Vomiting, Diarrhea, Assessment of dehydration, Management of shock and Fluid therapy

Identify the causes of diarrhea and vomiting Differentiate between infective versus non-infective causes Classify the severity of dehydration Formulate the emergency management of hypovolemic shock Determine fluid therapy after initial resuscitation (type & volume)

Vomiting
forceful expulsion of gastric contents
Often preceded by nausea Regurgitation passive, non-forceful ejection of gastric contents due to reflux through a relaxed esophageal sphincter

Physiology of Vomiting

Classification of Vomiting
According to nature: 1. Projectile---------- ICP or pyloric stenosis 2. Non Projectile------ GERD or any other causes. According to quality : 1. Bilious ( dark green) ----------- Always pathological and indicate obstruction beyond the ampulla of vater. 2. Bloody: red blood-------- Upper GI or massive lower GI bleed, coffee ground--------- old upper GI or lower GI bleeding 3. Non bloody, non bilious: usually clear or yellowish with remnants of previously ingested food--------most types of vomiting.

Clinical Clues to Diagnosis

a) Age of the patient b) Duration of symptoms - Acute onset: infective origin(AGE, meningitis, sepsis), acute gastrointestinal obstruction(pyloric stenosis) - Chronic onset: partial mechanical obstruction, motility disturbance, metabolic etiology.

 .
According to quality : 1.Bilious ( dark green) ----------- Always pathological and indicate obstruction beyond the ampulla of vater. 2.Bloody: red blood-------- Upper GI or massive lower GI bleed, coffee ground--------- old upper GI or lower GI bleeding 3.Non bloody, non bilious: usually clear or yellowish with remnants of previously ingested food--------most types of vomiting.

c) Nature: 1. Projectile---------- ICP or pyloric stenosis 2. Non Projectile------ GERD or any other causes
d)Timing - Nocturnal & morning : GERD - Soon after meal : Hyperthrophic Pyloric Stenosis ( common in infants) - Delayed vomiting( after more than 1 hour ingested food) : motility disorder - Cyclic vomiting***

Cyclic Vomiting:

stereotypic recurrent episodes of nausea and vomiting without an identifiable organic cause Idiopathic, happened in early childhood, unknown pathogenesis. Characterized by
I. Numerous of vomiting interspersed with well intervals II. Intervals of normal health between episodes III. Episodes that are stereotypic with regard to symptom onset and duration IV. lack of laboratory or radiographic evidence to support an alternative diagnosis V. high intensity

e) Vomitus 1.Bilious (dark green)- indicate obstruction beyond the ampulla of vater (intussusceptions,malrotation ) 2.Fresh Blood: upper GI bleed (Esophagitis, Peptic ulceration, Oral/nasal bleeding) 3.Coffee ground color : old upper GI or lower GI bleeding 4.Non bloody, non bilious(ingested food) pyloric stenosis 5.Feaculent : Lower intestinal obstruction

f) Associated features :
GI symptoms
Anorexia, nausea, retching, abdominal pain (common), diarrhoea

Neurologic symptoms
Headache, photophobia, neck stiffness

UTI symptoms
Dysuria, hematuria, incontinence

Other systemic reviews

Physical examination
Assess hydration status Abdominal examination eg: to look for tenderness, organomegaly, abdominal distension, presence of bowel sounds. Look for signs of severe infection eg: tense anterior fontanelle, meningism for meningitis. Examine for extraintestinal cause such as inflamed tympanic membrane in otitis media and renal punch in pyelonepritis and neurological examination

Investigation
Laboratory Investigations FBC, electrolyte ,BUN, ESR, venous blood gases, amylase Urine, blood, stool C&S

GI radiology Barium swallow/ meal, AXR, ultrasound abdomen, endoscopy Metabolic investigations blood gas,ammonia, blood and urine organic acids

Management
Depends on specific cause While investigating/ treating underlying pathology replace lost fluids, maintain hydration

Causes of vomiting
Infant GERD(most common) Over feeding Infection : - Gastroenteritis - meningitis - whooping cough - Otitis media - UTI intestinal obstruction - pyloric stenosis - Duodenal atresia - intussusception - malrotation - volvulus - hirschsprung ds Congenital adrenal hyperplasia Renal failure Child(pre-school) Gastroenteritis(most common) Systemic infection Intestinal obstruction Whooping cough GERD Coeliac disease Otitis media Meningitis Raised ICP School-age & Adolescent Gastroenteritis(most common) Peptic ulcer Systemic infection - pyelonephritis - meningitis -septicaemia Coeliac ds Appendicitis Migraine Pregnancy Medication Bulimia Anorexia

Diarrhoea
WHO definition: diarrhoea is the passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual. Excessive daily stool liquid volume (>10 mL stool/kg body weight/day (Nelson , Essential of Paediatrics,5th Edition) Normally, a young infant has about 5g/kg of stool output per day Childhood diarrhea represents an excessive loss of fluid and electrolytes in stools and is defined quantitatively as a total daily volume exceeding 20g/kg.

Classification
Acute < 2 weeks. Persistent 2- 4 weeks Chronic > 4 weeks.

Types of Diarrhoea
Primary Mechanism: Secretory Osmotic Inflammatory Motility related diarrhea
- Increased motility - Decreased motility

Decreased surface area

Secretory Diarrhoea
In this type of diarrhea there is both active intestinal secretion and decreased absorption of fluid and electrolytes. Little or no structural defects. Produce watery, normal osmalality stools. No stool leucocytes detected in the stool examination. Persists during fasting . Common cause:
a. b. c. Infection-cholera,E.coli Bile salt malabsorption following ileal resection Laxative(docusate sodium)

Osmotic Diarrhoea
Involve secretion of fluid into the bowel. This occurs because: a. Ingestion of non absorbable substance(Magnesium Sulphate) b. Patient has generalized malabsorption so that high concentration of solute remain in the lumen. c. Patient has transport defects such as disaccharide deficiency(lactase) or glucose-galactose malabsorption . Diarrhea stops when stop eating the malabsorptive substance or fasting. The stool is watery, acidic with the presence of reducing substances. There is an increase osmolality . No stool leucocytes detected.

Inflammatory Diarrhoea
There is damage of the intestinal mucosal cell

Leads to loss of fluid and blood.

In addition, there is defective absorption of fluid and electrolytes. In stool examination, there is presence of blood and increased WBCs.

Common cause are infective conditions (Shigella, Salmonella) and inflammatory conditions(UC and CD)

 It occurs due to abnormal motility of intestine which is increase or decrease in motility. A. Increased Motility Decreased transit time and increase frequency of defecation. Stool produced is loose to normal appearing stool, stimulated by gastro-colic reflex. Examples: Irritable bowel syndrome, postvagotomy ,hyperthyroid and dumping syndrome.

Motility related Diarrhoe

B. Decreased motility
due to defect in neuromuscular unit or stasis due to bacterial overgrowth. Stool is loose to normal appearing. Examples: 1) pseudoobstruction 2) blind loop

Decreased Surface Area

When there is decreased functional capacity. Produce watery diarrhoea. Examples: 1) short bowel syndrome 2) celiac disease 3) Rotavirus enteritis May require elemental diet plus parenteral alimentation.

Stool Characteristics & Their Soures

Stool Characteristics Appearance Volume Frequency Blood pH Reducing substances WBCs Serum WBCs Organisms Small Bowel Watery Large Increased Possibly positive but never gross blood Possibly <5.5 Possibly positive <5/high power field Normal Viral Rotavirus Adenovirus Calicivirus Astrovirus Norwalk virus Large Bowel Mucoid and/or bloody Small Increased Possibly grossly bloody >5.5 Negative Possibly >10/high power field Possible leukocytosis, Invasive bacteria E Coli Shigella species Salmonella species Campylobacter species Yersinia species Aeromonas species Plesiomonas species Toxic bacteria Clostridium difficile

Toxic bacteria E coli Clostridium perfringens Cholera species Vibrio species Parasites Giardia species Cryptosporidium species

Parasites Entamoeba organisms

Investigations:
Stool analysis
Macroscopic appearance Blood Blood , pus Blood, mucus Watery Rice-water stool Frothy Bloodstained Causes E.Coli (enterohaemorrhagic) Colitis Salmonella Shigella Inflammatory bowel disease Giardiasis Cryptosporidiosis Cholera Carbohyrate intolerance Campylobacter infection

 Stool culture & sensitivity Stool for Ova and Cyst - Giardiasis, crytospridiosis Stool PH level - <5.5 or presence of reducing substances indicates carbohydrate malabsorption. FBC, CRP, ESR UFEME BUSE Colonoscopy and endoscopy - Non-infectious etiology

Causes of acute diarrhoea

Infant Gastroenteritis Systemic infection Antibiotic associated Child Gastroenteritis Food poisoning Systemic infection Antibiotic associated Adolescent Gastroenteritis Food poisoning Antibiotic associated

Causes of chronic diarrhoea

infant child adolescent

Postinfectious secondary lactase deficiency Cows milk/soy protein intolerance Chronic nonspecific diarrhoea of infancy Celiac disease Cystic fibrosis AIDS enteropathy

Postinfectious secondary lactase deficiency Toddlers diarhea Irritable bowel syndrome Celiac disease Lactose intolerance Giardiasis Inflammatory bowel disease

GIT infection Inflammatory bowel disease Celiac ds Lactose intolerance Giardiasis Laxative abuse(anorexia nervosa)

Organisms
Viral
Rotavirus

Presentation
Watery stool - no blood @ mucus low grade fever, Vomiting Dehydration prominent

(commonest, up to 60% of cases in <2years of age) Calicivirus (norovirus) Astrovirus Adenovirus

Salmonella Yersinia

Bacterial

sp

Typhoid fever - Dysentry Differs from child vs adult Infants and child: diarrhea Adult: lesions of terminal ileum @ mesenteric lympadenitis
Enterocolitis Dysentery , High fever febrile convulsions Travelers diarrhea Profuse, rapidly dehydrating diarrhoea)

enterocolitica

Campylobacter Shigella

jejuni

V. Cholera/ ET E. coli / Vibrio parahaemolyticus

Organisms Parasites Giardiasis Entameoba histolytica Cryptosporidium

Presentation Acute onset , Ameobic dysentry Mild watery diarrhea (healthy) Severe prolonged diarrhea (immunocompromised)

Chemicals

Malabsorbed substance/ malabsorption Lactose intolerance Post infectious secondary lacrase deficiency Pancratic insufficiency (cystic fibrosis ) -Steatorrhea, - Failure to thrive(FTT) Cows milk/ soy product insifficiency Celiac ds - FTT after introduce gluten, - Abdominal distension - Buttock wasting Short bowel syndrome

Inflammation

Nonabsorb laxative Laxative abuse (anorexia nervosa ) Antibiotic associated Toxic ingestion Excess fruit juice (sorbitol) ingestion

Inflammatory bowel disease Crohn disease Ulcerative Colitis Irritable bowel ds Necrotizing enterocolitis

Causes

Causetive agents

Presentation
Fever Diarrhea Sudden onset Absence of pain Fever +/- bloody diarrhea

Gastroenteritis Viral

Bacterial

Extra-GIT Infection

Local infection

Otitis media
UTI URTI

Fever Ear pain/ discharge

Dysuria Frequency, incontinence Difficulty in swallow Swollen tonsil

Pneumonia / LRTI
Systemic infection Septicaemia Meningitis

Cough Fever Post-tussive vominting Sputum in vomitus

Seizures, diarrhea Photophobia, LOC, neck stiffness

Causes Gastrointestinal

Example GERD

Presentation Effortless not preceded by nausea chronic Epigastric pain Blood @ coffee ground vomitus Pain relieved by acid blockade Jaundice , Hx of exposure Fever Abd pain migrating to right lower quadrant/ tenderness Particular formula/ food Blood in stool

Peptic ulcer or gastritis Hepatitis Appendicitis

Allergic

Milk @ soy product protein intolerance

Other food allergic

In older children

Causes Anatomical obstruction

Example Intestinal atresia Midgut malrotation

Presentation Neonate, premature ~ polyhydromnious Sudden onset pain, GI bleed Shock Colicky pain Lethargy Red currant jelly stool Mass occsionally Colicky pain Mass

Intussusception

Duplication of cyst

Pyloric stenosis

<4 months old Nonbilious vomiting, postprandial Hunger state Visible peristalsis wave

Causes

Example

Presentation

CNS causes ( ICP)

Migraine syndrome
Hydrocephalus Cyclic Vomiting Syndrome

Relieved by sleep, headache

Large head, altered mental status Repetitive migraine headache @ Symptoms of irritable bowel (nausea,vomiting, abd pain)

Brain tumors

Morning vomiting Acceleratig over time Headache, diplopia

Presentation early in life, worsens when catabolic or exposure to substance

Metabolic disorder

IEM Galactosemia Adrenogenital syndrome DKA Liver failure Overfeeding

Others

Poisons/drugs

Lead, digoxin, theophyllin, erythromycin

Dehydration

Causes of dehydration

Assessment of dehydration (History)

Assess the onset, frequency, quantity and character of both vomiting and diarrhoea Recent oral intake Urine output Weight before illness Associated symptoms (fever, change in mental status) Past medical history (underlying medical problems, history of other recent infections, medications, immune compromised states) Social history

Physical Examination
Accurate body weight Vital signs (temperature, heart rate, respiratory rate, blood pressure) General conditions Eyes: sunken eyes, presence / absence of tears Mucous membrane moist or dry Respiratory pattern Bowel sounds Extremities (perfusion, capillary filling time) Skin turgor (anterior abdominal wall) Inspection of stool (presence of blood or mucous)

Investigation
Depends on clinical assessment
Renal profile Stool culture and sensitivity Urinalysis Full blood count

Assessment of dehydration
Percentage loss of body weight

Previous BW not available: Clinical signs for dehydration

Is essential for appropriate fluid management. Repeated assessment is often necessary. Most useful signs for significant dehydration
Prolonged capillary refill time (normal < 2 seconds) Reduced skin turgor Abnormal respiratory pattern

Simplified ways of classifying the degree of dehydration

Classification No signs of dehydration Some signs of dehydration Severe dehydration Fluid deficit as % of BW < 3% 3-9% > 9% Fluid deficit in ml/kg of BW < 30 ml/kg 30-90 ml/kg > 90 ml/kg Adapted from WHO 2005

Assessment of dehydration
Symptom No signs of dehydration (<3% loss of BW) Well, alert Mild to moderate dehydration (3-9% loss of BW) Normal/ fatigue/ restless/ irritable Severe dehydration (>9% loss of BW) Apathetic, lethargic unconscious Drinks poorly, unable to drink Tachycardia, with bradycardia in most severe cases Weak, thready, or impalpable Deep Mental status Thirst Heart rate

Drinks normally, Thirsty, eager to might refuse liquids drink Normal Normal to increased Normal to decreased Normal, fast

Quality of pulse Breathing

Normal Normal

Continue
Symptom No signs of dehydration (<3% loss of BW) Normal Present Moist Instant recoil Normal Warm Normal to decreased Mild to moderate dehydration (3-9% loss of BW) Slightly sunken Decreased Dry Recoil in < 2 seconds Prolonged Cool Decreased Severe dehydration (>9% loss of BW) Deeply sunken Absent Parched (very dry) Recoil in > 2 seconds Prolonged, minimal Cool, mottled, cyanotic Minimal

Eyes Tears Mouth and tongue Skin fold Capillary refill Extremities Urine output

Adapted from WHO 2005, CDC 2003

Sunken eyes

Dry tongue Diffuse mottled, bluish-gray appearance of this infant's skin suggestive of systemic poor perfusion

Pinching the child's abdomen to test for decreased skin turgor

Slow return of skin pinch in severe dehydration

A bit on hypernatraemic dehydration

Cause
Predominantly breastfed and were given inadequate breastfeeding Given inappropriately prepared infant formula

 Common symptoms
Hyperpnoea Muscle weakness Restlessness A characteristic high-pitched cry Insomnia Lethargy And even coma Convulsions are typically absent except in cases of inadvertent sodium loading or aggressive rehydration

EMERGENCY MANAGEMENT
1) Initial resuscitation -Secure airway, support breathing & restore circulation 2) Fluid Resuscitation Rapid restoration of intravascular volume Complications of rapid fluid given : Cerebral edema, hyponatremia, osmotic demyelination, death.

 Bolus 20 ml/kg of isotonic crystalloid over 510 minutes Assess vital signs and perfusion 1) Blood pressure 2) Quality of central and peripheral pulses 3) Skin perfusion 4) Mental status 5) Urine output

 If not improve, 20 ml/kg boluses to a total 60 ml/kg, ideally within first 30 to 60 minutes of treatment.

Further management
Once the patient stable, find and treat the cause Continue fluid therapy Assess the sodium level 1) Normal isotonic saline 2) Mild to moderate hyponatremia isotonic saline 3) Severe serum sodium at rate 0.5 mEq/L per hour

FLUID THERAPY AFTER INITIAL RESUSCITATION

ORAL REHYDRATION THERAPY (ORT)

Process of replacing essential body fluids and salts that a child loses in critical quantities during attacks of diarrhoea.

Most often, diarrhoea kills a child by dehydration, which means that too much liquid has been drained out of the child's body. So as soon as diarrhoea starts, it is essential to give the child extra drinks to replace the liquid being lost.
ORT is the giving of fluid by mouth to prevent and/or correct the dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home remedies to prevent dehydration must be started.

ORAL REHYDRATION SOLUTION (ORS)

Commonly, Oral Rehydration Salts (ORS) solution is given to treat dehydration resulting from all types of acute diarrhoeal diseases. Glucose- electrolytes (salt) mixed solution. Used to treat mild and moderate dehydration. To treat low concentrations of electrolytes in the blood (severe electrolyte depletion). Cheaper than IV therapy and has lower risk of complication.

The New Reduced Osmolarity formula for the ORS packet recommended by WHO and UNICEF contains:
Osmolarity (ORS) Sodium Chloride Glucose, anhydrous Potassium Citrate Total Osmolarity mmol/litre 75 65 75 20 10 245

INTRAVENOUS FLUID
Indication: Severely dehydrated. Moderate dehydration if there is no improvement after ORS Unconscious child Continuing rapid stool loss (> 15-20ml/kg/h) Frequent, severe vomiting, drinking poorly Abdominal distension with paralytic ileus, usually caused by some anti-diarrhea drug ( eg; codeine, loperamide) and hypokalaemia Glucose malabsorption

Types of solution
Solution (mmol/L) Na K Ca Cl lactate

NS 0.9%
0.45%NS in 5% dextrose (children) 0.18 % NS in 4.0% dextrose (up to 2 year) Hartmann s solution (Ringers lactate)

150 77 30 -

150
77 30 112

27

130 5

PLAN A: TREAT DIARRHOEA AT HOME

Counsel mother on 3 rules :1. Give extra fluid
Breastfeed frequently Give 8 packets ORS to used at home
Up to 2 years : 50-100ml after each loose stool 2 : 100-200ml after each loose stool

Give frequent small sips from a cup or spoon If chlid vomit, wait 10 minutes then continue but more slowly Continue giving extra fluid until diarrhea stop

2. Continue feeding
But avoid food with high simple sugar (osmotic load may worsen diarrhea)

3. When to return to the health facility

Not able to drink, breastfeed or drinking poorly Becomes sicker Fever Blood in stool

PLAN B: TREAT SOME DEHYDRATION WITH ORS

1. Give recommended amount of ORS over first 4-hour period:Age Weight In ml Up to 4 months 4-12 months 1-2 years <6kg 200-400 6 - <10kg 400-700 10 - <12kg 700-900 2-5 years 12-19kg 900-1400

2. Inform mother to: Give frequent small sips from cup or spoon If child vomit, wait 10 minutes then continue but more slowly Continue breastfeeding whenever child wants

3. After 4 hours: Reassess child and classify child for dehydration Select appropriate plan to continue (Plan A, B or C)

4. If mother must leave before completing treatment: Give her enough ORS packets to complete rehydration and 8 packets as recommended in Plan A Explain the 3 Rules (Plan A)

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

Start IV/IO immediately if child can drink, give ORS by mouth while drip is being set up give 100ml/kg Ringer lactate or normal saline :1st give 20ml/kg ASAP (repeat fluid boluses until perfusion improved) then give 80ml/kg over 5 h(age 12 m) or 2h 30 mnt (age >12m)

reassess child after every bolus and stop bolus once perfusion improve or when fluid overload suspected reassess child every 1-2 h during rehydration give ORS (5ml/kg/h) as soon as child can drink reassess an infant after 6h and child after 3h. Classify dehydration and choose appropriate plan

If IV/IO line fail to set up arrange for the child to be sent to nearest centre meanwhile as arrangements are made to send the child, try further attempts : try to rehydrate child with ORS (20ml/kg/h over 6h orally/orogastric tube. Continue to give ORS along the journey reassess child every 1-2 h give fluid more slowly if repeated vomiting or increasing abdominal distension reassess child after 6h classify dehydration choose appropriate plan

Fluid Therapy Calculation

Fluid deficit (ml) = % dehydartion X BW in grams Type of fluid solution: 1/5 normal saline 5 % dextrose solution or 1/2 normal saline 5 % dextrose with or without added KCl in the drip Maintenance fluid:
Age < 6 months 6 months to 1 year > 1 year a)first 10 kg b)Second 10 kg c)Subsequent kg 150 ml/kg/day 120 ml/kg/day 100 ml/kg 50 ml/kg 20 ml/kg Maintenance Fluid Required

Total fluid required (ml) = fluid deficit + maintenance fluid given over 24 hours

EXAMPLE
8 months old child weighing 5kg is 5% dehydrated and not tolerate oral intake.
Age < 6 months Maintenance Fluid Required 150 ml/kg/day

6 months to 1 year
> 1 year a)first 10 kg b)10 20 kg c)> 20 kg

120 ml/kg/day

100 ml/kg + 50 ml/kg for next 10 subsequent kg + 20 ml/kg for any subsequent kg

Rehydrating over 24 hours 1. Fluid deficit 5% x 5000 = 250ml 2. Fluid maintenance 120ml/kg/24h 120ml x 5kg = 600ml /24 h 3. Total fluids in first 24 hours 250ml + 600ml = 850ml 4. Rate of infusion 850ml/24h = 35ml /h

EXAMPLE
12 years old child weighing 30kg is 5% dehydrated and not tolerate oral intake.
Age < 6 months 6 months to 1 year > 1 year a)first 10 kg b)Second 10 kg c)Subsequent kg 150 ml/kg/day 120 ml/kg/day 100 ml/kg 50 ml/kg 20 ml/kg Maintenance Fluid Required

Rehydrating over 24 hours 1. Fluid deficit 5% x 30000 = 1500ml 2. Fluid maintenance First 10kg = 100ml/kg x 10kg = 1000ml Second 10kg = 50ml/kg x 10kg = 500ml Next 10kg = 20ml/kg x 10kg = 200ml Total = 1700ml 3. Total fluids in first 24 hours 1500ml + 1700ml = 3200ml 4. Rate of infusion =3200ml/24h = 133ml /h

Hyponatraemic Dehydration
Daily Na+ requirement 2 3 mmol/kg/day Na+ deficit (140 serum Na+) x 0.6 x weight (kg)

Definition = serum Na <130 mmol/l ORS solution is a safe and effective therapy for nearly all children with hyponatraemia 1/2 normal saline 5 % dextrose with 20 mEq/L KCl

Hypernatraemic Dehydration
Definition = serum Na > 150mmol/l If child shock, first resuscitation then rehydrate with ORS over 48 to 72 hours If fluid has been given to resuscitate, amount given should be subtracted from the fluid deficit (important to avoid giving too much fluid) Reduce serum Na+ slowly and not exceed 10 mmol/L per 24 hours (dramatic fall lead to cerebral oedema and seizures) Use normal saline 5 % dextrose for the duration of fluid replacement until serum Na+ is < 145 mmol/L Then use 1/2 NS 5 % dextrose or 1/5 NS 5 % dextrose Add KCl after the child passes urine Monitor blood urea serum electrolytes 6 hourly