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The vomiting child

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?

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The vomiting child

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  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) 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!) • Realisticgoal 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 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

  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 10-20 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

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