Advanced Paediatric Emergency Nursing

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Paediatric Assessment Triangle (PAT)

The PAT is a rapid (<30 sec) visual/auditory assessment performed BEFORE touching the child. It establishes a general impression and physiological category.

APPEARANCE

TICLS Mnemonic

Tone — muscle tone, movement
Interactivity — alert, responds to environment
Consolability — calmed by carer
Look / Gaze — tracks, focuses
Speak / Cry — strong cry, speech appropriate

WORK OF BREATHING

Audible sounds (wheeze/stridor/grunting)
Positioning (sniffing/tripod/unable to lie flat)
Retractions (sub/intercostal/suprasternal)
Nasal flaring
Head bobbing (infants)
Tracheal tug

CIRCULATION (Skin)

Pallor — vasospasm/anaemia
Mottling — poor perfusion
Cyanosis — central vs peripheral
Normal skin colour = adequate perfusion

PAT Interpretation — Physiological Category

Stable: Normal appearance, normal WOB, normal circulation

Respiratory Distress: Abnormal WOB only — increased WOB or abnormal sounds

Respiratory Failure: Abnormal appearance + abnormal WOB (fatigue, severe hypoxia)

Shock: Abnormal appearance + abnormal circulation (no increased WOB initially)

CNS/Metabolic: Abnormal appearance only — altered consciousness, seizure

Cardiopulmonary Failure: All three components abnormal — IMMINENT ARREST

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AVPU Consciousness Scale

A — AlertNormal

V — Voice responsiveGCS ~12

P — Pain responsiveGCS ~8

U — UnresponsiveGCS ~3

Clinical PearlP on AVPU = GCS ≤8. Airway protection reflexes compromised. Consider airway adjunct/intubation. Any child P or U requires senior review immediately.

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Weight Estimation

Standard Formula (1–10 years)

Weight (kg) = 2 × (Age in years + 4)

Example: 6 yr old = 2×(6+4) = 20 kg

Infant Formula (<1 year)

Weight (kg) = (Age in months ÷ 2) + 4

Example: 6-month infant = 3 + 4 = 7 kg

Broselow Tape

Gold standard — length-based weight estimation

Colour-coded zones with pre-calculated drug doses. Use supine length. Most accurate for children up to ~35 kg.

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Normal Vital Signs by Age

Age Group	Heart Rate (bpm)	RR (breaths/min)	SBP (mmHg)	SpO2 (%)
Neonate (0–28d)	100–160	40–60	60–80	≥95
Infant (1–12 mo)	100–160	30–50	70–90	≥95
Toddler (1–3 yr)	90–150	24–40	80–100	≥95
Preschool (3–5 yr)	80–140	22–34	80–100	≥95
School age (6–12 yr)	70–120	18–30	90–110	≥97
Adolescent (13–18 yr)	60–100	12–20	100–120	≥97

Hypotension FormulaMinimum acceptable SBP = 70 + (2 × age in years) for children 1–10 yr. Below this = decompensated shock. Note: children compensate well — hypotension is a LATE sign.

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Paediatric Glasgow Coma Scale (GCS-P)

Eye Opening (E)

Spontaneous4

To voice3

To pain2

None1

Verbal (V) — Modified

Words/coos/babbles5

Cries consolable4

Cries inconsolable3

Moans to pain2

None1

Motor (M)

Obeys commands6

Localises pain5

Withdraws to pain4

Abnormal flexion3

Abnormal extension2

None1

GCS ThresholdsGCS ≤8: Severely impaired consciousness — consider airway management. GCS <14: CT head indicated (see Trauma tab). Full score = 15. Minimum = 3.

CRITICAL REMINDERCall for senior help EARLY. Paediatric arrests are usually RESPIRATORY in origin — oxygenation and ventilation are paramount. Establish IO access if IV fails after 2 attempts or 90 seconds.

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Paediatric Basic Life Support (PBLS)

Safe? Stimulate. Check environment safe. Tap shoulders/call name. Shout for help.

Airway. Head tilt–chin lift (neutral position infants; sniffing position older children). Jaw thrust if C-spine concern.

5 Rescue Breaths. Mouth-to-mouth-and-nose (infants) or mouth-to-mouth (child). Each breath 1 second, visible chest rise. Assess for response between breaths.

Compression:Ventilation Ratio.

Child (1yr–puberty) 15:2 (2 rescuers) or 30:2 (1 rescuer)
Neonate 3:1 (2 thumb technique encircling hands)
Rate: 100–120 compressions/min

Compression Depth. At least 1/3 anteroposterior chest depth (~4 cm infants, ~5 cm children). Hard surface. Full recoil between compressions. Minimise interruptions.

AED. Attach as soon as available. Use paediatric pads/attenuator for children <8 years or <25 kg. If not available, adult pads can be used (anterior-posterior placement).

Check PulseBrachial artery (infants) or carotid/femoral (children). Take no more than 10 seconds. If uncertain — start CPR.

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PALS Algorithm — Shockable vs Non-Shockable

NON-SHOCKABLE (PEA/Asystole)

Continue CPR 2 min cycles
Adrenaline 0.01 mg/kg IV/IO immediately, repeat every 3–5 min
Identify and treat reversible causes (4Hs & 4Ts)
Rhythm check every 2 min

SHOCKABLE (VF/pVT)

Defibrillate: 4 J/kg (max 360J monophasic, 200J biphasic)
Resume CPR immediately (2 min)
Adrenaline after 3rd shock, then every 3–5 min
Amiodarone 5 mg/kg IV/IO after 3rd and 5th shock

Reversible Causes — 4Hs & 4Ts

Hypoxia — optimise airway/O2
Hypovolaemia — fluid bolus, blood
Hypo/hyperkalaemia & metabolic
Hypothermia — warm patient

Tension pneumothorax — decompress
Tamponade — pericardiocentesis
Thrombosis (PE/coronary)
Toxins — antidote/supportive

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Intraosseous (IO) Access — EZ-IO

Indications

Failed IV after 2 attempts OR 90 seconds in emergency. IO is first-line in cardiac arrest.

Sites (in order of preference)

Proximal tibia — 2 cm below tibial tuberosity, medial flat surface (most common)
Distal femur — 3 cm above lateral condyle
Humeral head — deltoid tuberosity (adults/older children)
Distal tibia — proximal to medial malleolus

All IV drugs and fluids can be given IO.Flush with 5–10 mL NaCl before each medication. Confirm position: no extravasation, flows freely, bone marrow aspirate confirms position.

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Post-Resuscitation Care (ROSC)

Targeted Temperature Management (TTM). Comatose children after ROSC: 32–34°C for 24h, then rewarm. Neonatal HIE: 33–34°C for 72 hours (specialist unit).

Ventilation. Target PaCO2 35–45 mmHg, PaO2 80–100 mmHg. Avoid hyperoxia and hypocapnia.

Glucose. Monitor BGL 30-minutely. Target 4–8 mmol/L. Treat hypoglycaemia with 2 mL/kg 10% dextrose.

Haemodynamics. Target normal MAP for age. Inotropes if needed. 12-lead ECG — exclude primary cardiac cause.

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Key Resuscitation Drug Doses

Drug	Dose	Route	Max Dose	Notes
Adrenaline (Epinephrine)	0.01 mg/kg (= 0.1 mL/kg of 1:10,000)	IV / IO	1 mg per dose	Every 3–5 min in arrest
Amiodarone	5 mg/kg	IV / IO	300 mg	After 3rd & 5th shock in VF/pVT
Atropine	0.02 mg/kg	IV / IO	0.5 mg (child) 1 mg (adolescent)	Min dose 0.1 mg; bradycardia with haemodynamic compromise
Adenosine	0.1 mg/kg first dose, 0.2 mg/kg 2nd	Rapid IV flush	6 mg / 12 mg	SVT — rapid proximal IV push
Glucose 10%	2 mL/kg	IV / IO	—	Hypoglycaemia; can use 25% dextrose diluted 1:1
Sodium Bicarbonate 8.4%	1 mmol/kg (= 1 mL/kg)	IV / IO	—	Only in prolonged arrest or confirmed severe acidosis
Calcium Gluconate 10%	0.5 mL/kg	Slow IV	20 mL	Hypocalcaemia, hyperkalaemia, CCB toxicity

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Croup (Laryngotracheobronchitis)

Most common: parainfluenza virus. Age 6 months–3 years. Seal-bark cough, hoarse voice, inspiratory stridor. Worse at night.

Westley Croup Score

Feature	0	1	2	3	4–5
Stridor	None	At rest (stethoscope)	At rest (unaided)	—	—
Retractions	None	Mild	Moderate	Severe	—
Air entry	Normal	Decreased	Markedly ↓	—	—
Cyanosis	None	—	With agitation	—	At rest
Consciousness	Normal	—	—	Depressed	—

Mild (0–2)Barky cough, no stridor at rest. Dexamethasone 0.15 mg/kg oral (single dose). Observe 2–4h, discharge if stable.

Moderate (3–7)Stridor at rest, retractions. Dexamethasone 0.6 mg/kg IM/oral. Nebulised adrenaline if not improving. Admit for observation.

Severe (≥8)Severe distress, cyanosis, depressed consciousness. Nebulised adrenaline 5 mg (5 mL of 1:1000) via nebuliser. Dexamethasone 0.6 mg/kg IM. O2. Consider anaesthetic team. Repeat adrenaline q20–30 min.

GCC Tip — Cold Mist NOT recommendedCool mist therapy has no evidence of benefit. Provide humidified oxygen. Allow child to adopt position of comfort. Minimise distress — agitation worsens stridor.

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Epiglottitis — EMERGENCY

DO NOT examine the throat. DO NOT use a tongue depressor. DO NOT upset the child.

Classic Presentation ("4 Ds")

Drooling — unable to swallow secretions
Dysphagia — severe sore throat/odynophagia
Distress — toxic-appearing, high fever (>38.5°C)
Dysphonia — muffled "hot potato" voice
Tripod position / leaning forward
Soft stridor (supraglottic)

Immediate Actions

Keep child CALM — allow position of comfort, do not separate from carer

Call anaesthetist + ENT + senior paediatrician immediately

Controlled intubation in THEATRE with surgical airway backup (tracheostomy)

IV access only after airway secured. Antibiotics: cefotaxime/ceftriaxone IV

Do NOT perform blood tests, IV, or any procedures until airway secured

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Bronchiolitis (RSV)

Commonest lower respiratory tract infection in infants. Peak age <12 months. Seasonal — GCC: November–April typically. RSV most common causative virus.

Clinical Features

2–3 day coryzal prodrome
Wheeze + crackles (fine, widespread)
Subcostal/intercostal retractions
Feeding difficulty (nasal congestion)
Apnoeas — especially premature infants <3 months
SpO2 may fall with feeds

Management (Evidence-Based)

Supported (evidence-based)

✓ O2 to maintain SpO2 ≥92% (≥94% if <6 weeks)
✓ NG/nasogastric feeds if unable to maintain oral intake
✓ HFNC (High Flow Nasal Cannula) for moderate–severe — reduces intubation rate
✓ CPAP — escalation step
✓ Apnoea monitoring (especially <3 months)

NOT recommended (no evidence)

✗ Salbutamol (bronchodilators not effective in bronchiolitis)
✗ Steroids
✗ Antibiotics (unless secondary bacterial infection)
✗ Ribavirin (routine use)

High-Risk Groups — Consider Early AdmissionAge <3 months, born <35 weeks gestation, congenital heart disease, chronic lung disease, immunocompromised, SpO2 <92%, poor feeding (<50% normal intake), apnoea episodes, social concerns.

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Acute Severe Asthma

Feature	Moderate	Severe	Life-Threatening
SpO2	≥92%	<92%	<92% + silent chest
Speech	Normal sentences	Short phrases	Unable to speak
HR	Normal	Tachycardic	Bradycardia
RR	Normal/mildly ↑	Increased	Exhaustion
Wheeze	Moderate	Loud	Silent chest

Management Stepwise

O2 to maintain SpO2 ≥94%. Salbutamol 2.5 mg (<5yr) / 5 mg (≥5yr) nebulised continuously or q20min in severe. Ipratropium bromide 0.25 mg q20min x3 (add in moderate-severe).

Prednisolone 1–2 mg/kg oral (max 40 mg) or IV hydrocortisone 4 mg/kg. Start within 1 hour.

Severe/Life-threatening: IV Magnesium sulphate 50 mg/kg (max 2g) over 20 min. IV Salbutamol infusion 1–5 mcg/kg/min. Consider heliox, CPAP, intubation (last resort — intubation in asthma is high risk).

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Paediatric Shock — Types & Recognition

Universal Shock Signs

Tachycardia (most sensitive early sign)
Prolonged capillary refill >2 seconds (warm) or >3 sec (cold)
Altered mental status / poor tone
Decreased urine output (<1 mL/kg/hr)
Weak/thready peripheral pulses
Hypotension — LATE sign (decompensated shock)

Shock Classification

Hypovolaemic: Dehydration, haemorrhage, burns

Distributive: Sepsis, anaphylaxis, neurogenic

Cardiogenic: Myocarditis, arrhythmia, structural heart disease

Obstructive: Tension pneumothorax, cardiac tamponade, massive PE

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Paediatric Septic Shock

Surviving Sepsis Campaign — Key TargetsAntibiotics within 1 hour. First fluid bolus within 30 minutes. Reassess after each bolus. Inotrope if no response at 40 mL/kg.

Recognition — SIRS in Children

Fever >38.5°C or hypothermia <36°C
Tachycardia for age OR bradycardia (<1yr)
Tachypnoea for age
Altered perfusion: CRT >2s, mottling, poor peripheral pulses
Altered mental status

Fluid Resuscitation

Fluid Bolus — 0.9% NaCl

10–20 mL/kg over 5–10 min

Reassess after EACH bolus. Beware fluid overload in cardiogenic shock. Maximum 40–60 mL/kg total in first hour (FEAST trial — avoid excess in malaria/dengue endemic areas).

Antibiotic Selection (GCC Context)

Empirical (community-acquired)

Ceftriaxone 100 mg/kg/day IV (max 4g)

+ vancomycin if suspected MRSA or Gram+ source. Add metronidazole if abdominal source.

Neonatal Sepsis

Ampicillin + Gentamicin IV

Add aciclovir if HSV suspected. Check local resistance patterns.

Inotropes (vasopressor-refractory)

Noradrenaline: 0.05–2 mcg/kg/min (vasodilated warm shock)
Dopamine: 5–20 mcg/kg/min
Adrenaline: 0.05–2 mcg/kg/min (cold shock)

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Anaphylaxis

Diagnosis — Any 2 of 3 systems involved after allergen exposure:

Skin/mucosal: urticaria, angioedema, flushing
Respiratory: wheeze, stridor, SpO2↓
Cardiovascular: hypotension, tachycardia, syncope
GI: vomiting, abdominal pain (less specific)

Adrenaline IM — FIRST-LINE

0.01 mg/kg IM (= 0.01 mL/kg of 1:1000)

Anterolateral thigh. Repeat every 5–15 min if no improvement. Max dose: 0.5 mg (child), 0.5 mg (adolescent). Auto-injector: <25kg → 150 mcg; ≥25kg → 300 mcg.

Adjuncts (after adrenaline)

O2 high flow. Salbutamol nebulised for bronchospasm. Chlorphenamine 0.2 mg/kg IV/IM. Hydrocortisone 4 mg/kg IV. Fluid bolus if hypotensive (10–20 mL/kg).

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Diabetic Ketoacidosis (DKA) in Children

Cerebral Oedema — Most Feared ComplicationOccurs in 0.5–1% of paediatric DKA. Highest risk: new diagnosis, age <5yr, bicarbonate therapy, excessive fluid administration, failure to correct sodium. Monitor conscious level HOURLY.

Fluid Protocol

Only resuscitate if clinical shock (10 mL/kg boluses — cautious)
Rehydration over 24–48 hours
Maximum rate = 1.5× maintenance (NOT calculated deficits in UK/GCC guidelines)
0.9% NaCl with KCl initially, transition to 0.45% NaCl once glucose <14 mmol/L
Add dextrose to IV fluid when glucose <14 mmol/L

Insulin Protocol

Start insulin AFTER 1 hour of IV fluids
Regular insulin 0.05–0.1 units/kg/hr
Do NOT give bolus insulin in DKA
Target glucose fall: 2–5 mmol/L/hr
Potassium monitoring critical — replace early

Cerebral Oedema Treatment

Mannitol 0.5–1 g/kg IV over 15–20 min
OR Hypertonic saline 3% 2.5–5 mL/kg IV over 15 min
Restrict fluids, nurse 30° head-up

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Paediatric Primary Survey — cABCDE

Catastrophic Haemorrhage Control. Direct pressure to external bleeding wounds. Tourniquet (limb only) — commercial tourniquet or improvised. Wound packing with haemostatic gauze. Life-threatening external haemorrhage addressed FIRST.

Airway with C-spine protection. Jaw thrust (not head tilt) if C-spine concern. Suction blood/secretions. OPA/NPA if required. RSI/Surgical airway if needed. Assume C-spine injury in significant mechanism.

Breathing. Assess chest symmetry, breath sounds, tracheal deviation. Tension pneumothorax: needle decompression (see below). Haemothorax: chest drain. SpO2 monitoring. O2 15 L/min high-flow.

Circulation. Two large-bore IV access (IO if fails). 10 mL/kg 0.9% NaCl bolus — reassess. Consider early blood products (MTP) in haemorrhagic shock. TXA within 3 hours.

Disability. GCS, pupils (size, reactivity, symmetry), AVPU, BGL. Sedation/analgesia once haemodynamically stable. Treat seizures.

Exposure/Environment. Full exposure — log roll, examine back. Prevent hypothermia (warm blankets, warm IV fluids, warm environment). Document all injuries.

MIST HandoverMechanism | Injuries found | Signs (vitals) | Treatment given. Delivered concisely to receiving team in <60 seconds.

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Tension Pneumothorax

Clinical Diagnosis — Do NOT wait for X-rayAbsent breath sounds + tracheal deviation (late) + haemodynamic compromise. In ventilated patient: rising airway pressures.

Needle Decompression

Site: 2nd ICS mid-clavicular line OR 4th/5th ICS mid-axillary line (preferred in obese/muscular)

Needle size: 14–16G cannula in children (larger than adults relative to chest wall thickness). Confirm with hiss of air.

Follow with formal chest drain (intercostal drain) as soon as possible. Safetynet decompression: flutter valve or underwater seal.

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Haemorrhagic Shock & MTP

Massive Transfusion Protocol (MTP) — 1:1:1

pRBC : FFP : Platelets = 1:1:1

Activate MTP early. Consider MTP if >40 mL/kg estimated blood loss. Calcium supplementation with each unit blood products.

Tranexamic Acid (TXA)

15 mg/kg IV (max 1g) over 10 min

Give within 3 hours of injury — evidence strongest within 1 hour. Follow with 2 mg/kg/hr infusion for 8 hours (or 15 mg/kg maintenance dose IV).

Permissive HypotensionTarget SBP 70–90 mmHg (isolated trauma, no TBI) until haemorrhage controlled. Avoid over-resuscitation with crystalloids.

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Paediatric Head Injury — CT Criteria (NICE)

Children <1 year — CT HEAD if ANY of:

Any head injury (high sensitivity protocol)
Suspicion of non-accidental injury
Post-traumatic seizure
GCS <15 on assessment
Tense fontanelle

Children 1–16 years — CT HEAD if ANY of:

GCS <14 at time of assessment
GCS <15 at 2 hours post-injury
Suspected open/depressed skull fracture or basal skull fracture signs
Post-traumatic seizure
Focal neurological deficit
LOC >5 minutes
Amnesia (anterograde or retrograde) >5 minutes
Abnormal drowsiness
Vomiting ≥3 times
High-energy mechanism

High-energy mechanisms include:Pedestrian/cyclist struck by vehicle, unrestrained occupant, fall >3m (or 3 × child's height), high-speed motor vehicle collision, non-accidental injury suspected.

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Non-Accidental Injury (NAI) — Recognition

Mandatory Reporting ObligationAll suspected child abuse must be reported as per GCC national child protection laws and hospital safeguarding policy. Document objectively; do not accuse directly.

Concerning Features in History

Inconsistent or changing history of mechanism
Mechanism inconsistent with developmental stage (e.g., "rolled off bed" in 3-week-old)
Delay in seeking medical attention
Multiple attendances for injury
Caregiver unaware of how injury occurred

Suspicious Injury Patterns

Bruising in non-mobile infant (<6 months)
Bruising in unusual locations (ears, neck, torso, buttocks)
Patterned bruising (hand slap, implement)
Multiple fractures at different stages of healing
Posterior rib fractures (highly specific for NAI)
Subdural haematoma (shaken baby — retinal haemorrhages)
Burns in unusual distribution (stocking/glove, symmetrical)

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Road Traffic Accidents (RTAs) — Leading Cause of Paediatric Trauma in GCC

Epidemiology

GCC has historically high road fatality rates; improving with enforcement (Saudi Vision 2030, UAE road safety campaigns)
Common: unrestrained children, front-seat passengers, children in laps
Speed-related major trauma; multi-organ injury patterns
Most common mechanism in paediatric ICU admissions across GCC

Nursing Priorities

Activate trauma team early — predict multi-system injury
Unrestrained children: higher energy forces, expect worse injuries
Lap-belt sign: suspect hollow viscus injury + lumbar spine fracture (Chance fracture)
Log roll mandatory — examine entire back
FAST ultrasound if haemodynamically unstable (free fluid)
Communicate with family — may be unwell themselves

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Near-Drowning / Submersion Injuries

GCC Context: Almost every GCC home, compound, and hotel has a private/semi-private pool. Peak season: June–September (school holidays + extreme heat). Age group: toddlers 1–4 years most vulnerable.

Immediate Management

Remove from water — minimise C-spine precautions unless clear trauma

Start CPR immediately if not breathing — 5 rescue breaths first (submersion = primary respiratory cause)

Do NOT waste time trying to drain water from lungs

Warm patient — hypothermia protective if cold water submersion

All children with submersion requiring resuscitation: admit for minimum 6–24hr observation (secondary drowning)

Secondary Drowning Awareness

Secondary/Delayed DrowningChild may appear well initially. Pulmonary oedema develops 1–24 hours later. Symptoms: increased work of breathing, cough, fatigue, altered behaviour. Any child with water aspiration → admit for observation.

Arabian Gulf / Red Sea Specifics

Saltwater submersion (osmotic gradient pulls fluid INTO lungs)
Beach/sea activities: rip currents, wave impact, coral injury
Jellyfish envenomation (Portuguese man-o-war in Arabian Gulf)
Sea urchin spine injuries

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Heat Stroke in Children

GCC ambient temperatures June–September regularly exceed 45°C. Children are disproportionately vulnerable. Cars heat to dangerous temperatures within minutes — car entrapment is life-threatening.

Classic GCC ScenarioToddler left in locked vehicle — temperature inside rises to 70°C+ within 20 minutes. Core temperature >40°C on arrival = heat stroke until proven otherwise.

Management — Cool FIRST, Then Investigate

Rapid cooling target: Core temp <39°C within 30 minutes. Immersion (cold water/ice slurry) most effective.

Remove all clothing. Cold IV fluids. Cooling blankets. Ice packs to groin/axillae/neck.

Manage complications: seizures (benzodiazepines), rhabdomyolysis (aggressive hydration), DIC (blood products), AKI (fluid management).

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Accidental Ingestion (Poisoning)

Peak age: 1–3 years. GCC households: medications (sedatives, cardiovascular), cleaning products, herbal remedies, traditional Islamic medicines (kohl/surma — lead toxicity).

Common GCC Agents

Iron tablets (prenatal vitamins — severe GI/systemic toxicity), calcium channel blockers/beta-blockers (cardiac effects), benzodiazepines (sedation), organophosphates (agricultural areas), kerosene/lamp oil (aspiration pneumonitis risk — do NOT induce vomiting), caustic ingestion (bleach/oven cleaner — no charcoal, no vomiting)

Poison Centre ResourcesSaudi Poison Centre: 0800 24 7 24 7 | UAE: NCEMA | Qatar: Hamad Medical Corporation Toxicology. Always contact the regional poison centre for management guidance.

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Consanguinity-Related Metabolic Emergencies (IEM)

GCC Context: Consanguinity rates 40–60% in parts of Saudi Arabia, Qatar, UAE, Kuwait. Autosomal recessive conditions including inborn errors of metabolism (IEM) are significantly more prevalent than in non-consanguineous populations.

Classic Presentation (Neonate/Infant)

Well at birth, deteriorates days 2–5 (when feeding established)
Poor feeding, vomiting, lethargy
Seizures unresponsive to standard anticonvulsants
Hypoglycaemia refractory to glucose
Metabolic acidosis (high anion gap)
Hyperammonaemia — irritability, encephalopathy
Unusual body/urine odour (specific to disorder)

Emergency Investigations & Management

BGL, blood gas, ammonia, lactate, LFT, U&E, FBC
Urine organic acids, plasma amino acids (call biochemistry lab)
STOP protein intake temporarily
IV glucose to suppress catabolism (high GIR — glucose infusion rate)
If hyperammonaemia: rifaximin, sodium benzoate/phenylacetate
Haemodialysis for severe hyperammonaemia (>500 μmol/L)
Pyridoxine 100 mg IV trial in seizure + IEM suspected
Contact metabolic team EARLY

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Camel & Horse Injuries

Traditional equestrian and camel racing culture in GCC. Children participate in camel jockeying (historically, now banned — robot jockeys used, but recreational injuries persist) and horse riding.

Camel kick/bite: massive soft tissue injury, crush injury, fractures, septic wounds (Pasteurella, Brucella)
Fall from camel: significant height (2–3m), head/spinal injury
Horse kick to face/chest: facial fractures, pulmonary contusion
Treat as high-energy trauma — full primary survey
Wound contamination: Gram-negative coverage, tetanus prophylaxis
Document for safeguarding — child jockeys now illegal under GCC law

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Hajj Paediatric Emergencies

Millions of pilgrims in Makkah — children travel as pilgrims with families. Unique mass-gathering medical challenges during Dhul Hijja.

Crush/Crowd injury: traumatic asphyxia — Jamarat bridge, Tawaf. Rapid extrication, respiratory support.
Heat exhaustion/stroke: outdoor rituals in extreme heat. Cooling, aggressive hydration.
Stampede injury: polytrauma pattern, multiple victims, mass casualty triage (START/JumpSTART for children).
Respiratory illness: MERS-CoV (although lower incidence now), respiratory syncytial virus, influenza in crowded conditions.
Dehydration: high ambient temperatures, inadequate fluid intake, vomiting/diarrhoea.
Hajj medical teams include paediatric specialists — escalate early.

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Arabic Language Pain Assessment Tools

Validated Arabic FLACC Scale (0–2 years / non-verbal)

Category	Arabic Key Term	Score 0	Score 1–2
Face	وجه (Wajh)	No expression	Grimace, frown
Legs	ساق (Saaq)	Normal position	Kicking, drawn up
Activity	نشاط (Nashat)	Lying quietly	Squirming, arched
Cry	بكاء (Bukaa)	No cry	Moans, cries
Consolability	تهدئة (Tahdia)	Relaxed	Difficult to console

Arabic FACES Pain Scale (3–12 years)

Validated Arabic translation. Show child the series of faces and ask: "أي وجه يشبه ألمك الآن؟" (Which face looks like your pain now?)"

😊

0
لا ألم

🙂

2
خفيف

😐

4
متوسط

😟

6
شديد

😣

8
أشد

😭

10
أشد ألم

Cultural NoteSome children in GCC may be stoic or reluctant to express pain due to cultural/family norms. Behavioural assessment (FLACC) may be more reliable than self-report in some contexts. Always involve parents as historians.