#MiniTeach: Not Keeping Anything Down
"A mother brings her 2-year-old child to the Children's Emergency Department "
She says that he has been continually vomiting for the past 3 days and has not tolerated anything to eat or drink for the past 36 hours. There is no history of a fever.
1. As the assessment nurse, how will you assess and manage this child?
Document the history carefully, and perform baseline observations including a BM.
Try to assess how dehydrated this child is (mild, moderate or severe).
If the child has a BM less than 3, seek medical attention immediately.
If the child is showing signs of dehydration but has a BM > 3, start an oral fluid challenge (see below) but prioritise the patient to be seen soon.
If the child is not clinically dehydrated and the BM is > 3, start an oral fluid challenge using Oral Rehydration Solution (PED stocks Dioralyte) and give the parents a drinking plan to record the fluid challenge (attached). A rough guide would be 5 mls every 5 minutes (equivalent to 60 mls/hr).
2. As the first doctor/PANP to see this child what specific features will you ask in your history to help you manage the patient?
Age of patient – those under 1 are at increased risk of dehydration, especially under 6 months.
Duration of symptoms – vomiting secondary to gastroenteritis usually stops by day 3, diarrhoea usually lasts 5-7 days, and stops within 3 days.
Frequency of vomiting – increased risk of dehydration if vomited > 3 times in 24 hrs.
Presence/absence/frequency of diarrhoea – increased risk of dehydration with ≥6 diarrhoeal stools in past 24 hours.
Presence/absence of bilious (green) vomit, presence/absence of blood/mucus in diarrhoea – suggests alternative diagnosis to gastro-enteritis.
Attempt to establish how much fluid child has managed tolerate – gives you an idea of your starting point.
Ask about urine output – in reality specific quantity has limited use but reduced versus normal output can be useful – beware diarrhoea masquerading as urine!
Other family members affected/contact with others with similar symptoms – suggests more likely to be infective in origin.
History of a fever – high grade fever is less likely to be due to viral gastroenteritis.
Recent travel abroad – many tropical diseases present with signs/symptoms of common childhood illnesses, and as such, take longer to diagnose unless specific travel history is ascertained.
3. How will you assess him for dehydration?
Using the examination findings in the NICE guideline paying particular attention to his pulse, RR, and responsiveness.
The assessment nurse has bought the patient to your attention, as his BM is 1.8, he has a pulse of 130 bpm, RR 40 bpm, and is drowsy, but rousable when his mother talks to him.
4. What is your immediate management?
Either Hypostop (liquid sucrose) if awake enough – this child is “V” on AVPU, so he would tolerate it, or iv access with 2 mls/kg 10% dextrose provided this is achieved within 5 mins of the low BM reading.
This patient will also need bloods for near patient testing, lab glucose, FBC, U+E, CRP (and B/C if fever predominant feature, or infant <3 months).
This child also needs a fluid bolus of 20 mls/kg 0.9% saline,due to the signs of drowsiness and a pulse of 140 with no Hx of a fever.
The BM should be repeated within 10 mins to ensure > 3.0 (if not, repeat steps above).
5. Should you perform a hypoglycaemia screen?
No. UHL Children’s Hospital/PED policy on the management of hypoglycaemia states that the screen should be performed when “there is unexplained (no obvious precipitating cause such as infection, prolonged starvation >18 hrs or prematurity) or recurrent hypoglycaemia”.
If this child failed to respond to the first amount of hypostop/dextrose, it should then be performed.
6. When should you perform a hypoglycaemia screen, what does it entail, and what does it screen for?
The sample must be taken at the time of hypoglycaemia, before any glucose is given.
DO NOT delay treatment of hypoglycaemia for more than 5 minutes.
So in unexplained/recurrent hypoglycaemia, it is important to obtain the blood before giving the hypostop/iv dextrose if at all possible.
What does it entail? At least 5 mls blood, to be sent on ice (from the plaster room in minors), that needs to get to the lab within 30 mins of sampling, plus, at soonest opportunity, a urine sample.
"Hypoglycaemia" boxes (large, bright yellow ) are held in Paeds and Resus that contain a list of the tests, what sample bottles are required and treatment for hypoglycaemia.
Samples are taken for blood gas, glucose and lactate, ammonia, U+E, cortisol and growth hormone, insulin and C-peptide, Free fatty acids and 3beta- OH butyrate, acylcarnitine, gal-1-Put and amino acids. Urine is needed for organic acids and urine reducing substances – don’t worry, no-one remembers it, that’s why there is a box!
The screen is important as it may be the only opportunity to diagnose rare paediatric metabolic/endocrine disorders, most of which are inherited.
After 10 mins he appears much improved. His pulse is 100 bpm, RR His BM is 3.3, he is talking and interacting with his mother and is asking for a drink.
7. What will your next steps be? (choose the best-fit answer)
a) Allow him to eat and drink, reassure Mum, and send him home?
b) Allow him to eat and drink, keep in PED for a while longer, and if doesn’t vomit, then send home?
c) Allow him to eat and drink, and refer to CAU (Children's Assessment Unit) for a period of observation?
d) Keep him nil by mouth until he is assessed by one of the paediatric team on CAU, and refer him?
e) Consider placing him on NG fluids and refer to CAU?
f) Keep him nil by mouth, but start him on some iv fluids?
g) Allow him to eat and drink but start on iv fluids, and refer to CAU?
Best-fit answer is g). By the time of presentation to ED with a BM of 1.8, this child has used up his physiological reserves.
The hypostop/iv dextrose bolus reverses the situation in the short term, and along with the fluid bolus, this child will have clinically improved.
However, this is a temporary measure and if replacement of the reserves is not addressed, the child will soon become hypoglycaemica again.
The best way to think about this is that the treatment of hypoglycaemia is a 'bolus of either oral or iv sugar as an immediate treatment followed by intravenous/NG fluids', and this needs to start whilst the child is in PED.
NG fluids versus iv fluids is always of consideration in fluid replacement, but for most practitioners, if you have already cannulated for bloods +/- iv dextrose, then why do another distressing procedure to the child when iv fluids would be well tolerated, and can always be stopped once the child is hydrated.
The child should be allowed to drink/eat as they wish, as there is no benefit in viral gastroenteritis to keeping the patient NBM.
After 10 mins he appears much improved. His pulse is 100 bpm, RR His BM is 3.3, he is talking and interacting with his mother and is asking for a drink.
8. If you were to give considered iv fluids, what fluids would you use and how would you prescribe them?
NICE recommends the use of 0.9% saline + 5% dextrose for fluid replacement. The patient requires his normal maintenance fluid plus replacement of his deficit.
Maintenance Fluid:
Maintenance fluid for children is weight based and involves calculating the rate.
For each child's weight, it is broken down into 3 sections – the first 10 kg, the second 10 kg and anything above the first 2 x 10kg:
For each kilogram between 0-10 kg, you allow 100 mls/kg/24 hrs
For the next kilograms between 10-20 kg, you allow 50 mls/kg/24 hrs
For any kilograms above 20 kg, you allow 20 mls/kg/24 hours.
For example, in a 23 kg child, its maintenance fluid requirement is:
100 mls/kg for the first 10 kg = 100 x 10 = 1000 mls
50 mls/kg for the next 10 kg = 50 x 10 = 500 mls
20 mls/kg for the last 3 kg = 20 x 3 = 60 mls
Total fluid requirement for 24 hrs = 1560 mls.
The hourly rate is the total amount divided by 24 = 65 mls/hr
For our 3 year old child, estimated weight is (2 x age) + 8 = 14 kg
Therefore his maintenance fluid is:
100 mls/kg for first 10 kg = 100 x10 = 1000
50 mls/kg for remaining 4 kg = 50 x 4 = 200
Hourly rate = (1000 + 200) / 24 = 50 mls/hr
Fluid Deficit:
It is usual to estimate the % dehydration as either 5% dehydrated (moderately) dehydrated and 10% (severly dehydrated/clinically shocked).
Replacement is then performed over 24 hrs or, more usually, 48 hours, as its slower, causing less osmotic fluid shift.
To calculate the amount of fluid required for replacement, the following formula is used:
percentage dehydration x weight of child in kg x 10 = deficit volume
This volume can then be replaced over 24 hours or 48 hours:
For replacement over 24 hours, the deficit volume is added to the maintenance fluid volume for 24 hours, then divided by 24 to provide an hourly rate.
For replacement over 48 hours, the deficit volume is divided by 2, then added to the maintenance fluid volume for 24 hours, then divided by 24 to provide an hourly rate.
For our 3 year old patient, I would estimate 5% dehydration, and want to replace this over 48 hours:
Maintenance fluid = 1200 mls
Deficit fluid = 5% x 14 kg x 10 = 700 mls. (To replace over 48 hours = 700 / 2 = 350 mls each day)
Total to be replaced in 24 hours = maintenance + deficit/2 = 1200 + 350 = 1550 mls / 24 hours = 64.5 mls/hr
