Vomiting resident survival guide (pediatrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Vomiting resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Pyloric stenosis
• Intestinal malrotation with volvulus
• Congenital intestinal obstruction
• Diabetic ketoacidosis
• Intussusception
• Necrotizing enterocolitis
• Gastroenteritis
• Meningitis
• Sepsis
• Shaken baby syndrome
• Hydrocephalus
• Congenital adrenal hyperplasia
• Inborn errors of metabolism
• Obstructive uropathy

Common Causes

Common causes of vomiting in pediatric population varies with age

Common causes of Vomiting in children

Birth-1 month	1 month-12 months	1 years-4 years	5 years-11 years	12 years-18 years
Gastroesophageal reflux Pyloric stenosis Intestinal atresia Intestinal malrotation with or without volvulus Milk protein intolerance Tracheoesophageal fistula Inborn errors of metabolism Meningitis Sepsis Urinary tract infection	Gastroenteritis Gastroesophageal reflux Over feeding Food protein-induced enterocolitis syndrome Post tussive emesis Urinary tract infection Infections Intussusception Foreign body ingestion Inborn errors of metabolism	Gastroenteritis Gastritis Urinary tract infection Infections like otitis media, sinusitis, pharyngitis Foreign body ingestion Post tussive emesis Toxic ingestion Food poisoning Celiac disease Constipation	Gastroenteritis Diabetic ketoacidosis Acute appendicitis Gastritis GERD Urinary tract infection Food poisoning Toxic ingestion Celiac disease Cyclic vomiting syndrome Migraine	Gastroenteritis Food poisoning Acute appendicitis Diabetic ketoacidosis Cyclic vomiting syndrome Migraine Pregnancy Eating disorder Toxic ingestion Drug induced vomiting Bowel obstruction Inflammatory bowel disease

FIRE: Focused Initial Rapid Evaluation

Check ABCDE ❑ Airway ❑ Breathing ❑ Circulation ❑ Deformity ❑ Exposure

❑ Assess vital signs ❑ Obtain IV access ❑ NPO (if persistent vomiting)

Unstable vital signs

Stable vital signs

Satbilize hemodynamics

Rule out life-threatening causes ❑ Pyloric stenosis ❑ Intestinal malrotation with volvulus ❑ Congenital intestinal obstruction ❑ Diabetic ketoacidosis ❑ Intussusception ❑ Necrotizing enterocolitis ❑ Gastroenteritis ❑ Meningitis ❑ Sepsis ❑ Shaken baby syndrome ❑ Hydrocephalus ❑ Congenital adrenal hyperplasia ❑ Inborn errors of metabolism ❑ Obstructive uropathy

Signs of dehydration ❑ Dry lips and mouth ❑ Sunken eyes ❑ Sunken fontanelle ❑ Drowsiness ❑ Irritabiltity ❑ Lethargy ❑ Decreased skin turgor ❑ Decreased urine output

Yes

No

Fluid replacement therapy

Electrolyte imbalance

Yes

No

Treat electrolyte imbalance

Detailed history and physical examination

Regurgitation

True Vomiting

Reassurance and Follow-up in OPD

❑ Frequency ❑ Effect on oral intake

Persistent and Hampering oral intake

Occasional and does not hamper oral intake

Antiemetics ❑ Ondansetron ❑ Domeperidone

Observation and Reassurance

Investigate and treat the underlying cause

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of vomiting in children.

Vomiting in Children

Characterization of Vomiting ❑ Onset (Abrupt or insidious) ❑ Frequency (persistent or occasional) ❑ Duration ❑ Time ❑ Color ❑ Odor ❑ Quantity ❑ Vomitus content (bile, blood, food particles) ❑ Effect on oral intake ❑ Projectile vomiting ❑ Relationship with food

Ask about associated symptoms ❑ Fever ❑ Abdominal pain ❑ Diarrhea ❑ Constipation ❑ Melena ❑ Headache ❑ Dizziness ❑ Visual problems ❑ Polyuria ❑ Polydipsia ❑ Dysuria ❑ Hematuria ❑ Flank pain ❑ Urinary problems ❑ Weight loss ❑ Early satiety ❑ Postprandial bloating

Obtain a detailed history ❑ Age (common causes of vomiting varies with age) ❑ Past medical history (recurrent episodes, Diabetes Mellitus) ❑ Any history of surgeries ❑ Medications/Foreign body ingestion/Poisoning ❑ Menstrual History (Pregnancy should be excluded in adolescent females) ❑ Travel History ❑ Exposure to contaminated food or water ❑ Illness in other family members

Examine the patient: Assess the volume status: ❑ General condition ❑ Thirst ❑ Pulse ❑ Blood pressure ❑Respiratory rate ❑ Eyes ❑ Mucosa Perform a general physical exam: ❑ Skin ❑ Pallor ❑ Jaundice ❑ Dehydration ❑ Mouth and Pharynx ❑ Ulcers ❑ Thrush ❑ Abdominal Examination ❑ Inspection ❑ Signs of previous surgery ❑ Abdominal distension ❑ Abdominal pulsations ❑ Abdominal peristalsis ❑ Palpation ❑ Abdominal tenderness ❑ Rigidity ❑ Guarding ❑ Abdominal mass ❑ CVA tenderness ❑ Rovsing's sign ❑ Psoas sign (suggestive of retrocecal appendix) ❑ Obturator sign ❑ Auscultation ❑ Decreased bowel sounds ❑ Increased bowel sounds ❑ Digital rectal exam (constipation or fecal loading) ❑ Testicular examination in males ❑ Neurological Examination (increased intracranial pressure) ❑ Extremities Examination (sepsis) ❑ Cardiovascular Examination ❑ Respiratory Examination

Order routine laboratory tests: ❑ CBC and differential ❑ ESR ❑ Basic Metabolic Profile ❑ Urinalysis ❑ LFT ❑ Serum glucose ❑ Pregnancy test

Regurgitation

Bilious vomiting

Bloody vomiting

Non-bilious, non-bloody vomiting

Abdominal X-ray

Upper GI bleed

Double bubble sign

Free air under the diaphragm

NG tube in misplaced duodenum

Dilated loops of bowel

Duodenal atresia

Perforation

Upper GI series

Contrast enema

Emergency laparotomy

Ligament of Treitz on the right side of abdomen

Microcolon

Rectosigmoid transition zone

Malrotation

Meconium ileus

Hirschsprung disease

Non-bilious, Non-bloody Vomiting

Non-bilious, Non-bloody vomiting

❑ Diarrhea ❑ Abdominal pain

Present

Absent

GI causes ❑ Gastroenteritis ❑ Gastritis ❑ Acute Appendicitis

Non-GI causes

Fever

Present

Absent

Infectious etiology ❑ Urinary tract infection ❑ Meningitis ❑ Sepsis ❑ Acute otitis media]] ❑ Pharyngitis

Symptoms/signs localize to a particular system

❑ Dysuria ❑ Oliguria ❑ Costovertebral angle tenderness

❑ Poluria ❑ Polydipsia ❑ Electrolyte abnormalities

❑ Headache ❑ Lethargy ❑ Altered mental status

Renal etiology ❑ Urinary tract infection ❑ Obstructive uropathy ❑ Pyelonephritis

Endocrine or Metabolic etiology ❑ Diabetic Ketoacidosis ❑ Adrenal crisis ❑ Congenital adrenal hyperplasia

Neurological or Metabolic etiology ❑ Hydrocephalus ❑ Intracranial mass occupying lesion ❑ Inborn errors of metabolism

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• Start oral fluids 30-60 minutes after the vomiting has stopped. Give clear fluids like water and clear broth frequently in small quantities
• Continue breastfeeding in small and frequent doses
• Continue the regular and full-strength formula in small and frequent doses
• Give 5-10 ml of oral rehydration solutions (ORS) such as Pedialyte every 15-20 minutes
• Reintroduce solid food like rice, toast, applesauce, cereals, and crackers 8 hours after the vomiting has stopped in kids
• Start the normal diet 24 hours after the vomiting has stopped
• Wash hands before feeding, eating, and cooking

Don'ts

• Do not give milk or solid food if the child is vomiting continuously
• Do not give any solid food until 24 hours of vomiting onset
• Do not give foods with sugars like juices and carbonated drinks

References

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