Rosen & Barkin's 5-Minute Emergency Medicine Consult (213 page)

• For mild to moderate dehydration, correct dehydration using oral rehydration therapy (ORT), 50 mL/kg and 100 mL/kg, respectively, over a 4-hr period:
  
  • Replace ongoing losses with 10 mL/kg of ORT for each stool.
    
  • Ideal ORT solution has a low osmolarity (210–250), glucose of about 2 g/dL, and sodium content of 50–60 mmol/L.
    
• For moderate to severe dehydration, correct dehydration using parenteral fluids combining maintenance and deficit requirements.
  
• If diarrhea is not associated with dehydration, use 10 mL/kg of ORT for each stool alone.
  
• Antibiotics only for defined acute enteritis: Routine use is not recommended; use only in either severe or invasive disease or patients who are immunocompromised or who have significant underlying GI conditions
  
  • Erythromycin for
    Campylobacter jejuni
    
  • TMP-SMX for:
    
    • Salmonella
      —complicated (infant <6 mo old, disseminated, bacteremia, immunocompromised host, enteric fever)
      
    • Shigella
      
    • Yersinia
      
    • E. coli
      —enteroinvasive
      
  • Metronidazole or vancomycin for:
    
    • C. difficile
      (severe and/or prolonged enteritis)
      
  • Neomycin for
    E. coli
    —enteroadherent
    
  • Furazolidone or metronidazole for
    G. lamblia
    
• Antidiarrheal agents
  not
  recommended
  
• Probiotics:
  Lactobacillus GG
  
  • Probiotics degrade and modify dietary antigens and balance the anti-inflammatory response to cytokines. They reduce the duration of diarrhea
    
• Post-ED diet:
  
  • While rehydrating, feed children with diarrhea age-appropriate diets.
    
  • Well-tolerated foods:
    
    • Rich in complex carbohydrates (rice, potatoes, bread)
      
    • Lean meats
      
    • Yogurt
      
    • Fruits
      
    • Vegetables
      
    • Full-strength milk and formula unless there is a strong suspicion of lactose intolerance
      
  • Avoid fatty foods and foods high in simple sugars.
    

• Ampicillin: 50–200 mg/kg/24h IV/PO q6h
  
• Erythromycin: 40 mg/kg/24h PO q6h; 10–20 mg/kg/24h IV q6h
  
• Metronidazole: 30 mg/kg/24h PO divided QID × 7 d
  
• Neomycin: 50–100 mg/kg/24h PO q6–8h
  
• TMP-SMX: 8–10 mg/kg/24h as TMP PO divided BID
  
• Vancomycin: 40–50 mg/kg/24h PO q6h
  
• Loperamide (not for use in children <6 yr old or in those with heme-positive stools): Age 6–8 yr, 2 mg PO div. BID; age 8–12 yr, 2 mg PO div. TID
  
• Cefixime: 8 mg/kg/d PO per day for 7–10 days
  
• Ceftriaxone: 50 mg/kg/d IV/IM for 7–10 days
  
• Lactobacillus GG
  and
  Saccharomyces boulardii
  : 5 billion doses/d
  
• Zinc: 10–20 mg/d for 10–14 days (children <5 yr)
  

• TMP-SMX for
  Salmonella
  and
  Shigella
  sp.
  
• Doxycycline for
  Vibrio cholerae
  
• Metronidazole for
  C. difficile
  

• Ceftriaxone and Cefotaxime for
  Salmonella
  and
  Shigella
  sp.
  
• Erythromycin for
  V. cholerae.
  
• Vancomycin for resistant
  C. difficile
  

FOLLOW-UP

• Surgical abdomen
  
• Inability to tolerate oral fluids
  
• 10% dehydration or greater
  
• Suspected complicated
  Salmonella
  enteritis
  
• Toxic-appearing child
  

• Improvement in the patient’s condition
  
• Caregivers of child can follow through with appropriate ORT and diet.
  
• Caregivers able to identify signs and symptoms of dehydration
  

• Immunocompromised host
  
• Conditions associated with complications such as seizures
  
• Underlying bowel disorders
  

Follow-up care depends on the length and severity of diarrhea, age of the child, and caregiver’s ability to comply with instructions:

• Uncomplicated diarrhea does not typically need follow-up.
  
• Neonates require strict follow-up care in a few days.
  

• History and PE assists in differentiating uncomplicated diarrhea from other, often more serious conditions in children.
  
• Vast majority of children with acute diarrhea do not need extensive lab tests, which are unlikely to affect the management.
  
• Treatment with antidiarrheals and antibiotics has very limited role in childhood diarrhea.
  
• Diagnoses like appendicitis, intussusception, UTI, and sepsis may need to be considered.
  

• Canavan A, Arant BS Jr. Diagnosis and management of dehydration in children.
  Am Fam Physician
  . 2009;80(7):692–696.
  
• Levy JA, Bachur RG, Monuteaux MC, et al. Intravenous dextrose for children with gastroenteritis and dehydration: A double-blind randomized controlled trial.
  Ann Emerg Med.
  2013;61:281–288.
  
• Spandorfer PR, Alessandrini EA, Joffe MD, et al. Oral versus intravenous rehydration of moderately dehydrated children: A randomized, controlled trial.
  Pediatrics
  . 2005;115:295–301.
  
• Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?
  JAMA
  . 2004;291(22):2746–2754.
  

See Also (Topic, Algorithm, Electronic Media Element)

Vomiting, Pediatric

CODES

• 008.8 Intestinal infection due to other organism, not elsewhere classified
  
• 008.61 Enteritis due to rotavirus
  
• 787.91 Diarrhea
  

BASICS

• Acute digitalis effects (elevated levels in children and intentional overdose):
  
  • Inhibits sodium-potassium ATPase pump in cell membranes
    
  • Allows more calcium ions to enter cell and cardiac cells to contract more strongly
    
  • Increases K
    ⁺
    extracellularly
    
  • Increases vagal tone
    
  • Slows atrioventricular (AV) node conduction (vagotonic)
    
  • Increases automaticity and conduction system refractory period
    
  • Bradydysrhythmias
    
• Chronic digitalis effects (therapeutic to toxic levels in elderly patients):
  
  • Inhibits sodium–potassium ATPase pump in cell membranes
    
  • Increases intracellular calcium
    
  • Increases vagal tone
    
  • Bradydysrhythmias
    
  • Increases automaticity
    
  • Usually hypokalemic secondary to diuretic use
    
  • Tachydysrhythmias
    

• Digoxin/digitoxin pharmaceuticals
  
• Plants and animals containing cardiac glycosides:
  
  • Foxglove
    
  • Oleander (white and yellow)
    
  • Lily of the valley
    
  • Dogbane
    
  • Red squill
    
  • Cane toad, Colorado River toad
    

DIAGNOSIS

• Toxicity onset: 2 hr after PO ingestion and 15 min following IV
  
• Toxicity:
  
  • Occurs with normal digoxin levels (chronic)
    
  • May be absent with elevated digoxin levels (acute)
    
• Cardiovascular:
  
  • Dysrhythmias:
    
    • Paroxysmal atrial tachycardia (PAT) with AV block
      
    • Bidirectional ventricular tachycardia (VT) is pathognomonic
      
    • Premature ventricular contractions (PVCs) most common
      
    • Nonparoxysmal accelerated junctional tachycardia
      
    • VT
      
    • Ventricular fibrillation
      
    • Atrial fibrillation/flutter
      
    • Bigeminy
      
    • Bradycardia
      
    • Nonparoxysmal atrial tachycardia
      
    • AV blocks
      
    • Sinus arrhythmia
      
    • Premature atrial contraction
      
  • CHF exacerbation
    
  • Hypotension
    
  • Shock
    
  • Cardiovascular collapse
    
  • Syncope
    
• CNS:
  
  • Mental status changes:
    
    • Agitation
      
    • Lethargy
      
    • Psychosis
      
• Visual perception:
  
  • Blurred
    
  • Scotoma
    
  • Green to yellow halo
    
  • Photophobia
    
  • Color perception changes
    
• GI:
  
  • Anorexia, nausea, vomiting, abdominal pain