1. The vomiting child
EMC SDMH 2015

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

3. What sort of vomiting?

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

5. 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)

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

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

8. 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

9. 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

10. NSW Guideline

11. 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

12. Mild/Mod dehydration If failing to meet input – NGT and admit
1-2 vomits not treatment failure
NGT set up to deliver 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

13. 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

14. Questions?

15. PAEDIATRIC IV FLUIDS

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

17. 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

18. 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

19. 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 mins
If persistent hypoglycaemia, repeat and seek Paediatric advice

20. Problems -
See worksheet !

21. 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