Rosen & Barkin's 5-Minute Emergency Medicine Consult (776 page)

Vomiting, Pediatric

CODES

• 643.00 Mild hyperemesis gravidarum, unspecified as to episode of care or not applicable
  
• 787.01 Nausea with vomiting
  
• 787.03 Vomiting alone
  

BASICS

• A chronic, idiopathic disorder characterized by recurrent, discrete episodes of disabling nausea and vomiting separated by symptom-free intervals lasting a few days to months
  
• Adult population – average age of diagnosis is 31:
  
  • Average age of onset is 21
    
• Pediatric population – average age of diagnosis is 5
  
• General characteristics:
  
  • Phase 1: Interepisodic phase:
    
    • Symptom free
      
  • Phase 2: Prodrome:
    
    • Varying intensity of nausea and diaphoresis
      
  • Phase 3: Emetic phase:
    
    • Intense nausea/vomiting/retching/dry heaving up to 7 days
      
  • Phase 4: Recovery phase:
    
    • Improvement of nausea and tolerance of PO intake
      

• True incidence and prevalence in adult general population unknown due to limited data and research, increasing recognition in syndrome
  
• In pediatric population, cyclic vomiting syndrome affects 0.04–2% of population with estimated new cases 3/100,000 annually
  

• Etiology unknown
  
• Pathophysiology is also unknown and is under research:
  
  • Limited research suggests multifactorial factors such as autonomic, central, and environmental to be involved
    

DIAGNOSIS

Commonly present to ED with unexplained onset of nausea/vomiting and abdominal pain.

• History of similar prior episodes
  
• No preceding trigger identified at times but typically when asked specifically may identify
  
• Will complain of abdominal pain, usually epigastric
  

May have benign physical exam or various findings based on degree of dehydration:

• Normal vital signs or abnormal vital signs demonstrating:
  
  • Tachycardia
    
  • Hypotension (including orthostatic hypotension)
    
  • Tachypnea
    
• Cool extremities and/or delayed (>2 s) capillary refill indicating shock
  
• Varying degrees of consciousness:
  
  • Alert, lethargic, or obtunded
    
• Dry mucous membranes:
  
  • Sunken eyes
    
  • Dry/sticky or cracked mouth
    
• Poor skin turgor
  
• Oliguria or anuria
  

May present with above in addition to refusal to eat/drink, reduced or lack of tear production, sunken fontanels, reduced or absent urine output (reduced wet diapers)

Must rule out other potentially serious conditions (see Differential Diagnosis)

• Perform necessary exam and lab or radiographic tests necessary to rule out other conditions with similar presenting signs and symptoms
  
• Cyclic vomiting has no specific diagnostic feature nor specific biochemical marker
  
• Extensive list of other diagnostic possibilities
  
• Diagnosis of adult cyclic vomiting is based on Rome III criteria:
  
  • Stereotypical episodes of vomiting regarding onset (acute) and duration (<1 wk)
    
  • At least 3 episodes in the past year
    
  • Absence of nausea/vomiting between episodes
    

• CBC
  
• Electrolytes, BUN/Cr, glucose
  
• Liver enzyme, liver profile
  
• Lipase
  
• Lactate
  
• Urinalysis
  
• Pregnancy test
  
• Toxicology screen/drug levels:
  
  • Acetaminophen
    
  • Salicylic acid
    
  • Alcohols:
    
    • Ethanol, isopropanol, methanol, ethylene glycol
      
  • Digoxin
    

Atypical severity or atypical episodes should raise suspicion of underlying disorder not due to cyclic vomiting:

• Tailor imaging to individual patient presentation
  

Outpatient gastric emptying study should be done to r/o gastroparesis or other gut motility disorders as cause of frequent emesis.

• Infectious:
  
  • Appendicitis
    
  • Pyelonephritis
    
  • Pneumonia
    
  • Cholecystitis
    
• Metabolic/endocrine:
  
  • Renal failure/uremia
    
  • Electrolyte disorder
    
  • Diabetic ketoacidosis
    
  • Thyroid disorder
    
  • Adrenal insufficiency
    
  • Pheochromocytoma
    
  • Pregnancy or hyperemesis gravidarum
    
• Renal:
  
  • Nephroureterolithiasis
    
  • UVJ obstruction/hydronephrosis
    
• GI:
  
  • Gastroparesis
    
  • Bowel obstruction
    
  • Peptic ulcer disease
    
  • Cholelithiasis
    
  • Pancreatitis
    
  • Malrotation with volvulus
    
  • Inflammatory bowel disease
    
• CNS:
  
  • Intracranial hemorrhage
    
  • Brain tumor
    
  • Hydrocephalus
    
  • CVA
    
• Cardiovascular:
  
  • Anginal equivalent
    
  • STEMI/NSTEMI
    
• Toxicology (examples):
  
  • Cannabinoid hyperemesis
    
  • Mushroom toxicity:
    
    • >100 species
      
  • Acute alcohol/toxic alcohol ingestion:
    
    • Ethanol, isopropanol, methanol, ethylene glycol
      
  • Alcohol withdrawal
    
  • Heroin withdrawal
    
  • Any acute/subacute ingestion; consider:
    
    • Acetaminophen
      
    • Salicylic acid
      
    • Digoxin
      
• Psychiatric:
  
  • Self induced
    
  • Bulimia
    
  • Anorexia
    
  • Anxiety
    

Munchausen by proxy

TREATMENT

• Address airway/breathing/circulation
  
• Initiate IV, oxygen (if indicated), place on cardiac monitor
  
• Start IV fluids if presenting with vomiting and/or abnormal vital signs
  

• Address airway/breathing/circulation
  
• Continue IV/O
  ₂
  (as indicated), cardiac monitor
  
• Address abnormal vital signs specifically hypotension and tachycardia:
  
  • Adults: 500 to 1000 mL bolus 0.9% NS
    
  • Pediatric: 20 mL/kg bolus 0.9% NS
    

• Supportive care in acute phase
  
• Abort emetic phase of nausea/vomiting with antiemetics
  
• IV 0.9 normal saline:
  
  • Add dextrose after initial boluses
    
• Correct electrolyte abnormalities
  
• Treat pain with analgesics
  
• Provide light sedation for very symptomatic patients
  
• Administer gastric acid suppressants:
  
  • H
    ₂
    receptor antagonist
    
  • Proton pump inhibitors
    
• Consider antimigraine triptans
  

• Ondansetron 4–8 mg IV/PO/ODT q4–8h prn
  
• Metoclopramide 10 mg IV/IM q2–3h prn 4–8 mg IV/PO/ODT q4–8h prn
  
• Prochlorperazine 5–10 mg IV/PO/IM (peds: 0.1 mg/kg/dose PO/IM/PR) q6–8h prn
  
• Promethazine 12.5/25 mg PO/IM/PR q4–6h (IV use common but not approved) (peds: 0.25–1 mg/kg PO/IM/PR q4–6h prn if >2 yr)
  

• Ketorolac 15–30 mg IV
  
• Lorazepam 0.5–1 mg IV/IM/PO
  
• Morphine 0.1 mg/kg IV
  
• Sumatriptan 4–6 mg SC-repeat in 1 hr prn
  

• Cimetidine (H
  ₂
  -blocker): 800 mg PO at bedtime nightly (peds: 20–40 mg/kg/24 h)
  
• Famotidine 20 mg IV q12h
  
• Pantoprazole 40 mg IV q24h
  
• Ranitidine 50 mg IV/IM q8h
  

FOLLOW-UP