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Vomiting, Pediatric, Emergency Medicine

Basics

Description

- Complications: - Aspiration - Mallory " Weiss tear - Boerhaave syndrome

- PMHx: - History of similar - Past surgical history

- Cardiovascular: - Quality heart tones - Pulses, perfusion

- Child/adolescent: - GI: Gastroenteritis, obstruction (hernia, adhesions, intussusception, foreign body, bezoar), pancreatitis, appendicitis, peptic ulcer, peritonitis, paralytic ileus, trauma (duodenal hematoma) - Metabolic/endocrine: Diabetic ketoacidosis, uremia, adrenal insufficiency - Infectious: Gastroenteritis, UTI, sinusitis, upper respiratory infection, sepsis, meningitis, encephalitis, pneumonia, hepatitis - Neurologic: CNS mass/tumor, CNS bleeding (often due to trauma), cerebral edema, concussion, migraine - Other: Toxicologic, (nonaccidental) trauma, pregnancy, bulimia

  • Forceful, coordinated act of expelling gastric contents through the mouth; characterized by nausea, retching, and emesis; no gastric contents are expelled during retching.
  • Emesis results from sustained contraction of abdominal muscles and diaphragm; at the same time, the pylorus and antrum contract.

Etiology

Mechanism:

  • GI/mechanical: Gastroesophageal reflux (GER), meconium ileus, necrotizing enterocolitis, hypertrophic pyloric stenosis, intussusception, malrotation with midgut volvulus, Hirschsprung disease, congenital obstructions (atresias, stenoses, and webs), hernia, foreign body/bezoar, pancreatitis, appendicitis, paralytic ileus
  • Metabolic/endocrine: Inborn errors of metabolism (amino acidurias, fatty acid oxidation disorders, urea cycle defects), uremia, diabetic ketoacidosis, congenital adrenal hyperplasia, kernicterus
  • Neurologic: CNS bleeding (often due to trauma), tumor, hydrocephalus
  • Infectious: Otitis media, UTI, pneumonia, sepsis, gastroenteritis, meningitis/encephalitis
  • Feeding problems: Chalasia, improper technique (overfeeding, improper position), milk allergy
  • Other: Toxicologic, nonaccidental trauma, pregnancy

Diagnosis

Signs and Symptoms

  • General:Appearance variable depending on the underlying causeSigns of dehydration, including tachycardia, tachypnea, pallor, decreased perfusion, and shockAltered mental status may occur secondary to shock, hypoglycemia, or extra-abdominal conditions (sepsis, inborn error of metabolism, increased intracranial pressure, toxicologic poisoning).
  • Vomiting characteristics:Assess color, composition, onset, progression, and relationship to intake and position.Nonbilious emesis is caused by a lesion proximal to the pylorus.Bilious (green) emesis indicates obstruction below the duodenal ampulla of Vater; in infants, bilious emesis is associated with a more serious underlying condition (malrotation, volvulus, intussusception, bowel obstruction); may also be due to adynamic ileus or sepsis.Bloody emesis (hematemesis) involves a lesion proximal to the ligament of Treitz; bright red bloody emesis has little or no contact with gastric juices due to an active bleeding site at or above cardia. "Coffee-grounds " emesis results from reduction of heme by gastric secretions.Feculent odor suggests lower obstruction or peritonitis.Undigested food in emesis suggests an esophageal lesion or one at or above the cardia.GER: Begins shortly after birth, remains relatively constant, usually with normal weight gain.Hypertrophic pyloric stenosis: Begins insidiously at 2 " 6 wk of age and progresses, becoming increasingly forceful (projectile) after feedings.Obstruction and/or ischemic bowel (malrotation with midgut volvulus, intussusception, necrotizing enterocolitis): Sudden onset associated with rapid progression to appearing ill out of proportion to the duration of illness; abdomen distended and tender.
  • Abdominal:Distention suggests obstruction.Peritoneal signs suggest inflammation and possible perforation.
  • Complications:AspirationMallory " Weiss tearBoerhaave syndrome

History

  • Constitutional:
  • Vomiting characteristics:Timing, durationBilious?Bloody?
  • Associated symptoms:DiarrheaAnorexiaAbdominal painDysuriaInguinal swelling
  • PMHx:History of similarPast surgical history

Physical Exam

  • General:General appearance, vital signs, hydration status
  • Cardiovascular:Quality heart tonesPulses, perfusion
  • Abdominal:Tenderness, distention, massBowel sounds
  • Genitourinary:Scrotal swelling, tenderness, mass
  • Rectal:Presence of blood, mass, tenderness

Essential Workup

Exclude life-threatening causes of vomiting.

Diagnosis Tests & Interpretation

Lab

  • As indicated by history and physical exam and consideration of differential:Metabolic assessment (glucose, electrolytes)Infection assessment (CBC, culture " urine)Pregnancy tests for females of childbearing age

Imaging

  • As indicated by differential considerations
  • Abdominal radiographs (flat plate, upright, and decubitus) helpful for evaluation of obstruction or perforation
  • Pelvic and abdominal US for evaluation of hypertrophic pyloric stenosis, intussusception, appendicitis as well as pelvic or scrotal pathology
  • Abdominal CT scan helpful for evaluation of appendicitis, mass/tumor often requiring contrast

Diagnostic Procedures/Surgery

Nasogastric tube:

  • Location, character, and severity of gastric bleeding

Differential Diagnosis

  • Neonate/infant:GI/mechanical: GER, meconium ileus, necrotizing enterocolitis, hypertrophic pyloric stenosis, intussusception, malrotation with midgut volvulus, Hirschsprung disease, congenital obstructions (atresias, duplications, imperforate anus. stenoses, and webs), hernia, foreign body/bezoar, paralytic ileusMetabolic/endocrine: Inborn errors of metabolism (amino acidurias, fatty acid oxidation disorders, urea cycle defects), uremia, congenital adrenal hyperplasia, kernicterusNeurologic: CNS bleeding (often due to trauma), tumor, hydrocephalusInfectious: Otitis media, UTI, pneumonia, sepsis, pertussis, meningitis/encephalitisFeeding problems: Chalasia, improper technique (overfeeding, improper position), milk allergyOther: Toxicologic, nonaccidental trauma
  • Child/adolescent:GI: Gastroenteritis, obstruction (hernia, adhesions, intussusception, foreign body, bezoar), pancreatitis, appendicitis, peptic ulcer, peritonitis, paralytic ileus, trauma (duodenal hematoma)Metabolic/endocrine: Diabetic ketoacidosis, uremia, adrenal insufficiencyInfectious: Gastroenteritis, UTI, sinusitis, upper respiratory infection, sepsis, meningitis, encephalitis, pneumonia, hepatitisNeurologic: CNS mass/tumor, CNS bleeding (often due to trauma), cerebral edema, concussion, migraineOther: Toxicologic, (nonaccidental) trauma, pregnancy, bulimia

Treatment

Pre-Hospital

Not applicable

Initial Stabilization/Therapy

  • Fluid resuscitation with 0.9% NS IV; caution if concern about increased intracranial pressure.
  • Determine bedside fingerstick glucose.

Ed Treatment/Procedures

  • Continue fluid resuscitation and correction of electrolyte imbalance if present.
  • Decompress stomach with nasogastric or orogastric tube if abdomen distended or vomiting persistent.
  • Continue evaluation for underlying cause.
  • Consider antiemetic medications.
  • Surgical consultation if acute abdomen; antibiotics if peritonitis or other systemic infection present

Medication

Antiemetics may be helpful once the underlying cause of vomiting has been determined.

First Line

Ondansetron: 4 " 8 mg (peds: 0.1 mg/kg per dose) IV or PO q6h

Second Line

  • Metoclopramide: 10 mg (peds: 0.1 mg/kg per dose) PO q6h
  • Prochlorperazine: 2.5 " 5 mg (peds: 0.1 mg/kg per dose) IV, IM, or PR q6h
  • Promethazine: 12.5 " 25 mg (peds: 0.25 mg/kg per dose) PO, PR, or IM q6h

Follow-Up

Disposition

Admission Criteria

  • Unstable vital signs, including persistent tachycardia or other evidence of hypovolemia
  • Serious etiologic condition or inability to exclude serious etiologic conditions
  • Intractable vomiting or inability to take oral fluids
  • Inadequate social situation or follow-up

Discharge Criteria

  • Stable; able to tolerate oral fluids
  • Benign etiology considered most likely and serious or potentially important etiologies excluded
  • Parental understanding of instructions to advance clear liquids slowly and return for continued vomiting, abdominal distention, decreased urination, fever, lethargy, or unusual behavior

Issues for Referral

  • Chronic or recurrent episodes of vomiting or abdominal pain:Pediatric gastroenterology

Followup Recommendations

PCP in 1 " 2 days

Pearls and Pitfalls

  • Determine presence or absence of bile or blood in emesis.
  • Bilious vomiting in the neonate is an important anatomic abnormality such as malrotation until proven otherwise.
  • Consider causes of vomiting other than just GI (see Differential Diagnosis).

Additional Reading

  • Chandran L, Chitkara M. Vomiting in children: Reassurance, red flag, or referral? Pediatr Rev. 2008;29(6):183 " 192.
  • Claudius I, Kou M, Place R, et al. An evidence based review of neonatal emergencies. Pediatric Emergency Med Practice. 2010;7(6):1 " 22.
  • Hostetler MA. Gastrointestinal disorders. In: Marx JA, Hockerberger RS, Walls RM, et al., eds. Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis: Mosby; 2010:2168 " 2187.
  • Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of pediatric appendicitis, intussusception and Meckel diverticulum. Surg Clin North Am. 2012;92(3):505 " 526.

Codes

ICD9

  • 530.81 Esophageal reflux
  • 787.03 Vomiting alone
  • 787.04 Bilious emesis
  • 578.0 Hematemesis

ICD10

  • K21.9 Gastro-esophageal reflux disease without esophagitis
  • R11.10 Vomiting, unspecified
  • R11.14 Bilious vomiting
  • K92.0 Hematemesis

SNOMED

  • 422400008 Vomiting (disorder)
  • 71419002 Bilious vomiting
  • 235595009 Gastroesophageal reflux disease (disorder)
  • 8765009 Hematemesis (disorder)