Summary: Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis: UK NICE Guideline: Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84 CPS Guideline: Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy History: onset of diarrhea and/or vomiting (gastro is sudden in onset) duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days) sick contact pathogen exposure travel history History suggestive of increased risk of dehydration: young age (esp 5 diarrhea in 24h >2 vomiting in 24h no oral intake signs of malnutrition Think about differential diagnosis if: fever >38 in children younger than 3 months fever >39 in children older than 3 months (fever workup required) shortness of breath or tachypnoea altered conscious state neck stiffness bulging fontanelle in infants non-blanching rash blood and/or mucus in stool bilious (green) vomit severe or localised abdominal pain abdominal distension or rebound tenderness. SSx of dehydration and shock Table 1 in NICE Increasing severity of dehydration No clinically detectable dehydration Clinical dehydration Clinical shock Symptoms (remote and face-to-face assessments) Appears well Red flag Appears to be unwell or deteriorating – Alert and responsive Red flag Altered responsiveness (for example, irritable, lethargic) Decreased level of consciousness Normal urine output Decreased urine output – Skin colour unchanged Skin colour unchanged Pale or mottled skin Warm extremities Warm extremities Cold extremities Signs (face-to-face assessments) Eyes not sunken Red flag Sunken eyes – Moist mucous membranes (except after a drink) Dry mucous membranes (except for 'mouth breather') – Normal heart rate Red flag Tachycardia Tachycardia Normal breathing pattern Red flag Tachypnoea Tachypnoea Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses Normal capillary refill time Normal capillary refill time Prolonged capillary refill time Normal skin turgor Red flag Reduced skin turgor – Normal blood pressure Normal blood pressure Hypotension (decompensated shock) Table 2 in CPS TABLE 2 Clinical assessment of degree of dehydration * Mild (under 5%) Moderate (5-10%) Severe (over 10%) Slightly decreased urine output Slightly increased thirst Slightly dry mucous membrane Slightly elevated heart rate Decreased urine output Moderately increased thirst Dry mucous membrane Elevated heart rate Decreased skin turgor Sunken eyes Sunken anterior fontanelle Markedly decreased or absent urine output Greatly increased thirst Very dry mucous membrane Greatly elevated heart rate Decreased skin turgor Very sunken eyes Very sunken anterior fontanelles Lethargy Cold extremities Hypotension Coma *Some of these signs may not be present SSx of hypernatremic dehydration: jittery increased muscle tone hyperreflexia convulsions drowsiness or coma Labs: No routine blood work Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia Blood gas if shock suspected Stool culture if: blood and/or mucus in stool immunocompromized septicemia suspected travel history diarrhea not improved by day 7 uncertainty about diagnosis of gastroenteritis
