NWTS Referral Number: 08000 848382

NWTS Referral number: 08000 848382 RMCH PICU: 0161 7018080 AHCH PICU: 0151 2525241/42

NWTS REFERRAL INFORMATION Patient Name: Date of birth & age Hospital Name

Weight Sex Date of admission Gestational age at birth: Current Location Corrected age (if < 2y): A&E / Paed Ward / HDU Paediatric Consultant Anaesthetic Consultant Theatre / Adult ITU / Other

GP name Direct Line to Ward: Mobile: Bleep: Other specialists contacted (Name/Grade/Speciality)

Names of Parents/Guardians:

Working diagnosis

Clinical Details DateIntubation and Time details of injury (if trauma) Name and grade of person intubating:

Anaesthetic agents and dose used:

Grade of intubation: ETT size Oral / Nasal ETT length Cuffed / Uncuffed

Problems during intubation

Observations at time of referral Airway – Oral / Nasopharyngeal Clear / Compromised / Intubated / Tracheostomy (size, make)

C Spine: Collar/Blocks/Spinal board/Stretcher NGT/OGT placed? CXR findings:

Breathing: SV/CPAP/Vented/HFOV PIP/PEEP Ti RR/Hz FiO2 MAP TV iNO SpO2 Oxygen Index: MAP x FiO2 x 100 / PaO2(mmHg) = (for potential ECMO pts only) Circulation:Immunisation: Fluid boluses (ml/kg) Medications:Why given: Cap Refill/HR/BP/Base Excess Heart Rate: Crystalloids PMH BP (S/D/Mean): including allergies and previous PICU admissions Cap Refill(Central): Colloids Urine Output: Blood products

Maintenance [Type & dose (ml/h)] Inotropes [Which? / dose(mcg/kg/min)] Patient known to: RMCH / AHCH Birth History (including days ventilated, CPAP days, SCBU days, home O2) Specialists involved in the past: Access (No./site/size) Peripheral Central Arterial

Sedation & Paralysis GCS ( /15) : E M V Pupil size: R L A V P U Pupil reaction: R L Safeguarding concerns Blood sugar: Named SocialFontanelle: Worker Seizures / Posturing Anticonvulsants: Named Paediatrician Osmotic Rx:

Temp: Rash: Y / N Antibiotics Samples NeedName for & isolation: Grade ofY / person N filling form:

1 NWTS Referral number: 08000 848382 RMCH PICU: 0161 7018080 AHCH PICU: 0151 2525241/42

NWTS REFERRAL INFORMATION

Laboratory Investigations Hb Urea Creatinine WCC N L Na K Platelets CRP ALT AST PT/INR Albumin iCa APTT/ratio Fibrinogen D- Toxicology dimers Others

Blood Gases Time Time Time Time Time Sample Art / Ven / Cap Art / Ven / Cap Art / Ven / Cap Art / Ven / Cap Art / Ven / Cap pH pCO2 pO2 BE Bicarbonate Chloride Lactate Blood sugar Action

2 NWTS Referral number: 08000 848382 RMCH PICU: 0161 7018080 AHCH PICU: 0151 2525241/42

NWTS REFERRAL INFORMATION Time Referred to NWTS: Name/grade person making call: Advice Received (date/time) 1