The vomiting child EMC SDMH 2015

Objectives Recognise potentially serious causes for vomiting in children Assess dehydration effectively Understand principles and strategies for management for gastroenteritis in children

What sort of vomiting?

History Volume and frequency Colour? Post feeds? Post–tussive? Acuity Time of day Associated fever, general well being Bowel motions

Emergency concerns Neonate (0-2mths) Infant (2-12 mth) Congenital intestinal obstructions Pyloric stenosis Malrotation Hernia obstruction UTI/Meningitis/Sepsis ICH/Head injury Inborn error metabolism, (Congenital Adrenal Hyperplasia) GORD, Gastroenteritis Infant (2-12 mth) Intestinal obstruction /Intussusception UTI/Meningitis/Sepsis /AOM/Strep. Throat ICH/Head injury Hypoadrenalism GORD, Gastroenteritis Child (>12 mth) Intestinal obstruction/Intussusception/ Appendicitis/Torsion UTI/Meningitis/Sepsis/AOM/Strep throat/Pneumonia ICH bleed/mass; Migraine(older) Hypoadrenalism/DKA Drugs/Medications Gastroenteritis Pregnancy + psychogenic (older children)

Gastroenteritis Requires triad of symptoms Vomiting, Fever and Diarrhoea >22000 admissions to hospital/yr 3-4 deaths annually 70-80% viral - RSV

Assessing severity Degree dehydration? Typically overestimated Weight best method Tables such as this previously used 

Dehydration Clinical signs poorly predictive <4% nil clinical signs Tachypnoea, poor cap. refill, decreased skin turgor more predictive of 5% dry Simplified 4 point scale as predictive as 10 point scale Score 1-4 mild/mod, 5-8 severe dehydration

Management in ED Rehydration! Treatment of infection rarely required Enteral rehydration safe, effective, beneficial and cost-effective Breast feeding encouraged to continue where possible Strategy based upon presenting severity

NSW Guideline

Mild/Moderate Dehydration Oral rehydration therapy (ORT) Hydralyte solution/ice block optimal Aim 0.5ml/kg per 5 mins. Can be done by parents (encourage!) Realistic goal setting with parents Average 10kg child = 60 ml/hr Ondansetron wafer 2-4 mg may be useful

Mild/Mod dehydration If failing to meet input – NGT and admit 1-2 vomits not treatment failure NGT set up to deliver ORS @ target rate Bloods not required if NGT utilised Discharge can be considered if -Child considered mildly dehydrated or not dehydrated and losses not profuse -Passes urine in ED -Parents competent at administering ORS -Able to return to ED and/or follow up

Severe dehydration ORT not appropriate Requires rapid IV/IO access Bolus 20ml/kg N/S Repeat if required. Failure to improve – reconsider diagnosis Once shock resuscitated, proceed with standard IV rehydration Check UEC and BSL

Questions?

PAEDIATRIC IV FLUIDS

Resuscitation Normal Saline 20ml/kg bolus Repeated x3 PRN >60ml/kg? = critical illness or ongoing volume loss  GET HELP

Rehydration Traditional N/4 (0.225%) solution now NOT recommended Rehydrate with 0.9% saline + 5% dextrose Calculations now ‘deficit + maintenance’ Deficit = Wt (kg) x % dry x 10 = mL required Aim to replace deficit over 24 hrs NB – deficit >5% unusual if for ward management

Maintenance Weight may be estimated by {(age+4) x 2} for age 1-9yrs (but actual weight vastly preferable) Maintenance calculated per kg i.e 12 kg child = (100 x 10) + (2 x 50)/24 = 45ml/hr OR (4 x 10) + (2 x 2) / hr = 44ml/hr Standard maintenance will have 20mmol/L K per bag

Hypoglycaemia If IV fluids being administered, UEC and BGL should ALWAYS be sent Correction of hypoglycaemia (BSL <2.6) – give 2mL/kg of 10% dextrose Recheck in 10-20 mins If persistent hypoglycaemia, repeat and seek Paediatric advice

Problems - See worksheet !

Summary Take clear vomiting history – check actually has pathology ALWAYS consider alternatives before diagnosing gastroenteritis esp. if triad absent ORS first and second line therapy for mild + mod dehydration! Consider NGT before IV. If using IV , saline+5% now standard therapy. Check calculations and Na before ward transfer