A 10-month-old boy, previously fit and well, presented to his A&E at 4 o’clock in the morning with severe respiratory distress. He had a barking cough and inspiratory stridor and was diagnosed with croup. On admission he was treated with two back-to-back adrenaline nebulisations and oral dexamethasone. His work of breathing improved and he was admitted to the paediatric ward for observation. A few hours later, his work of breathing became laboured with increasing stridor, tracheal tug and significant subcostal recession. His respiratory rate was 40 breaths per minute and his heart rate was 170 bpm. He was given a budesonide and adrenaline nebuliser and again his work of breathing and stridor settled.

The parents of a 4-week-old baby brought her in to the A&E after an unsettled night of high-pitched crying and high temperature with an inability to settle her and a refusal to feed. They had noted a progressive rash from the day before involving redness of her hands and feet and a fine, red papular rash over her body. She had had coryzal symptoms and a low-grade temperature the whole week, but had been otherwise well, as had her 2-year-old sibling.

A 3-year-old boy who was previously fit and well was reported to have fallen down the stairs at home 4 days previously and had been brought to his local hospital A&E with vomiting.

A term, ‘newborn baby’, with normal antenatal scans was referred to the transport service with severe cyanosis. There were no maternal risk factors for infection and the baby weighed 3.0 kg. The baby was born by caesarean section and after birth was noted to have ongoing cyanosis with saturations variable between 50% and 60%, although she appeared otherwise vigorous. There was mild subcostal and intercostal recession with tachypnoea. Due to the ongoing significant cyanosis despite oxygen, she was intubated and ventilated in 100% oxygen, with only marginal improvement in saturations. No murmur could be heard. The clinical examination prior to intubation is noted in Table 15.1.

The success of an organisation is dependent on some fundamental requirements being met. This is true for a retrieval service.

A 9-year-old girl had been admitted to A&E with drowsiness and reduced responsiveness. She had not been eating or drinking properly for the past day or so and the parents were concerned.

A 17-month-old little girl was referred to the regional retrieval service for urgent transfer. She was normally fit and well and had presented 3 hours previously to A&E at her local district general hospital with a 1-day history of diarrhoea and vomiting with intermittent fever (although she had been apyrexial for the past 8 hours). During her wait in A&E she had deteriorated and been moved to the resuscitation bay.

A 10-year-old, 45 kg boy with a background of sickle cell disease had presented to his local A&E with a 5-day history of abdominal pain, and a more recent 2-day history of back and shoulder pain. The morning of the presentation, he had started vomiting and was noted to be jaundiced by his accompanying parent. His mum reported he normally had a haemoglobin of 80–90 g/L and he had had no in-patient hospital stays previously.

A 13-day old baby presented to her local hospital with respiratory distress and a history of poor feeding for a few days. The baby had no history of maternal risk factors for infection and had normal antenatal scans. At the time of referral, she was self- ventilating in air with sternal and subcostal recession. She had a 2/6 systolic murmur and a firm liver, enlarged to her umbilicus. Pre- and post-ductal saturations were 92% on admission with upper limb/ lower limb blood pressure as shown in Table 52.1. CXR identified cardiomegaly and opacification of the right lung fields. Her abdomen was distended but soft. She had microscopic blood present on urine bedside testing. She was sleepy but responsive with a flat fontanelle. The referring hospital had sent relevant blood tests as noted in Table 52.2 and commenced IV cefotaxime.

A baby boy with a tertiary centre diagnosis of complete heart block was delivered at 34 weeks of gestation via emergency caesarean section at the local hospital because of fetal bradycardia. The mother had been diagnosed with anti-Ro/La antibodies during the pregnancy. The antenatal scans at the tertiary referral centre were normal to date. The baby was born in good condition but developed an increased work of breathing 5 minutes after birth and was intubated after 20 minutes due to desaturations related to a bradycardia of 50 to 60 bpm. The baby was referred to the regional cardiac centre and the paediatric retrieval team for transfer.

A 2-year-old girl with known spinal muscular atrophy (SMA) was referred with a 3-day history of worsening tachypnoea and increasing lethargy. She was no longer tolerating feeds and had visible mild intercostal and subcostal recession. Initially the child had improved on high flow nasal cannula (HFNC); however, oxygen requirements gradually increased to FiO2 of 0.64 in 3 L/kg HFNC by the time of referral.

A referral call was received regarding an 11-year-old boy who had presented to the A&E of his local hospital about 2 hours earlier. The boy, who appeared well grown, had been on a school rugby trip the week before and had broken his finger during a tackle. During the tour he felt he had performed disappointingly, and admitted that his running seemed ‘heavy’. The week following the tour, he had developed increasingly severe abdominal pain and become breathless playing on the trampoline with his sister. His parents felt he had also become pale and quieter than usual.

A baby girl was referred at 18 hours of age. She had presented due to parental concerns of poor feeding and change in colour. She had been seen by the neonatal team and taken to the NICU where her referral observations were recorded as below in Table 16.1.

An 11-year-old girl, previously fit and well, presented with a 1-week history of feeling unwell, very tired, extremely lethargic and breathless on exertion, on a background of being non-specifically unwell for the previous 2 months. She had no other specific symptoms and was afebrile at the time of presentation. On the morning of presentation, she had an acute onset of severe respiratory distress and was pale, very cold and unable to talk. She reported she had not been to the toilet for most of the previous day and night. Her mother was extremely alarmed by her colour and brought her to her local A&E department by car, although she was unable to walk from the car park and required a wheelchair.

A 4-year-old child was brought into their local district general hospital in his mother’s arms having fallen from a first storey window (around 5 metres in height), and rolled off the porch roof part of the way down. Mum was alerted to the fall by his 5-year-old sister, who was with him when he climbed on the dresser under the window and then fell out of the open window. Mum ran out the house to find the child prone outside the porch, crying and trying to get up on hands and knees. He had some bleeding from his forehead, face, nose and a little from the mouth. She picked him up, called the neighbour for help and took him immediately to the local A&E.

A 6-month old, 8-kg baby was brought into A&E by ambulance, after mother called 999 following a pale, blue, floppy episode at home.

A previously fit and well 8-year-old presented with a non-specific week’s history of worsening general condition, small blood-tinged vomits as well as vague abdominal pain and difficulty eating and drinking. She had attended her GP who had prescribed a proton pump inhibitor for reflux. This made no significant difference to the child’s symptoms. In the week preceding presentation, she had fainted three times while walking upstairs. The morning of presentation, she was noted by her mother to be grey and lethargic and was brought into A&E, where she vomited 250ml of coffee ground blood.

Since 1995, Paediatric Critical Care Retrieval has been growing and developing in the UK. In the late 1990s, Paediatric Retrieval was delivered by almost every PICU in the United Kingdom with over 20 services of varying size, throughout the country.