Recognition of a seriously unwell child

Any person, 4 weeks to 15 years, presenting unwell without a clear clinical focus.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Airway

Breathing

Circulation

Disability

Exposure

Fluids

Glucose

Assessment

Intervention

BGL

Measure BGL. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated If BGL over 10 mmol/L: check blood ketones escalate as per local CERS protocol

Focused assessment

Complete a secondary survey.

No specific focused assessment. Use clinical judgement and A to G assessment to determine focused assessment.

Precautions and notes

• Signs of serious illness are often difficult to recognise in children. Complete a structured assessment and consider parental or carer concerns.
• Ongoing tachycardia and respiratory distress, despite analgesia, is a concern for serious illness.

Interventions and diagnostics

Specific treatment

• Consider switching to another protocol following initial A to G assessment.

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Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

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Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

• FBC, UEC, CRP/procalcitonin, VBG with lactate
• Urinalysis:
  • Patient who can void in the toilet: mid-stream urine
  • Patient who is not toilet trained: clean catch or catheter urine
  • Send for MC&S based on clinical presentation. Keep the sample refrigerated if transport is delayed.
  • Refer to urine sampling appendix for further detail
• Seriously unwell: coags, blood cultures
• Consider for specific fever sources: wound swab, sputum culture, stool culture and respiratory viral screen

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au