My first registrar post in Australia was in a mixed ED with children. The most common question I statement I encountered was
I’m not sure if this child needs to come into Hospital
I use the CHANDLER assessment tool to highlight potential red flags for paediatric admission. If 2 of the major groups are seen, the child should be strongly considered for admission and Paediatric specialist involvement.
C – Colour
- Pale- perhaps dehydrated
- Blue- cyanosed, hypoxic, hypothermic
- Red- Rash, Burn, infection
- Pink- healthy
H – Hydration status
- Moderate dehydration (4-6% loss)
- Capillary refill time >2 secs
- Mild decreased skin turgor
- Severe dehydration(>7% loss)
- Capillary refill time >3secs
- Deep acidotic breathing
- Signs of shock (Tachycardia, Hypotension, altered mental state)
- Decreased skin turgor
- Sunken eyes
A – Alert
- GCS status
- Is the patient awake, smiling and interacting.
- With neonates are they looking around, interested in their surroundings- reaching out for things put in front of them or are they floppy and disinterested.
- For older children are they tired and miserable looking or hard to rouse.
- Is the child inconsolable
N – Nutritional Status
- Fat reserves
- Does the child have good nutritional reserve and appear to be on normal weight limits?
- Are they very underweight? Consider serious medical/surgical illness; anorexia or even neglect in the home?
- Is the child overweight? Consider weight related issues such as Diabetes.
D – Dysmorphia
- *Important to remember associations of certain conditions with particular syndromes
- Example – Congenital Heart Disease in children with Down’s Syndrome.
- These children can get sick very quickly.
- Children with syndromes also have an increased incidence of renal abnormalities and swallowing issues and at risk for aspiration
L – Limbs
- Are all the limb moving – particularly important in neonates or young toddlers with obvious communication issues.
- Take note of children not moving arms or legs, examining thoroughly for tenderness.
- Caution in those also with a limp.
- Problems may not be obviously in the knees or lower aspect of the leg but in the hip, or even in genitalia in boys.
- Consider Non-accidental injury also in children <2yrs
E – External Supports
- This can be noted on your first interaction with the child as parents or Ambulance bring them in.
- Does the child require external supports such as:
- Wheelchair or splint. Does the parent carry them (when they can easily walk)
- Oxygen, nebulisers or IV fluids
- Sedation or significant analgesia prior to arrival
- Cooling aids (wet towels/ ice packs etc)
R- Respiratory Distress
- Is the child’s breathing becoming compromised.
- Increased Respiratory rate for age
- Accessory Muscle use
- Posturing- tripod position
- Sternal and Sub/intercostal recession
- Tracheal Tug
- Nasal Flaring and head bobbing