I find that one of the most difficult patients for me is the infant with (non-bilious) vomiting but no diarrhea. The differential is just too extensive. I mean you can't do an upper GI and ultrasound on everybody and abdominal plain films aren't sensitive. So what do you do? If they are very sick appearing then I would go towards a sepsis work-up, if it's bilious then that's pretty clear cut, if it's projectile then it's fairly straightforward. But most of these kids are very well appearing, the TM's are clear and they do not display signs of severe dehydration. But I feel things can still be missed after the whole Zofran then oral challenege protocol. Does anyone have any particular approach to these cases?
These vomiting kids w/o diarrhea. Frustrating, what to do?
- Thread starter prolene60
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Solution:
Have kids. Have a couple. You know what kids do?
They barf. They get fevers. They cough, and they have boogers. Un-sick ones. Constantly. Have a couple and you'll immediate be an assay for sick-kid/not-sick-kid. No other tests needed, just "Parent Eye." An attending told me this in residency and I thought it was the stupidest thing I'd ever heard.
But he was right.
You'll also learn how murderous it is to have a kid who's "not sick" torturing you all night by screaming and coughing and vomiting all over your carpet all night while not being "sick." You'll realize, hauling off to the circus environment of the ED at 4 am is only half as painful as staying home with a sick kid. You'll never look at those 3am moms with the same scorn again.
I know that doesn't help you right now, but here's a shortcut just as good, probably better. You wanna know how sick a kid is? Just ask...That's right. Jut ask the mom. ("Yeah, yeah, I've heard that before. Doesn't work, not as good as a decade of schooling). Ask. She'll tell you. Put all your Peds EM, PICU rotation stuff aside for a minute and ask. Just sit there. Look at the kid for a little while. Look at the mom. Try to absorb how worried she is. And ask, "I know I'm the doctor and you brought your son/daughter here to be checked out by me, but if you had to be the one to decide, 'How sick would you say Bobby is? How worried are you?'"
90% of the time you'll get your answer. Then you put that information through you Peds EM filter machine and come up with a plan. It works. Never blow off mom-stinct (mothers intuition) especially if an experienced mom. Trust me. I'm not a mom, but I live with one. They know.
Have kids. Have a couple. You know what kids do?
They barf. They get fevers. They cough, and they have boogers. Un-sick ones. Constantly. Have a couple and you'll immediate be an assay for sick-kid/not-sick-kid. No other tests needed, just "Parent Eye." An attending told me this in residency and I thought it was the stupidest thing I'd ever heard.
But he was right.
You'll also learn how murderous it is to have a kid who's "not sick" torturing you all night by screaming and coughing and vomiting all over your carpet all night while not being "sick." You'll realize, hauling off to the circus environment of the ED at 4 am is only half as painful as staying home with a sick kid. You'll never look at those 3am moms with the same scorn again.
I know that doesn't help you right now, but here's a shortcut just as good, probably better. You wanna know how sick a kid is? Just ask...That's right. Jut ask the mom. ("Yeah, yeah, I've heard that before. Doesn't work, not as good as a decade of schooling). Ask. She'll tell you. Put all your Peds EM, PICU rotation stuff aside for a minute and ask. Just sit there. Look at the kid for a little while. Look at the mom. Try to absorb how worried she is. And ask, "I know I'm the doctor and you brought your son/daughter here to be checked out by me, but if you had to be the one to decide, 'How sick would you say Bobby is? How worried are you?'"
90% of the time you'll get your answer. Then you put that information through you Peds EM filter machine and come up with a plan. It works. Never blow off mom-stinct (mothers intuition) especially if an experienced mom. Trust me. I'm not a mom, but I live with one. They know.
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If the child is not sick, the first thing I do is I try oral Zofran, wait 15 minutes, and then attempt a PO challenge. If the child keeps everything down, I discharge home.
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You vomit after failing PO challenge, then its IV, labs and any imaging i think is needed. Then repeat PO challenge after IV zofran and IV fluids.. fail that.. admission.
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I'm not in EM but I am a parent and my first thought on this was the same as what Birdstrike posted.
Kids barf. The end. Some of them do it because they're sick as s*** and if they don't get diagnosed and treated, they'll die. But the vast majority are just barfing...because that's what kids do.
Now...how you sort those two groups...that's the real issue. And again, Birdstrike has it figured out. Ask the parent who brought them in (some of us dads do in fact know our parenting head from our ass) if this is normal or not. If they say no, or can't answer the question (because they don't in fact know their parenting head from their ass), then you need to start worrying about them.
My kid can boot and rally like a Phi Delt during pledge week. We've only taken her to the doctor (not the ED) once in 7 years for vomiting, and that was when it was 24h straight, 2-3x/hr and she could barely lift her head off the bed. That was not normal. She did fine with some IVF and IV zofran in the day treatment unit and went home and ate her weight in mac and cheese a few hours later.
Kids barf. The end. Some of them do it because they're sick as s*** and if they don't get diagnosed and treated, they'll die. But the vast majority are just barfing...because that's what kids do.
Now...how you sort those two groups...that's the real issue. And again, Birdstrike has it figured out. Ask the parent who brought them in (some of us dads do in fact know our parenting head from our ass) if this is normal or not. If they say no, or can't answer the question (because they don't in fact know their parenting head from their ass), then you need to start worrying about them.
My kid can boot and rally like a Phi Delt during pledge week. We've only taken her to the doctor (not the ED) once in 7 years for vomiting, and that was when it was 24h straight, 2-3x/hr and she could barely lift her head off the bed. That was not normal. She did fine with some IVF and IV zofran in the day treatment unit and went home and ate her weight in mac and cheese a few hours later.
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I don't have kids (and never will have) so I can't use the "parent eye" approach. I have seen enough kids in the ED to recognize sick versus not sick. About 90% are in the "not sick" category. They get Zofran challenge and home. If you are in the "sick" or "fail Zofran" category then you get IV and labs. If they are still "sick" or in the "double fail" category then they get admitted. The whole thing should take less than 2 hours to get a dispo.
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if you do Zofran, PO challenge. Make sure there is a delay in when the PO challenge occurs.
Some nurses will give them a juice at the same time as the medicine.
This leads to a sure fire vomit.
I always write an order for PO challenge 30 minutes after Zofran.
Some nurses will give them a juice at the same time as the medicine.
This leads to a sure fire vomit.
I always write an order for PO challenge 30 minutes after Zofran.
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I second bird's approach....plus additional caveat....
I tell the mom straight out...it doesn't matter what I tell you or what I do, if at the end of this your kid doesn't pass "the mom test" and you're uncomfortable taking him home, then we come up with another plan.
and i ask myself....what would I do if this were my kid? would I line and lab him? would I scan him? and then I tell the mom I promise you that I will do for your kid whatever I would do to mine. Seems to get the job done everytime
I tell the mom straight out...it doesn't matter what I tell you or what I do, if at the end of this your kid doesn't pass "the mom test" and you're uncomfortable taking him home, then we come up with another plan.
and i ask myself....what would I do if this were my kid? would I line and lab him? would I scan him? and then I tell the mom I promise you that I will do for your kid whatever I would do to mine. Seems to get the job done everytime
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I 100% agree with Birdstrike! Kids are just little vomit sacks waiting to be set off, and a lot of people just want reassurance.
How old are you talking about though? I think that this is one of those presentations where the kid's age makes a big difference in how I approach it. I don't use zofran if there only a few months old. Fatty toddlers have a bit more reserve. The important questions for me are 'how does he act in between vomiting,' 'is he peeing/making wet diapers,' and on physical exam, how tachycardic are they in mom's arms, and what's the cap refill/pedal pulses and mental status.
If mom isn't comfortable and really thinks something is going on, I'd get a KUB, BMP, IV bolus, PO challenge or admit for obs. Again, it depends on the age.
How old are you talking about though? I think that this is one of those presentations where the kid's age makes a big difference in how I approach it. I don't use zofran if there only a few months old. Fatty toddlers have a bit more reserve. The important questions for me are 'how does he act in between vomiting,' 'is he peeing/making wet diapers,' and on physical exam, how tachycardic are they in mom's arms, and what's the cap refill/pedal pulses and mental status.
If mom isn't comfortable and really thinks something is going on, I'd get a KUB, BMP, IV bolus, PO challenge or admit for obs. Again, it depends on the age.
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As was mentioned above, if the child fails PO Zofran, then I move to IV Zofran and fluids. I will also check a metabolic panel to look for electrolyte imbalance – although I will admit that it and the CBC are typically normal. If the child seems to be in pain, then I might get a KUB and/or an ultrasound. If there is a fever, I will at least check a urinalysis. Everything comes in steps, but the final disposition – even for admission – can usually be done in less than two hours.
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The other thing to keep in mind is figuring out what the parent is worried about. I trained at a local children's mecca, and saw all sorts of weird chronic stuff. And more times than I'd like to admit, when I asked why mom was worried, (once I could get their confidence), it was because mom's first child died of X, and younger sib is now having similar symptoms of when little Johnny was diagnosed with leukemia/meningitis/insert horrible condition here. Address the concern, save the encounter - and the inevitable second visit.
I also don't have children (and am not planning on it), but asking mom gets you the answer most of the time as silly as it sounds.
I also don't have children (and am not planning on it), but asking mom gets you the answer most of the time as silly as it sounds.
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I'm surprised at the number of people getting labs on these kids. If vitals are normal, kid is peeing, normal abdominal exam, they usually get 12 hour recheck and home. 90% never show up at 12 hours and do just fine. This is a really common complaint at my place (we see a lot of Peds). I agree with the poster above... Kids vomit. It's what they do. If they're otherwise acting normally, WITH NORMAL VS, I don't get labs. I don't really care if they vomit in the ED either. If they're peeing, they're keeping enough down to go home.
