Pediatric Vomiting and Diarrhea
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þ Gastrocolic Reflex
 - Infants poop every time they feed.
 - At some point, they stop doing this. This is not constipation, this is a 
   cause for celebration.

þ Vomiting in neonates
 - All neonates have Grade IV reflux (spitting up)
 - Ask if projectile ("If I were sitting here, would it hit me?"
 - Bilious (yellow or green) is always an emergency in a neonate. Call surgeon, 
   get UGI. 
 - May be sign of ^ICP
 
þ Volvulus
 - Mostly in older people, but can occur in first month with a congenital 
   abnormality where there is a band. 
 - time is bowel call surgeon.
 - double-bubble on plain film
 - consider UGI to look for corkscrew appearance
 - consider ultrasound
 
þ Pyloric Stenosis
 - used to be firstborn of upperclass family.
 - hungry
 - may see peristaltic wave or olive
 - ultrasound
 - if spitting a lot, get ultrasound to rule out stenosis
  
þ Vomiting in infants
 - Intussception? Classic at 8-9 months
  + only 20% with colicky pain, vomiting, bloody stool
  + check plain film: look for crescent sign (end of intussception)
  + if plain film negative for FB (get lower neck) or intussception, get US or 
    BE.
 - Swallowed FB?
 - Fever?
 - Diarrhea? Good sign, probably GE but not any of the other scary things that 
   cause just vomiting.
 - Choking?
 - Level of activity?
 - TESTICULAR EXAM
 
þ Kids
 - Appy? Mostly diagnosed in kids < 5 after ruptured
 - Cough? Might be post-tussive from asthma
 - HA? Meningitis?
 - DKA? Check urine dip
 - Hx suggestive of ingestion (staying with grandma)
 - Trauma? (wrestling with older brother)
 - Nausea? If patient is running around fine, with occasional vomiting without 
   nausea, suspect ^ICP, get CT
 - TESTICULAR EXAM
 - If stomach started hurting before vomiting, makes bad stuff more likely 
 
þ Dehydration
 - can give glucose to fluids, not likely to develop hyperglycemia, helps clear 
   ketones; glucose containing fluids at 1.5x maintenance
 - if can't get IV
  + NG rehydration on a pump has only a 4.3% failure rate
  + clysis: INFUSE study 2 months to 10 years: worked quite well, used a bit of 
    hyaluronidase, quite safe, only 1 case of cellulitis, well-accepted by 
    parents. Scapula most common place.    
 
þ Zofran etc. for kids
 - (Phenergan: black box warning, even with tiny doses, sedates to the point of 
   respiratory depression and even a few deaths.) 
 - Works, safe, but doesn't help all that much.
 - 0.2 mg/kg
 - 8-15 kg: 2 mg
 - 15-30 kg: 4 mg
 - repeat x1 if vomit within 15' of taking medicine
 - Ondansetron (Zofran) given to children who are mildly to moderately
   dehydrated because of diarrhea and vomiting improves their ability to
   comply with oral rehydration and reduces the need for intravenous
   hydration. (LOE = 1b)
   [Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for
   gastroenteritis in a pediatric emergency department. N Engl J Med
   2006;354:1698-1705.]
   Exclusions: Those with a body weight of less than 8 kg (17 pounds), who
   were severely dehydrated using standardized symptoms (eg, clammy or cool
   skin, very dry mucosa, no tears, moderate tachycardia, no urine for at
   least 6 hours, limp, and lethargic), and those with significant
   comorbodities were excluded.
 - Sturm JJ et al, Ann Emerg Med 2009: no increase in missed diagnosis with 
   Zofran
 - Also shown in another survey: 
   Nava-Ocampo, A. A., J. M. Alarcon-Almanza, et al. (2004). "Undocumented drug 
   utilization and drug waste increase costs of pediatric anesthesia care." 
   Fundamental & clinical pharmacology 18(1): 107-112. The present study was 
   performed in order to identify the cost of drugs used without documenting 
   them in the patients' file and the wastage of drugs in a pediatric 
   anesthesiology ward. In a prospective, blinded, observational design, drug 
   utilization of 610 consecutive patients, undergoing an elective or emergency 
   surgical procedure was evaluated. The number of undocumented drugs per 100 
   requested units and the number of wasted drugs per 100 requested units were 
   computed and multiplied by its corresponding unitary cost. The median 
   undocumented cost was 92.4 US dollars (95% CI 17.2-216.6 dollars) per 100 
   requested units. Succinylcholine (40 mg/2 mL) was the main undocumented drug; 
   its use was not documented in approximately 50% cases in which this 
   neuromuscular blocking agent was requested. However, rocuronium and 
   nalbuphine had the highest unjustified cost, 770.6 dollars and 847.0 dollars 
   per 100 requested units, respectively. Ketorolac, diclofenac, metamizol, 
   furosemide, methylprednisolone, sodium bicarbonate, and cisatracurium were 
   requested and documented. The median cost of wasted drug was 141.8 dollars 
   (95% CI 55.8-448.2 dollars) per 100 requested drugs. More than 80% of 
   adrenaline, naloxone, flunitrazepam, ephedrine, and cisatracurium were 
   wasted. However, the highest cost of wasted drugs was for ondansetron, 
   cisatracurium, methylprednisolone, and rocuronium. The uncontrolled 
   availability and use of drugs may represent an important amount of resources 
   wasted without any awareness of the staff in a department of pediatric 
   anesthesia.