Peds Case 15- 4Wk/o W Vomiting

Front 1

Where is the vomit coming from?
Undigested food:
Digested food:
Bile:
Blood:
Feculent:

Back 1

Undigested food: Esophageal or gastric origin
Digested food: Gastroduodenal origin
Bile: Postampullary origin
Blood: Above the ligament of Treitz
Feculent: Bacterial overgrowth, colon, necrotic bowel

Front 2

nml newborn feeding and stooling

what's a temp?

Back 2

breastfed infant initially stools approximately 6 to 8 times per day, although this number often decreases by 1-2 months of age

4-week-old will typically breastfeed every 2 to 4 hours for 10 to 15 minutes on each breast. The infant may sleep up to 5 hours at a time during the night

rectal temperature above 100.4 F (or more than 38 C) is considered a fever

Front 3

dehydration may include

Back 3

decreased activity level, decreased urine output and increased thirst (in children old enough to indicate thirst). Signs may include tachycardia, tachypnea (if associated with acidosis) weight loss, decreased production of tears, tacky or “dry” mucous membranes, sunken fontanelle and delayed capillary refill. Hypotension and loss of skin turgor (e.g., skin tenting) may be seen with severe dehydration.

Comparing current dehydrated weight to a previous euvolemic weight is a useful and simple way to determine the percent of weight loss and the degree of dehydration.

Front 4

Gravida, Para

Back 4

total # of preg including abortions

viable infants at least 500g and 20wks given birth to regardless if they are alive (multiple birth is one parous event)

Front 5

Apgar

Back 5

assess if child needs ressus

heart rate, resp effort, muscle tone, response to nasal suctioning, color

not predict neonatal mortality, cerebral palsy, or cog development

Front 6

GE reflux

Back 6

vomiting no bile
decreased PO b/c post paranial pain

Front 7

pyloric stenosis

Back 7

escalating pattern of forceful nonbilious vomiting
vigorous appetite

Hypertrophic pyloric stenosis
male:female ratio 4:1
most common reason for an abdominal operation in the first 6 months of life
> in northern Europeans, < in African-Americans, very rare in Asians.
aggregate in families, esp children of an affected mother
higher incidence in infants with blood O or B.

vomiting starts at 3-4 weeks of age, but symptoms may develop as early as 1 week of age and as late as 3 months
almost never symptomatic in the newborn nursery
vomiting may have variable force, but classically projectile
immediately after feedings as the pylorus becomes progressively more obstructed
nonbilious.
no Fever nor diarrhea
Appetite initially preserved, though severely dehydrated =lethargy and decreased feeding
palpating the pyloric mass (firm, mobile, 2 cm, olive shaped, in the midepigastrium above and to the right of the umbilicus); easier to palpate after vomiting when the musculature more relaxed.
jaundice may be associated with pyloric stenosis

significant electrolyte abnormalities assc w continuous vomiting
hypochloremic metabolic alkalosis, due to the loss of hydrochloric acid in the vomitus.
Na low K nml

dx w Pyloric ultrasound
GI study w contrast if no experienced US-er= very narrow pyloric channel (sometimes referred to as the string sign), indentation of the hypertrophied pylorus on the antrum of the stomach, and delayed gastric emptying

Front 8

CNS disease

Back 8

must be considered in vomiting w/o fever or diarrhea
includes nonaccidental trauma

Front 9

enteritis

Back 9

diarrhea may be absent early in the course but is there if it is true enteritis
nonbilious vomiting
fever
decreased PO

Front 10

SBO

Back 10

vomiting (bilious below the ligament of Treitz)
decreased PO
no fever or diarrhea

Front 11

metabolic disorders

Back 11

vomiting
diminished PO due to lethargy and irritability

Front 12

UTI

Back 12

vomiting (nonGI)
decreased PO
fever
diarrhea

Front 13

new born screening

Back 13

All state programs: PKU and congenital hypothyroidism. More than 40 programs screen for sickle cell disease, and 48 screen for galactosemia.

Some: congenital adrenal hyperplasia, homocystinuria, maple syrup disease and biotinidase deficiency

A few: cystic fibrosis and tyrosinemia

Front 14

signs of dehydration

Back 14

decrease in weight and tachycardia are early indicators of dehydration, and that a drop in blood pressure is associated with severe dehydration

Front 15

weight gain is expected per day in a 4-week-old infant?

Back 15

5-30 grams (0.5 - 1 oz)

Front 16

adventitious sounds

Back 16

abnml sounds

Front 17

diarrhea

Back 17

diarrhea is a change in stools, usually defined as a passage of loose or watery stools. It may also be defined as excessively frequent stools or increased volume. The average stool output for a child is about 100 grams per day. Objectively, diarrhea is defined as stool output greater than 10 grams/kg/day in children who weigh less than 20 kg, or 200 grams total in 24 hours in children weighing more than 20 kg.

infxn most common cause of acute diarrhea
leading cause of death in children
second common cause of death world wide (children and elderly in developing countries from dehydration

Front 18

acute vs. persistent vs. chronic diarrhea

Back 18

Acute diarrhea lasts less than 14 days;
"persistent" diarrhea lasting more than 14 days
chronic- longer than 1 month

Important clinical history includes the onset of illness, duration of symptoms, weight loss, whether contacts are sick, history of traveling to an endemic area, exposure to an untreated water, medication use and daycare attendance.

phys exam: dehydration and signs of systemic toxicity.
Fecal leukocyte, lactoferrin and occult blood are often present in patients with diarrhea due to bacterial infection (i.e., salmonella, shigella, Yersinia), which cause diffuse colonic inflammation.
useful in febrile patients with significant acute diarrhea because if negative, the likelihood of getting a positive culture is very low.

degree of dehydration is to subtract the patient's dehydrated weight from their weight prior to the illness. The assumption is that all of the weight loss is from total body water. The weight loss in grams is equivalent to the water loss in cc's

Front 19

diarrhea and electrolytes

Back 19

Most episodes of dehydration caused by gastroenteritis are isonatremic, and serum electrolytes determination is often unnecessary.
Electrolyte levels measured in:
(1) Children with moderate to severe dehydration; (2) Dehydrated children whose history and physical findings are inconsistent with a straightforward diarrheal episode; and (3) Children at risk for hyponatremia or hypernatremia.

hypernatremic dehydration requires very slow replacement of fluids 1meq/2hr (10meq/24hr).
occurs when water intake is reduced in the face of excessive water loss (from vomiting or diarrhea). ingestion of hypertonic fluids (boiled milk, home-made solutions to which salt is added, improperly mixed formula or significantly inadequate breast milk supply).

Hyponatremic dehydration develops when there is ingestion of hypotonic fluids, such as fluids without salt (including free water) and improperly mixed formula.

Infants with pyloric stenosis may also have significant electrolyte abnormalities associated with continuous vomiting.
hypochloremic metabolic alkalosis, due to the loss of hydrochloric acid in the vomitus.
sodium and potassium are nml

Front 20

most common cause of gastroenteritis at this age group?

Back 20

Rotavirus
(Reoviridae)

affects almost all children by age 5
most common in winter months in temperate climate.
most severe disease and high proportion of severe episodes.
dx rotavirus antigens in feces, done by two methods: enzyme immunoassay (EIA) 95-100% sens and spec or
latex agglutination (LA). much faster, but is less sensitive and specific.

fecal-oral route. Outbreaks in daycare centers
incubation 48 hours
selectively infects and destroys villus tip cells in the small intestine (duodenum)
upper villus enterocytes are differentiated, which have both digestive and absorptive functions: (1) Digestive: hydrolysis of disaccharide; (2) Absorptive: transport of water and electrolytes via glucose and aminoacid co-transporters
spared enterocytes secrete water and electrolytes creating an imbalance in the ratio of intestinal fluid absorbed to secreted.
Malabsorption of complex carbohydrates (lactose)

In 2006, the U.S. licensed RotaTeq, an oral, human-bovine reassortant rotavirus vaccine.
three doses= efficacy against severe gastroenteritis 98%; against any severity, efficacy is 74%.
at 2 months, 4 months, and 6 months
side effects include a slightly increased incidence of mild, self-limited vomiting and diarrhea within 7 days after vaccination.
Unlike the previous rotavirus vaccine (Rotashield), no increased incidence of intussusception

Front 21

Oral rehydration solution

Back 21

commercially prepared solutions in cases of mild dehydration bc as effective as intravenous therapy and is much less costly.
also in moderate dehydration (10-15%) once vomiting stops x

advantages over IV therapy:
cheaper
administered in home.
evaluated glucose electrolyte solutions with Na 50-90 mmol/L successful in 90% of the patients and with fewer complications than IV therapy.

available commercially: Na 45-50 mmol/L. These solutions (Naturalyte, Pediatric electrolyte, Pedialyte, Infalyte, Rehydralyte) best for maintenance.
mild or moderate dehydration.

Glucose-electrolyte solutions, formulated on physiologic principles vs popular, nonphysiologic liquids used to treat diarrhea that have low electrolyte content and that are hypertonic due to their high glucose content.
ex: apple juice, colas and ginger ale.
dehydrated should be fed as soon as they have been rehydrated

Front 22

Calculating Fluid Therapy for Children with Dehydration (4 steps)

Back 22

1. Support cardiovascular circulation
diminished urine output or impaired cardiac output (tachycardia)
IV fluid bolus of 20 mL/kg of normal saline (without dextrose) over 20 minutes to one hour repeated until the patient urinates and tachycardia improved.
Caution w increased ICP, renal failure or cardiac failure.

2. Correct dehydration
calculate and replace the patient's current fluid deficit.
multiply weight in grams (grams and milliliters are interchangeable) by the estimated percent dehydration
mild-moderate dehydration- replaced over next 24 hours: half replaced over the first 8 hours and second half over final 16 hours
hypernatremia (Na >150) should have their deficit replaced evenly over 48 hours, not to drop the sodium faster than 1mEq/2hrs.
deficit replaced with either IV or oral rehydration solutions.
oral route, no more than 5 to 10 mL every 1-5 minutes.
D5 1/4 normal saline. A solution of D5 1/2 normal saline may be used for patients >10kg.
once voiding, 20 mEq/L of KCl should be added to the IV fluids.

3. Provide maintenance fluids
Maintenance fluids fxn of metabolic rate and replace usual body losses
infants <10kg, 100 mL/kg/d.
either IV or oral rehydration solutions, or with full-strength formula or breast milk.
addition to the bolus and deficit fluids

4. Replace any ongoing losses
ongoing vomiting and/or diarrhea, insensible losses from fever or tachypnea.
stool volume over 5g/kg/4hr should be replaced w 1/2 normal saline with 20mEq of KCL (no dextrose)

Front 23

Holliday-Segar formula:

Back 23

0-10 kg: 100 mL/kg per day
10-20 kg: 1000 mL (+ 50 mL/kg for each >10 kg) per day
>20 kg: 1500 mL (+ 20 mL/kg for each >20 kg) per day

100 mL/kg/day for the first 10 kg of body weight
50 mL/kg/day for the second 10 kg of body weight
20 mL/kg/day for each additional 1 kg of body weight

Front 24

refeeding after ORT

Back 24

early refeeding showed that the duration of the diarrhea was reduced by 0.43 days b/c better nutrition

start 6hrs after rehydration started