paediatric gastroenteritis : emergency medicine

1. PAEDIATRIC GASTROENTERITIS
Assessment
EM001
Consider in any Child with Diarrhoea +/- Vomiting
The hallmark is increased stool frequency with alteration of stool consistency
Differential: Urinary Tract Infection; Otitis Media; Respiratory Tract Infection; Surgical Disorders
DMIST Handover from ambulance
Look for IMCI DANGER SIGNS and TRIAGE Patient using SATS
Measure and Record Vital Signs. Check GLUCOSE
RED
IMCI Danger Signs:
- Fitting
- Lethargic or Floppy
- Not drinking anything
- Vomiting everything
OR
SOB or Rapid Breathing
Cold Hands with poor pulse
> 2 signs of Dehydration
OR
SATS score > 7
Examination
Primary: Assess ABCDE's then Secondary Head to Toe Examination
IMCI Danger Signs
Signs of shock (See Criteria below)
Assess Hydration Status (See Criteria below): WEIGH CHILD or estimate weight
Assess nutrition status
Signs of Sepsis and Systemic search for any source of infection
SAMPLE History
Signs/Symptoms: Stool: Duration, Frequency, Consistency; Blood or Mucus, Vomiting, Fever, Drinking/Wet Nappies?
Allergies. Medications.
Past Medical History: RVD Status. Birth History, Growth, Immunizations (RTHC)
Events: Contacts. Travel History
ORANGE
Priority Signs:
- Tiny Tot < 3 months
- Visible wasting or oedema
OR
Failed 4 hour ORS trial
OR
SATS score 5 - 6
GREEN
No signs of
Dehydration
OR
SATS score 0 - 2
YELLOW
1 Sign of Dehydration
OR
SATS score 3 - 4
ASSESSMENT OF SHOCK
Assessment
Level of Consciousness
Peripheral Pulses
Peripheral Temperature
CRT
Shocked (Intravascular Dehydration) Not Shocked (Extravascular Dehydration)
Depressed or Lethargic
Absent, Weak or Thready
Cool or Cold
> 3 secs
Normal or Lethargic
Palpable and Normal
Warm
< 3 secs
Drafted 2010; review January 2013. Ref: Tintinallis. Rosens Emergency Medicine. IMCI guidelines. ETAT guidelines.
Western Cape paediatric guidelines
ASSESSMENT OF HYDRATION STATUS
Criterion No DehydrationSevere Dehydration Some Dehydration
Weight Loss Nil+/- 5 %+/- 10 %
Clinical Signs Nil
Skin Pinch NormalSlow but < 2 sec> 2 sec
Restless or Irritable
Thirsty or Drinks Eagerly
Decreased Urine Output
Dry Mouth
Crying without tears
Sunken Eyes
Very Sunken Eyes
Lethargic
Page
1
Pulse Rate
Signs of Dehydration
Very Rapid Normal or Rapid
Normal to Severe Some or Severe
TRIAGE THE PATIENT
CLASSIFY PATIENT FOR MANAGEMENT: 1. Shocked? 2. Hydration Status 3. Comorbidity 4. Age < 3months
COMORBIDITY: Is the patient malnourished: Visible wasting or oedema ?

2. PAEDIATRIC GASTROENTERITIS
Management
SHOCKED SOME
DEHYDRATION
SEVERE DEHYDRATION NO
DEHYDRATION
RESUSCITATE
IV/IO bolus N/S 20 ml/kg
as fast as possible
(10 ml/kg if wasted/oedematous)
Unable to site IV/IO - Insert NGT:
Start ORS at 30 ml/kg/hr
(10 ml/kg/hr if wasted/oedematous)
Able to take PO
Urine Dipstix if Pyrexial
- Supply ORS and cup
- Calculate Volume (table below)
- Give Small Volumes:
20-50mls every 15min
- If child vomits:
Give smaller Volume at a time
- If child has loose stools:
Give Extra 10ml/kg
- Continue breast feeding as usual
Caregiver to alert nurse if child
repeatedly vomits or refuses to drink
Record on Chart
Reassess at 2 hours or sooner if required
Check ABC; Watch for Danger Signs; Weigh the child
Reclassify: Assess Hydration, Vomiting and Willingness to Drink
Amount of ORS over 4 Hours
Age
Weight
Mls
4-12
months
1-2
years
2-5 years
6-10 kg 10-12 kg 12-19 kg
400-700
mls
700-900
mls
900 -
1400 mls
IF NEEDS TRANSFER
CONSULT
PAEDIATRIC FLYING SQUAD
CRITERIA
DISCHARGE
Record Visit
on RTHC
Provide ORS
Educate
caregiver:
- How to give
ORS and feed
the child
- Danger signs
to look out for
Zinc x 10 days
<1yr 10 mg/d
>1yr 20 mg/d
Drafted 2010; review January 2013. Ref: Tintinallis. Rosens Emergency Medicine. IMCI guidelines. ETAT guidelines.
Western Cape paediatric guidelines
EM001 Page 2
Assess Nutrition Status
Wasted
Oedematous
Severe
Malnutrition
Well Nourished
Insert NGT
Infuse ORS @
10 ml/kg/hr
Site IV to
Take Bloods
BC; FBC; U&E;
Protein; Albumin;
Venous Gas
Set up IV
Commence 1/2DD
IV @ 20 ml/kg/hr
FOR UP TO 4
HRS
(NGT if unable -
Infuse ORS 20ml/
kg/hr)
Take Bloods:
U&E
Assess and Manage ABC's
Administer OXYGEN
Check Sugar: Treat if < 3mmol/l
(5ml/kg 10% dextrose IV)
Site IV (preferred) or IO Line
Call for help: EM Consultant or
Paediatric Registrar
STILL
SHOCKED
REASSESS PATIENT
NO LONGER
SHOCKED
- Assess hydration
- Use appropriate
protocolRepeat IV/IO
bolus as
above
Do ABG; Blood Culture; Na; K; Cl;
Urea; Creat; FBC
Ceftriaxone 50 mg/kg IV stat
Give 1/2 DD IV @ 20 ml/kg/hr
(10 ml/kg/hr if wasted/oedematous)
Review Regularly
Admit Level 3
Paediatrics
Assess and Manage ABC's
Administer OXYGEN
Check Sugar: Treat if < 3mmol/l
(5ml/kg 10% dextrose IV)
Admit Level 2
Paediatrics
Admit Level 2
Paediatrics
START ORS TRIAL
Vomiting everything or taking nothing
Some Dehydration.
Failed Trial of ORS Continue ORS trial
Reassess 2 hours later
NOTE STARTING TIME ON CHART
Encourage mother to breastfeed
Otherwise withhold oral feeds
Failed Trial
of ORS
Not Dehydrated
ORS retained
Increased weight
Child still drinking
Record on Chart - Reassess at 2 then 4 hours
Check ABC; Watch for Danger Signs; Weigh the child
Reclassify: Assess Hydration, Vomiting and Willingness to Drink
Not Dehydrated
ORS retained
Increased weight
Child drinking
Shocked or
Severe
Dehydration
Follow
protocols
Some Dehydration
No Increased Weight
Not Drinking
Admit Paediatrics
Stop
NGT
Try OralVomits Retained
If still
SHOCKED
consider
Intubation and
Inotropes
REASSESS PATIENT
Admit Level 2
Paediatrics
NO LONGER
SHOCKED
- Assess hydration
- Use appropriate
protocol Admit Paediatrics
(Consider Level 2)
STILL
SHOCKED
REASSESS PATIENT
NO LONGER
SHOCKED
- Assess hydration
- Use appropriate
protocolRepeat IV/IO
bolus as
above Admit Level 2
Paediatrics
Well Nourished Malnourished OR <3 mths
Insert Size 8 NGT: Attach NGT Drip set
and 200 mls bottle of ORS
Start ORS via NGT FOR UP TO 4 HRS
NOTE STARTING TIME ON CHART
Encourage mother to breastfeed
Otherwise withhold oral feeds
Admit Level 2
Paediatrics
ORS @ 20ml/kg/hr
ORS @ 10ml/kg/hr
Increase Infusion to
30ml/kg/hr