Workflow for GE
Cat 2
- <6/12
- SIS 8
- Mild to mod dehydration
- Abdo distension
Cat 2+
- Bilious or bloody vomiting
- Severe abdo pain (6-10)
All else Cat 3
- Can prescribe trial of feeds if has history of vomiting, no abdo pain, episode of vomiting more than 30 min ago
If unstable, Cat 1 Resus
- ABCs
- istat (glucose), FBC, UEC
- Fluid resus with NS 20ml/kg for pre-shock/shock
- Correct hypoglycaemia, hyponatraemia
- After initial resuscitation, maintenance fluid with 5%Dextrose and 0.45% NS or 5% dextrose and 0.9% NS, including fluid deficit over 48H
- Include maintenance fluid
- Admit HD/ICU
Acute gastroenteritis and viral gastritis is a diagnosis of exclusion.
Other important differential diagnoses:
1) Non-GI infections
- pneumonia, UTI, otitis media, septicaemia, meningitis
2) Surgical
- intussusception, torsion of testis, IO, appendicitis, volvulus, post-op complications
3) CNS
- space occupying lesion, meningitis, encephalitis
4) Metabolic
- DKA, CAH, endocrine, inborn errors of metabolism
5) HUS
6) Toddler's diarrhoea
7) Food allergy/intolerance
8) Hirschprung's enterocolitis
9) IBD
10) Bact GE (dysentry)
11) Myocarditis
12) Poisoning
Rehydration
Determine if min, mild, mod dehydrated
MIN or nil (<3%loss of body weight)
- High risk, definite admission to GW
- Exisiting comorbidity (congenital heart disease, short bowel syndrome, heart failure, ileostomy)
- <6/12 old ,with vomiting >1x past 24H (excludes mild regurgitation and post tussive vomiting), or frequent and large volume stools, or feeding less than normal, or irritable
- High risk, for observation in ED
- <6/12 with criteria for admission but carer refuses (to sign AOR even if pt succeeds in trial of feeds)
- More than 6/12 old with vomiting, unable to retain >1/2 of feeds past 24H and unable to retain at least 1 normal feed past 4H
- If >1yo, start ondansetron (1st line)/supp domperidone (2nd line) before starting ORS
- If <1yo, do not give anti-emetic, start trial of feeds
- Start trial of feeds x 1 hour. Start 30 min after PO ondan/1 hour after supp domperidone
- If pt vomits more than 1x or cannot complete prescribed fluids, ADMIT
- If fulfils discharge criteria, discharge with GE advice, information pamphlet, Lacteol Forte, Hydralyte (chargeable). DO NOT DISCHARGE WITH ANTI-EMETIC
- Low-risk, DISCHARGE
- <6/12 with no criteria for admission
- >6/12 with no vomiting, can retain >1/2 feeds past 24H and has 1 normal feed past 4H
MILD (3-5% loss of body weight)
- If high-risk (<1yo or no competent caregiver),
- ADMIT
- While waiting for admission, start Oral rehydration therapy (ORT) 10ml/kg/hr over 4 hours (over 15 minute aliquots) (e.g. 10kg child requires 100ml every hour, therefore prescribe 25-30ml ORT Q15m x 4H)
- For 1yo or more, with vomiting and unable to retain more than half of normal feeds in 4H, offer oral ondansetron (1st line) or supp domperidone (2nd line) if distressed, before starting ORT
- If no high risk criteria,
- Give oral rehydration therapy 10ml/kg/hr x 2 hours (over 15 minute aliquots)
- If unable to retain more than half of feeds in past 24H and unable to retain more than 1 normal feed for past 4H, offer anti-emetic before starting ORT
- If vomits more than 1x or unable to complete prescribed volume over the required period, ADMIT
- If succeeds in 2H of oral rehydration therapy (no vomiting), and fulfils discharge criteria, discharge with instructions to complete the remaining 2H of oral rehydration therapy 10ml/kg/hr, and advise on maintenance oral fluids and GE advice
- Document all advice related to ORT and GE management
MODERATE (6-9% loss of body weight)
a) Vomiting not significant, but fluid loss from diarrhoea > oral intake
b) Vomiting within past 3H, & unable to retain fluids x 6H
- PO ondansetron (1st line) / supp domperidone if distressed before ORT
c) Uncertain of Dx, possibly severely dehydrated , tachypnoeic, drowsiness
- FBC, I-stat, UEC, IV-plug, KIV IV fluids
For moderately dehydrated cases,
ADMIT
Expedite admission (S/T shift nurse IC)
- ORT 60-90ml/kg over 6H in 15min aliquots while waiting for admission
- Counsel caregivers: Your child has mod dehydration due to vomiting/diarrhoea/gastroenteritis
- He will need admission for rehydration. Oral route will be tried, but IV will be necessary if PO fails. We will also need to monitor his vital signs, hydration status and ongoing losses through his stool or vomit
- Simple investigations may be done
TRIAL OF FEEDS (if minimally dehydrated) not the same as ORS. If child prefers other liquids, non-fizzy drinks or milk may be given instead.
- If <3yo, 15ml Q 15min x 4 (1 hour)
- If >3yo, 30ml Q 15min x 4 (1 hour)
USE OF ANTI-EMETICS
- Do not use anti-emetics unless vomiting is due to GE
- Do not use if there is
- post tussive vomiting
- significant abdominal pain/tenderness
- Abdominal distension
- After head injury
- Do not use if there is nausea without vomiting
- Do not prescribe on discharge
ONDANSETRON
- Risk of accentuating diarrhoea
- Oral fluids may be started 30 min after therapy
DOMPERIDONE SUPP
- Risk of extra-pyramidal symptoms (neck arching, tongue twisting)
- Oral fluids may be started 1 hour after therapy
- May be less effective if there is ongoing diarrhoea
- Dose 0.1-0.2mg/kg/dose
REVIEW BEFORE DISCHARGE
- If patient vomits 1x, rest 30min before restarting oral fluids trial (trial of feeds 1 hour, ORS 2 hours)
- Review patient for discharge 30min after last feed
- After 2nd episode of vomiting, review for hospitalization
CRITERIA FOR DISCHARGE
- Has retained prescribed oral fluids
- Age appropriate normal mental status
- No vomiting
- No abdominal pain, abdo soft and not distended
- No tachycardia, vitals stable (document!), not toxic
- Not dehydrated
- Reliable, competent caregiver
- Advice on GE/vomiting/abdo pain and when to return
- Provide patient leaflets
- Withhold solids for 8H and give small frequent clear feeds
- Explain appropriate types, frequency and volume
- For diarrhoea, calculate how much fluid for each stool
- Emphasise importance of maintaining oral hydration
- Do not give too many medications
- Lacteol forte for diarrhoea
- Paracetamol for fever
- Magnesium carbonate for abdo colic
- Barrier cream (silicon cream or zinc oxide Desitin (non-standard) for perianal excoriation
- If pt has mild dehydration and successfully completed 2 H of ORT, prescirbe another 2H of ORS in sachets for home
- If min dehydrated, advise for clear fluids / diluted milk to be given. Hydralyte is chargeable
- If <6/12, check bottle hygiene and document. Ensure adequate sterilization
- If bloody GE, and child well and >3/12 old, stool CS and Abx not indicated. Discuss with senior. If bloody GE and child <3/12, unwell, ADMIT.
