The vomiting child

AETIOLOGY 
Surgical vs non-surgical

Surgical

• Pyloric stenosis
• Intussusception
• Volvulus
• Appendicitis
• Adhesion bands
• Incarcerated hernia
• I/O
• Torsion of testis
• Head injury

Non-surgical

• Sepsis
• CNS 
• space occupying lesion (tumour, abscess)
•  meningitis
• benign intracranial hypertension
• encephalopathy (Reye's)
• ICH (haematoma)
• Metabolic  
• DM
• inborn errors of metabolism
• adrenal insufficiencies
• GE / viral (food poisoning, infections)
• Reflux
• Over feeding / mother craft/ aerophagy
• Drugs/toxins - leading to ileus / encephalopathy
• Vestibular 
• otitis media 
• vestibular dysfunction
• Pregnancy

HISTORY

A) NATURE OF VOMITING

• Bilious/non-bilious/bloody
• Onset - acute, acute on chronic, chronic, recurrent bouts
• Amount, frequency
• Type - projectile, forceful, regurgitation
• Relation to meal - is it soon after feeds
• Appetite
• Any overfeeding? Especially if water is given with milk
• Technique of burping
• First time parents

B) BOWEL HABITS

• Diarrhoea, constipation or stringy stools (Hirschprung)

C) ASSOCIATED SYMPTOMS

• Fever
• Abdo pain, tenderness
• Diarrhoea
• Dysuria
• Headache
• Earache
• Recent injury
• Recent ingestion
• Ataxic gait

D) HYDRATION

• Number of wet diapers
• Last passage of urine or change of diapers
• History of scanty urine

EXAMINATION

A) ASSESS SEVERITY OF VOMITING

• Degree of hydration/acidosis
• Altered mental state (?underlying encephalopathies/metabolic disturbances e.g. hypoglycaemia, acidosis)

B) ABDOMEN

• Distension, mass, bowel sounds
• Tenderness
• Groin for testes and hernias 

C) CNS

• Fontanelles
• Facial/scalp bruising (NAI)
• Cranial nerves
• Fundoscopy for stigmata of NAI and raised ICP
• Nystagmus, gait
• Ears for infection/bleed

INVESTIGATIONS

• Urilax/UFEME - TRO UTI
• FBC - If Fever
• Hypocount - If lethargic/dehydrated
• UEC - If suspecting electrolyte abnormalities or Ix dehydration before discharge. KIV admit if low HCO3 or abnormal electrolytes
• AXR - If suspecting surgical abdomen

DISCHARGE ADVICE

• Strategy for home is small frequent feeds or soft diet of choice
• 1/2 hour after vomit, can give feeds for 1-2 hours
• If <3yo, 15ml Q15min
• If >3yo, 30ml Q15min
• If tolerating can gradually increase amount
• RETURN IF
• persistent vomiting
• Bilious vomiting
• Very little urine over 8 hours
• Increasing lethargy
• Taking poor intake of oral fluids