When should a pediatric patient be sent to the emergency room (ER)?

When to Send a Pediatric Patient to the Emergency Room

Pediatric patients should be sent to the emergency room immediately when they show signs of respiratory distress, altered mental status, severe dehydration, suspected trauma, uncontrolled bleeding, suspected poisoning, or when they are unresponsive or have abnormal vital signs for their age group. 1

Life-Threatening Conditions Requiring Immediate ER Care

Respiratory Emergencies

• Severe respiratory distress with:
  • Increased work of breathing (retractions, nasal flaring)
  • Cyanosis or oxygen saturation below 92%
  • Stridor at rest or audible wheezing
  • Inability to speak or cry due to breathing difficulty

Cardiovascular Emergencies

• Signs of shock:
  • Tachycardia with poor perfusion
  • Delayed capillary refill (>2 seconds)
  • Hypotension (late sign in children)
• Pulse <60 beats per minute with signs of poor perfusion 1

Neurological Emergencies

• Altered mental status or decreased level of consciousness
• New onset seizure or status epilepticus
• Suspected stroke symptoms (even in children) 1
• Severe headache with vomiting or neurological deficits

Trauma

• Head injury with loss of consciousness or vomiting
• Suspected fractures with deformity or severe pain
• Significant burns (>10% body surface area)
• Penetrating injuries
• Multiple trauma from high-energy mechanisms

Specific Clinical Scenarios Requiring ER Evaluation

Fever

• Infants <3 months with fever ≥38°C (100.4°F)
• Children with fever >39°C (102.2°F) AND:
  • Appearing toxic or severely ill
  • Persistent high fever for ≥3-4 consecutive days 2
  • "Double-sickening" pattern (improvement followed by new fever) 2

Dehydration

• Signs of severe dehydration:
  • Decreased urine output (<1 ml/kg/hr)
  • Dry mouth, sunken eyes, absent tears
  • Lethargy or altered mental status
  • Persistent vomiting preventing oral rehydration

Abdominal Pain

• Severe, persistent abdominal pain
• Abdominal pain with vomiting and signs of dehydration
• Abdominal pain with fever and signs of toxicity

Choking/Foreign Body

• Witnessed choking event with persistent symptoms
• Partial airway obstruction not relieved by basic maneuvers 1
• Complete airway obstruction (requires immediate EMS activation) 1

Special Considerations

Age-Specific Concerns

• Neonates (<28 days): Any fever, poor feeding, lethargy, or color change
• Infants: Inconsolable crying, bulging fontanelle, or failure to feed
• Toddlers: Inability to recognize caregivers, severe lethargy

Chronic Conditions

• Children with ventricular shunts showing signs of malfunction (headache, vomiting, altered mental status) 1
• Children with known cardiac conditions showing signs of decompensation
• Diabetic children with signs of ketoacidosis (vomiting, abdominal pain, altered mental status)

Pain Management Considerations

• Severe pain unresponsive to appropriate home management
• Pain requiring parenteral analgesia or procedural sedation 1

Common Pitfalls in Decision-Making

Delayed Presentation

• Children may compensate well until sudden decompensation
• Tachycardia and poor perfusion are more reliable indicators of shock than blood pressure
• Respiratory rate alone may not indicate respiratory distress; look for increased work of breathing

Communication Barriers

• Language barriers may complicate assessment; use professional interpreters when available 1
• Cultural considerations may affect symptom reporting and understanding of illness severity

Medication Safety

• Suspected medication overdose requires immediate ER evaluation 3
• Medication errors are common in pediatrics and may require emergency assessment 4, 5

When Telephone Triage is Appropriate vs. ER Referral

Telephone Advice Appropriate For:

• Mild fever (<39°C) in well-appearing children >3 months with adequate fluid intake
• Minor trauma without deformity, severe pain, or altered function
• Mild respiratory symptoms without distress

ER Referral Required For:

• Any concern for airway, breathing, or circulation compromise
• Significant trauma requiring imaging or procedural intervention
• Severe pain requiring parenteral medication
• Persistent vomiting or dehydration preventing oral intake

Remember that pediatric patients can deteriorate rapidly, and when in doubt about the severity of a child's condition, it is safer to refer to the emergency department for evaluation rather than risk delayed care for a potentially serious condition.