When to Go to the ER for a Sick or Injured Child

When should you bring your child to the ER? And when is it safe to stay home?

This is a really important question, and one I’m very excited to answer! I get to see little ones every day in the emergency department, as an Emergency Medicine physician, I wish I had the chance to talk through these points with every parent.

Of course, *disclaimer* the below information is limited in the time we have together and if you are unsure, always err on the side of caution and go to the ER! We can’t cover every scenario, and if you feel something is amiss, trust your gut! I am also writing to the broader population, but if your child has health problems (like asthma, sickle cell disease, born premature, etc.) I would speak with your primary care physician about illnesses they are more prone to.

Kiddos are resilient, and their bodies do a really good job of healing themselves. Especially with bumps, scrapes and viruses, often, children will do fine without visiting a doctor.

But there are some important situations, where coming to the doctor can be really helpful.

We’re going to discuss a lot of important information, so definitely pin this now so you can come back to it later!

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Reasons to Go to the ER Now

To begin, call 911 or come straight to the ER for any problem with their ABCs (Airway, Breathing, and/or Circulation)

• Airway – Many different things can compromise your child’s airway:
  • Most commonly we think of choking or drowning. If you are not already CPR certified, I would recommend becoming so. If you suspect your child is choking, and they are no longer coughing, you should begin maneuvers to remove the obstruction and call 911.
  • Sometimes infections, like epiglottitis, can cause your little one’s throat to become swollen. If it sounds like it is difficult to move air when they breathe, this should be seen immediately by a physician.
  • Allergic reactions, specifically anaphylaxis, can cause the inner mouth or airway to become swollen very quickly. If you suspect this is happening and you have an epi pen, use it. Whether or not you have an epi pen, call 911 immediately.

• Breathing – Children have smaller airways than adults, and respiratory problems, even a cold, can affect them more severely. Watch for:
  • If they are breathing MUCH faster than normal FOR THEM.
  • You can hear audible wheezing. This is not just for people with asthma, sometimes viruses, or even getting something caught in the airway can cause wheezing.
  • If your child has increased work of breathing, like they are using their belly and neck muscles to move air, when normally they don’t need to.  Here’s an example video showing these symptoms.

• Circulation – This can be a bit harder to tell in a child. Come to the ER if:
  • Your child has bleeding that is difficult to control with firm pressure from your hand.
  • They are too light headed to walk or act normally. This could be a sign their blood pressure is low.

Now that we have the scariest things out of the way, here are common complaints, and reasons to bring to the ER versus potentially stay at home:

When to Go to ER for Fever in Children

Fever can be a tricky complaint. While the many fevers are not dangerous, it is important to know what to watch for.

Additionally, if your child is vaccinated, the risk of life-threatening infections is lower. Unvaccinated children are at high risk for dangerous conditions like diphtheria and should consider going to the ER early in an infection’s course.

• First, make sure it’s actually a fever! If you do not have a thermometer, go buy one, and if you have one, be sure to check when you are concerned your child has a fever. Rectal temperatures are the most accurate in children < 3 years old. Often viral infections may make us feel warm, but not cause a fever.
• Fever in infants less than three months old (>100.4°F) need to go to the ER. During this period, the infant’s immune system does not present life-threatening infections like older children, and this may mask things like meningitis, or bacteria in the bloodstream
• Between 3 and 36 month olds should be evaluated if their fever is greater than 102.2°F
• Fevers > 104°F should be evaluated by a physician

Causes of Fever in Children

• Upper respiratory infection: If your child has multiple different components of their upper respiratory tract involved (cough, runny nose, earache and sneezing), chances are they have a virus. Unless these symptoms are causing problems with their ABCs (see above), most of the time we will encourage symptom control, and close follow up with their primary care provider.

“The Flu” is a viral infection, and most of the time, children do NOT require antiviral medications unless they are immune-compromised, have respiratory problems or are under five years old. Avoiding getting the flu in the first place, is the safest possible plan.

• Ear pain or discharge: If the MAIN or ONLY symptom is fever with tugging or pulling at the ears, it is possible this is an ear infection. If that is the case, your child may need antibiotics, and you should be seen. You can also go to an Urgent Care or your pediatrician’s office for this evaluation.

• Sore throat: If the MAIN or ONLY symptom is fever and sore throat (without cough or runny nose), this could be a sign of a bacterial infection. Viruses can also cause these symptoms and they do not always need antibiotics.

• Cough: If the MAIN or ONLY symptom is fever and cough, and this has gone on for several days, your doctor may consider doing a chest X-ray to evaluate for pneumonia.  X-rays are not always available at a pediatrician’s office and this would probably require an ER or Urgent Care. However, starting with a visit (or at least call) to your pediatrician is a reasonable course of action.

• Urinary symptoms: Signs of urinary issues may include pain with urination, dark or smelly urine, and increased frequency. Little girls and under one-year-old boys can easily get urinary tract infections. If they have a fever with the above symptoms, you should consider getting them evaluated.

• Nausea/vomiting/diarrhea: Often these symptoms are caused by viral infections which are self-limited, and last a few days. However, these symptoms can also occur with intra-abdominal infections like appendicitis. If you find that your child’s symptoms of abdominal pain, vomiting or fever are worsening, not improving with medication, or they have blood in their stool, you should go to the ER for evaluation.

• Headache with or without neck pain: While fever is a common cause of headache, headaches can be a sign of a more serious infection like meningitis. If headache is the MAIN or MAJOR symptom with or without fever, and/or your child has severe pain with neck movement, weakness in their arms or legs, difficulty speaking or changes in vision, you should go straight to the ER.

• Rashes: Often viruses will cause rashes. However if your child does not have any viral symptoms, and has a focal red, warm and/or painful area of skin, it could be a bacterial infection that needs antibiotics. Certain viral rashes can also be life-threatening, especially if your child is not vaccinated, these include measles and rubella. Even if your child is healthy and these infections will be tolerated by them, measles, mumps and rubella are very dangerous to pregnant women and infants. Rashes can also be a sign of a body’s negative reaction to a medication or allergen, and if you suspect this, go see a doctor.

Treatment of Fever in Children

Fevers are the body’s defense against infections.

Children have strong immune responses, and while a high fever feels scary, if your child is well-appearing, it is likely your child’s appropriate response to the infection.

Unless your child looks very ill, it is often reasonable to attempt to symptomatically treat fever and its symptoms for 1-2 days before considering going to the ER. Often during that time-frame, fevers will resolve without any intervention from a doctor. If their symptoms become concerning, or persist over 3 days, it’s time to head to the ER.

You do not need to always treat fever, but often it makes your children (and you!) feel better to do so. If your child does not have any allergies you can use Ibuprofen then Acetaminophen, one then the other, every three to four hours, to keep fevers down. They are different kinds of medication and if you follow the dosing and time limitations (six hours between doses of the SAME medication), you will not be in danger of overdosing on either.

Here is a handy reference with their dosing for your child’s weight (not age).

Read  10 Easy Ways to Naturally Boost Your Family’s Immune System

Lacerations: When to Go to ER for a Wound

• Very dirty wounds – Exposed to dirt, mud, stool, ocean or lake water, rusty metals, etc. If your child does NOT have their tetanus vaccine, and gets a dirty laceration, you should take them to the ER to get the vaccine. People still die of this bacteria every year.

• Deep wounds – If the wound shows fat/muscle tissue or is gaping (if you let go of the wound and it falls open), it may need sutures or glue.

• Wounds in sensitive areas – Wounds in areas (like the face or genitals) where a larger scar is undesirable. Note: ER doctors sew up cuts on the face Every. Single. Day. Generally you do not need a plastic surgeon unless the ER physician thinks it is necessary. You will get the same outcome with both kinds of doctors. Asking for a plastic surgeon often just gets a longer wait time.

• Bites – Animals or humans

• Joint lacerations – When the wound is on or spans across a joint

• Uncontrollable bleeding – If a wound will not stop bleeding, even with pressure from your hand or bandage

• Projectile wounds – Any wound caused by a high speed projectile (bullet, dart, arrow, etc)

• Laceration with foreign body – If there is concern for retained foreign objects (like broken glass or metal)

Child Bumped Head – When to Worry

Kid head injuries can be extremely scary for parents. While children are often very resistant, be sure to go to the ER for evaluation if your child exhibits:

• Uncharacteristic behavior
• Loss of consciousness or significant “dazed” period
• Large scalp hematoma or possible skull fracture
• Severe headache
• Vomiting
• Changes in vision, speaking or balance
• Weakness in arms or legs
• Seizure following the injury

Or if the injury was due to a:

• Fall over 3 feet
• Significant car or bicycle crash

Or if something feels “off” with your child.

We do not always do CT scans for these patients, often we will observe them instead of expose them to radiation. However if your child’s symptoms are significant, it is important they are evaluated promptly.

If your child does not have the above symptoms and had a low risk injury (like a trip or fall from standing) these generally do not need to go to the ER unless one of the above develops.

Bones and Joint Injuries – When to go to the ER?

Go to the ER for evaluation if your child’s exhibits:

• Obvious deformity of the bone or joint
• Severe pain or swelling around the injury
• No pulse, or change in color in the hand or foot of the injury limb
• Inability to move the limb, or numbness or tingling in the area
• If the child is unable to put weight on the arm or leg, or will not move it

Important! If something looks broken or deformed, DO NOT attempt to put in back in place unless you cannot feel a pulse. Only then line it up so that you can feel a pulse, then stop moving it and go to the ER.

Other Important ER-Worthy Complaints

There are many other scary signs and symptoms of an unwell child that we haven’t covered yet.

If your child has any of these chief complaints, these are high risk for serious causes and should go to the ER:

• Chest pain
• Shortness of breath
• Seizures
• Confusion or altered mental status
• Testicular pain or swelling
• Fainting
• Severe pain which does not improve with pain medication
• Inability to keep liquids down, or is too dehydrated to make urine or tears
• Severe abdominal pain (appendicitis and intussusception are complaints that begin with this symptom)

Insider ER Tips

By this point we’ve covered when to go to the ER with your child.  So if you do go to the ER, please remember:

1.  Bring all medications the child takes regularly
2.  If the child is not fully vaccinated, bring their vaccination card so we know which ones they’ve gotten
3.  Do not let them eat or drink anything, especially if they are being evaluated for broken bones or abdominal pain. (They may need a procedure, and eating could delay their care.)
4.  Bring something for the children (and yourselves) to do because often the wait can be long

And while we’ve talked about a lot of very scary things, remember that children are very resilient and do well the majority of the time.

As much as possible, if an emergency arises, remember that the better you do by remaining calm and focusing on getting your child to the ER, the better they will do.

Please let us know any questions or comments you have! And thank you to Rachel and Jo for letting me guest on their wonderful blog.

Dr. Kathy is a board-certified Emergency Medicine physician that completed medical school in New York City, residency in Texas, and currently practices as an attending physician in California. When she is not working in the ER she enjoys exploring the outdoors and traveling with her family.