A nurse in an emergency department is caring for a client who reports vomiting and diarrhea

• Related Pathway
• Gastroenteritis/Dehydration, Inpatient

• Related Video
• How to Treat Dehydration from Stomach Bugs in Children

Triage
ED Nursing Pathway Standing Orders: Gastroenteritis/Dehydration

ORT

• Preferred method very successful in treating healthy children with GE/dehydration.
  • Children with no/mild dehydration can be discharged home after ORT education.
  • Provide 1-2 mL/kg, max 30 mL every
    5 minutes.
  • Differs from PO challenge which is offering ad lib fluids.
• ORT Instructions for the Medical Team
• Instructions for the Family
• ORT Record Sheet
• How to Treat Dehydration from Stomach Bugs in Children

DEFINITION OF ORT FAILURE

• > 1 emesis after Ondansetron
• Refusal to take from syringe/cup for
  > 30 minutes

HYPOGLYCEMIA

• Defined as glucose < 70 in all ages
• Give 2mL/kg of D10W
• Start glucose containing maintenance fluids immediately
• Recheck glucose in 30 minutes

• Frontline Ordering Clinician (FLOC) Team Rapid Assessment
• Mental status, vital signs
• History & physical exam
• Dehydration Assessment Tools
• Consider POC glucose, BOHB if suspected moderate/severe dehydration

Significant Hypoglycemia
straight to IV Rehydration

Minimal/Mild Dehydration

• Consider Ondansetron
• Nursing discharge teaching
• Give instruction sheet
  to family
• Provide oral syringes, medicine cup
• ORT video

Moderate Dehydration

Beta-
hydroxybutyrate,
BOHB < 3

Beta-
hydroxybutyrate,
BOHB > 3

• Consider Ondansetron
• RN Plays ORT video
  Provides ORT Record Sheet, syringe
• Initiate ORT 20 minutes after Ondansetron
• Assess PO intake 1 hour after Ondansetron

ORT Success

ORT Failure

IV Rehydration

• Basic Metabolic Profile
• Treat hypoglycemia with 2 mL/kg of D10W
  • Recheck glucose every 30 mins until normal
• NS 20 mL/kg IV
• Consider D5NS 20 mL/kg over 60 min to assist in ketone clearance
• Start glucose containing maintenance fluids if initially hypoglycemic
• ORT vs admission

Reassess
Vital Signs, Clinical Appearance, Ongoing Losses

• Dehydration mild of resolved
• ORT Teaching
• Discharge to continue ORT at home
• Have family review
  Oral Rehydration Video

• Considerations for admission:
• ORT failure
• Hypoglycemia and/or significant electrolyte abnormalities
• Continue need for IV Rehydration
• Medical condition requiring inpatient care

Severe Dehydration

Posted: August 2007
Revised: June 2022
Authors: M. Joffe, MD; M. Blackstone, MD; J. Lavelle, MD; D. Hoser-Glatts, RN

Red Flag Exclusion Criteria

• Child at risk of significant harm

• Suspected non-accidental injury

• Unplanned repeat ED presentation

• Child ≤ 2 years

• Adult ≥ 65 years

• Hydration status in adults assessed as moderate (≥ 5%) or severe (≥ 10%) dehydration

• Children assessed as having mild (3%) dehydration who have failed Trial of Oral Fluid

• Blood in vomit or stool

• Green in vomit

• Vomiting without diarrhoea

• Abdominal tenderness or distension

• Increasing / worsening abdominal pain

• Diabetes

• Immunocompromised

• Altered level of consciousness / agitation

• History of workplace injury

• Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Observations Charts

Additional Observations

1. Assess hydration status including

• Urine output

• Mucous membranes

• Thirst

• Skin turgor

• Capillary refill

1. Blood glucose level

2. Obtain MSU and complete urinalysis if positive leucocytes or nitrites send for MCS as per local protocols

3. Consider obtaining a stool sample & send for MCS & OCS as per local protocols

4. Commence fluid balance chart

Additional History

Social / infectious contacts history

Management Principles

1. Gastroenteritis clinical practice guidelines (paediatric or adult) should be used in conjunction with this NMG

2. Commence trial of fluids using a recommended oral rehydration solution (ORS) e.g. Gastrolyte® or Hydralyte™ as per Standing Orders

3. Consider administration of an antiemetic as per Standing Orders

Ondansetron 4mg tablet / wafer

OR

For adult patients ≥ 20 years only, administer metoclopramide with the following considerations:

• Tablet: if patient has not vomited in the past hour and is tolerating small frequent amounts of oral fluid

• Parenteral: if patient is currently vomiting and unable to tolerate small amounts of oral fluid

1. Document assessment findings, interventions, investigations and outcomes

References / Further Resources

1. Patient Factsheet - Diarrhoea and Vomiting

2. NSW Health (2014) Infants and children: Management of Acute Gastroenteritis (4th Ed.) NSW Kids and Families, Sydney

3. NSW Ministry of Health (2012) Gastroenteritis in an institution: Control Guideline for Public Health Units, NSW Ministry of Health, Sydney

4. Furyk, J.S,. Meek, R.A., Egerton-Warburton D. (2015) Medicines in the treatment of emergency department nausea and vomiting. The Cochrane Collaboration, London.