trip to the ED. A rash that is itchy with no other symptoms may be an allergic reaction but doesn’t always mean life-threatening and can be investigated in a clinic setting. If you are unsure of what may be causing the reaction you may need to start a food diary and list the food your child eats and note if a reaction occurs. Another culprit can be new laundry detergent or soap, grass, and environmental allergies. More and more children are developing life threatening allergies and its pertinent parents can identify the trigger.
BREATHING EMERGENCIES: This consists of the lower airway, the bronchi (large branches of the lungs) and the lungs. Health Care Professionals (HCP) also consider any ventilation issues, that is problems with gas exchange (oxygen and carbon dioxide), to be part of B.
- Asthma: The sound of a child trying to force air out of their lungs when they are having an asthma attack is a sound that make my sphincters tighten and palms sweat. I had one mom that brought her child in because he wouldn’t stop whining, well, he wasn’t whining he was trying to increase his PEEP, or simply force air out of his lungs! So sounds are important and most parents that have a child with known Asthma, get very good at distinguishing between normal breathing sounds and abnormal breathing sounds. But if asthma is new to you and your family, better safe than sorry if you are concerned about your child’s breathing. Breathing should be easy and regular, if your child is using their belly and ribs to breath, they may be struggling. If they are breathing too fast or slow, this may also indicate an emergency. If you note breathing difficulties or abnormal sounds and your child has a blue inhaler, use it. Even if you decide to have them checked out, use the blue inhaler. Two main points to remember for the asthmatic child: Firstly, if your child isn’t sleeping well their asthma may be exacerbated. Secondly, if your child has a cough when they are active or when they are in cold air, that may also be an asthma issue. Try a blue puff if you have one and see if that improves the cough, not all children with asthma have a “wheeze”, some will only have a cough.
- Viral illness: Sometime difficulties breathing isn’t asthma but a viral illness that is affecting the lungs. If you child is having difficulties breathing, making an abnormal sound, has blue lips or overly fatigued or tired, go to the emerge. Best thing a parent can do for their child’s overall health is have them vaccinated. Nowadays, there is so much crap out there about immunizations causing harm to children it difficult for parents to weed out the truth. Take it from me, vaccinations save lives and I have never read anything contrary to this fact, and I see it firsthand in our ED everyday. The other topic parent’s need to be cognisant of is that viral illnesses can’t be treated with antibiotics. So if you are unsure if you child has a viral or bacterial illness but isn’t having any airway, or breathing issues, then booking a doctors appointment is a great option in getting a clear idea of what is causing your child illness. Antibiotics should be prescribed with caution and not always the answer. I know parents can find it frustrating that you bring your child to the ED for the doctors to tell you they are ok and just let the illness runs its course. We are not brushing you off, prescribing antibiotics for the sake of “doing something” is harmful and will not help your kid get better any faster. Viral illness can be weeks of symptoms but still don’t require medication – and sometimes the answer is rest and chicken noodle soup.
- Pneumonia: One of the main reasons I see kids in the ED with breathing issues is the development of a pneumonia. It’s important to understand that a pneumonia can be a virus or a bacteria. Typically, most pneumonias we see have started because the child is unwell with some viral illness and mucous has built up in the lungs and created a perfect environment for brewing bacteria, that will cause a pneumonia or consolidation of infection in the lungs. Children with pneumonia can develop a fever, decreased appetite, breathing issues like too fast or laboured, (they are working hard to breath), they may have a cough, or they may not. If your child has been unwell for a while and just isn’t bouncing back or a fever has returned it may be time to get checked out. It is appropriate to have them check out in an ED as they may require a chest X-ray and need to have the oxygen levels checked.
CIRCULATORY EMERGENCIES: This can refer to problems with how the heart pumps, or issues with the volume of blood being pumped.
- Heart Conditions: My mother was born with a congenital heart condition that wasn’t identified until she was four years old. The symptoms that tipped her parents off where, activity intolerance, delayed growth, and Shortness of Breath (SOB). Somewhat vague but if there is concern about your child’s growth and development is worth seeing your family doctor. However, if your child is having breathing difficulties, has blue nails or lips, or extreme fatigue, then a ED visit is appropriate (see this where there is some overlap as a circulatory problem may look like a breathing problem, but leave that to the professionals to figure out). Heart problems can include: the shape of the heart, how it’s parts (the anatomy) is working, or is can an issue with the beating of the heart (conduction). Symptoms that would alert you to a heart problem could be: Changes in their skin colour, breathing issues, of changes in their activity.
- Overt Bleeding and Dehydration: Obviously if your child has suffered a trauma and is bleeding then they need to be seen urgently. Another source of low blood volume is dehydration – most commonly associated with fever. When you child has a fever, they “burn” off they fluids quickly and if not drinking well or if the fever persists, they can run the risk of becoming dehydrated. Another source of dehydration is prolonged vomiting and or diarrhea, where kids are getting rid of their fluids via the gastrointestinal tract. Common signs of dehydration in children, is reduced wet diapers or pees, some kids get constipated or the poop is harder than normal. Babies may not be able to make tears when they cry and can have dry lips and tongues. Later signs would include changes to skin colour, increased heart rate and changes in breathing. If you are concerned at about dehydration especially in babies, that is an emergency. It’s ok if a child’s food intake reduces when they are sick, but fluids are important and they need to keep drinking. There are great fluid replacement drinks you can get at your local pharmacy if vomiting or diarrhea has persisted. Also don’t be afraid to try an anti-nausea medication, like Gravol to see if you can increase their oral intake by reducing the likelihood of vomiting. Kids may be reluctant to drink if they have a sore throat, so again try some pain reducing medications like Advil or Tylenol (even if they don’t have a fever) in order to get them to drink fluids. If nothing is working and they aren’t making pee, bring them in for urgent assessment.
- Infection and Fevers: I have already touched on how fevers can cause dehydration, but infection and prolonged fever can be a life-threatening condition that we in the “biz” refer to as Sepsis. Simply sepsis is infection in the blood, and this can make your child extremely sick. Your parent gut will tell you something is wrong, and usually there will be changes to your child’s skin colour, they may be floppy or listless, and have changes in their consciousness and or breathing, all equalling an Emergency Room visit.
Disability: Refers to neurological (or brain) functioning of your child. And can be a late sign of issues with A, B, C, or can be caused by a brain problem.
- Changes in Mentation: When we talk about mentation, we talk about how our brain is working. Parents know their child’s normal behaviours so if your child is difficult to wake, not staying awake or acting confused this can be a change is mentation. A Child’s behaviour does fluctuate and if they were up late or have lacked sleep then being tired the next day would be normal. But if paired with fever or breathing difficulties than this could be sign the brain isn’t getting what it needs. I often refer to the brain as the princess of the body, if she doesn’t get the sugar and oxygen she wants when she wants it, she will cause a problem, and you will know it.
- Blood Sugars: If your child is a diabetic and their sugar is too low or too high and they are not responding to your usual care plan, then bring them to the ED. If your child is irritable, making lots of pee, and complaining of thirst and or tummy pain, they may be having high sugars and need investigations, depending on your comfort and the child’s physical status that can be done in a clinic or ED.
- Head Injuries and Seizures: More and more attention is being paid to children and head injuries, either from sports or accidents, and this is a great thing. If your child has hit their head and had a loss of consciousness (or blacked out), then they need to be seen as soon as possible. If your child hit their head with no loss of consciousness but has vomited and complaining of not feeling well, then they also need to be seen in a ED. Minor head injuries with no other symptoms can be seen in a clinic, and just an FYI, gone are the days of waking head injured people up, we now know that it’s normal to want to rest the brain, and as long as the person’s breathing is normal and they wake up easily then they are ok to sleep and rest. Many adolescents I see who have been active in high-contact sports, have had many concussions or brain injuries, this makes them more likely to suffer long-term effects, like depression, cognitive impairment, and changes in personality. It’s important for parents to promote a “health over sports” mentality, and if your child has already had a concussion it might be time to rethink the extracurricular activity. Seizures can happen because of an undiagnosed brain problem, or the result of a head injury, poisoning, or a bad infection. Seizure activity consists of involuntary movements of the head, arms, or legs, but can also look like your child is “lost in space”. These movements or lack of, will then be proceeded by a phase of your child being confused, angry, or tired. Any abnormal movements and or sudden confusion is an emergency.
THE REST OF THE ALPHABET
- Lacerations or cuts – if the cut is gapping or “smiling at you”, then it will need sutures (stitches) and that can be done in some clinics, but you may have to access and ED.
- Urinary Tract Infections (UTI) or swelling of genitals – sometimes the only symptoms of an UTI is a fever with no other symptoms, UTI’s are not always a ED visit, that would depend on how your child looks and how long they have had symptoms, however an untreated UTI can turn into a bad infection so it’s worth getting checked out sooner or later. Swelling of genitals is not normal and should be investigated, depending on the severity your child may feel more comfortable with their regular health care provider or if you’re concerned an ED visit is ok.
- Abdominal Pain – kids will have tummy aches on/off throughout their little lives. Tummy pain that gets better with medicine or a bowel movement is probably nothing serious, but tummy pain that is not treated with medication or is accompanied with fever and nausea or vomiting may be a serious health condition and needs an ED assessment.
- Injuries that cause a child not use a limb or walk with full weight bearing – kids will not want to move a limb because it hurts not because it’s broken, so it can be helpful for parent to watch their child, when the child doesn’t know your watching, to see if they naturally use the affected limb. Any obvious deformities in a limb would need a trip to the ED and have an x-ray. Also fractures and broken bones are the same thing, and I often hear parents talk about a fracture as being like a sprain, but really fracture is just a fancy word for cracked.
- Any Eye injuries – eyes are important and if you child receives an injury to their eye’s or complains of eye pain then come to you local ED. If you suspect your child has pink eye you can seek help from your pharmacist as there are some over the counter options to try.
- Voicing of self-harm or changes in your child’s behaviours that worries you – children can have mental health problems, which may or may not be related to situation that they are dealing with. If you as the parent are at all worried about your child’s mental health, have them seen sooner than later.
TIPS FOR COMING TO AN EMERGENCY ROOM
- Be prepared to wait – Emergency Department are organized to see the sickest people and children first. The word triage comes from the Latin word to sort and this is what the Triage Nurse’s job is. Therefore, if your child vital signs are stable then you may have to wait.
- If you are accessing a rural hospital be aware that doctors are not always in the department and they may be called in basis on the RN’s assessment of your child. Coming earlier than later is best, this also helps if a specialist needs to be called.
- Bring along the “binky”, or “boo boo” that they love. Their favorite stuffy or toy can help them feel secure in a foreign environment.
- Things may seem worse at night, take a moment to relax and go through the A, B, C, and D’s. If all is good, then most likely you can wait until morning to seek medical advice.
- If you have medication to treat certain symptoms, do it. It tells HCP a lot if you gave Tylenol and the child continued to not want to move their injured limb. Just remember to tell the triage nurse what you gave and the dose and the time you gave it.
- Tell you children what to expect so they aren’t scared when the doctor and nurse must examine them.
TIPS FOR HEALTH CARE PROVIDERS
- Don’t fear peds – use tools to remind you of weigh appropriate doses, and age appropriate vital signs.
- Don’t be afraid to use sedation if you need to get IV access or lab work – a great route is intranasal, and it makes the experience easier for you, the patient, and the family.
- Get the kids weight within your initial assessment.
- Fussy children and babies are good, floppy is not.
- Have access to toys, stickers, or bubbles so that you can distract or reward the child during your care.
- Don’t forget the parents – watching your child get sutures or an IV can be difficult, provide reassurance to parents and explain your treatment and interventions clearly.
- Remember what it’s like to be a parent – even if you don’t have children think about how it feels to have someone you love to be in pain or sick.
Kids are resilient and when given the opportunity show courage when dealing with health issues. Use the guide to educate yourself on what is an emergency and what isn’t but never let anything sway you from your gut.
In Canada, there is some informational resources to support you as a parent.
- Health Links BC – a BC resource but most provinces have their own website.
https://www.healthlinkbc.ca/explore-health-topics
- Here To Help – this is a resource for all ages, but it’s really great for parent who are concerned about their older child’s mental wellbeing.
- BC Children’s Hospital – this link takes you to a great page on child safety and refers you to government guidelines for things like trampolines.
http://www.bcchildrens.ca/health-info/healthy-living/child-safety
No matter if you’re a nurse or a parent, your intuition is the best assessment tool you have, so listen to yourself.
