ChildandAdolescentHealthService PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Diarrhoea+/vomiting
Backgroundand practicenotes Scope Assessmentand initialintervention Workingdiagnosis andinvestigations Management Patienteducationand dischargeinformation Medications Managementflowchart Associateddocuments Clinicalaudit Definitionofterms

NursePractitioner ClinicalProtocol EmergencyDepartment

Clinicalprotocolauthorship andapproval References Acknowledgement Disclaimer

Backgroundandpracticenotes
MostchildrenpresentingtotheEmergencyDepartment(ED)withgastroenteritisandnocomorbiditieswillnotrequireany interventionotherthanparentalreassuranceandeducation.Mildcasesofgastroenteritisareusuallyselflimitingandmay cause mild dehydration, which can be treated or prevented by continued feeding and drinking appropriate amounts of fluids. Breastfeeding of affected babies should continue even during oral rehydration1,8,11 as it is thought that this may reduce stool output and shorten duration of diarrhoea.1 Parameters of severity of dehydration vary widely in the literature.6,8,9Forthepurposeofthisclinicalprotocol,thefollowingdiagnosticcriteriaofmildandmoderatedehydrationwill beused.8 Nodehydration Mildtomoderatedehydration (<3%weightloss) Nosigns (38%weightloss) Drymucousmembranes Reducedurineoutput Sunkeneyes Minimalornotears Diminishedskinturgor(pinchtest12secs)

Useoforalrehydrationsolutionistherecommendedfirstlinetherapyfortreatingmildtomoderatedehydrationinchildren with gastroenteritis.2,11 Enteral (oral or nasogastric) rehydration is a much safer means of rehydration compared with intravenous rehydration because it avoids the risks associated with rapid fluid and electrolyte shifts.8 Diarrhoea and vomitingsettlesmorequicklyandappetitereturnsearlierwithuseoforalrehydrationtherapy.8Oralrehydrationtherapy hasbeenshowntobeaseffectiveasintravenoustherapyintreatingmildtomoderatedehydrationinacutegastroenteritis.2 The use of antiemetics for children with gastroenteritis who are vomiting are not routinely indicated, however this issue remains controversial.3,4 Ondansetron has been shown to reduce the frequency of vomiting, improve the success and compliancewithoralrehydrationtherapy2,4,5andreducetheneedforintravenoustherapyinsomecases.2Therehavebeen reports of increased frequency of diarrhoea after its usage, however this is usually transient and well tolerated.2 Some workplacepracticesupportsOndansetronuseinchildrenwithgastroenteritisbutisreservedasasingleoraldoseforthose 9 1,8 withpersistentvomiting. Antidiarrhoealsshouldnotbeusedforacutediarrhoeainchildren. Theydonotreducefluidand 1 electrolyteloss,maydelayexpulsionoforganismsandmaycauseadverseeffects. Featuressuggestiveofadiagnosisotherthangastroenteritisinclude:abdominalpainwithsignificanttenderness,distension, mass or guarding, hepatomegaly, vomiting of blood or bile, bloody diarrhoea, red current jelly stools, pallor, jaundice, 8 systemicallyunwelloutofproportiontothedegreeofdehydration,shockandaneonatewithdiarrhoea. Vomitingalone 8 shouldnotbediagnosedasgastroenteritis. Thefollowingconditionsshouldbeexcludedastheymayhavesimilarfeatures: appendicitis, antibiotic associated diarrhoea, meningitis, haemolytic uraemic syndrome, urinary tract infection and other gastrointestinalsurgicalconditionssuchasintussusceptionandpartialbowelobstruction.
NursePractitionerClinicalProtocol DateIssued:October2011 Diarrhoea+/vomiting DateRevised:January2012 EmergencyDepartment ReviewDate:October2013 PrincessMargaretHospital Authorisedby:PMHEmergencyDepartment Perth,WesternAustralia ReviewTeam:PMHEmergencyDepartment Thisdocumentshouldbereadinconjunctionwithdisclaimerinthisclinicalprotocol

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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Scope NursePractitioner Childrenolderthan12monthsofagewithacute onsetofdiarrhoea+/nausea,vomiting,fever, abdominalpain

Outcomes Identifypatientssuitablefor EmergencyNurse Practitioner(ENP)clinical protocol Identifypatientsnotsuitable Infantslessthan12monthsofage forENPclinicalprotocoland Underlyingsignificantmedicalpathology refertoSeniorMedical eg:previousgastrointestinalsurgery,metabolic Practitioner(SMP) disorders,inflammatoryboweldisease Evidenceoffailuretothrive Childrenpresentingwithhistoryofvomitingbileor However,patientcanbe managedbyENPin blood,redcurrentjellystoolsormalenaorpale, consultationwithSMPif floppyepisodes appropriate Unwelllookingorsepticappearance Evidenceofshockorseveredehydration Cardiovascularinstability Severeabdominalpain Vomitingwithoutdiarrhoea Historyofdiarrhoeaforgreaterthan10days+/ vomitingforgreaterthan7days Outcomes Abnormalprimarysurvey identifiedexitENPclinical protocolandrefertoSMP

MedicalPractitioner+/ NursePractitioner

Assessmentandinitialintervention Primarysurvey Airway Breathing Circulation Disability Exposure Signsandsymptomsofcurrentillness:frequency andnatureofstoolsandvomits Oralintake,volumeandfluidtype Urineoutput,numberofwetnappies Abdominalpain Urinarysymptoms Levelofactivity Riskfactors;recenttravel,knowninfectious contacts,antibioticrelateddiarrhoea Pastmedicalhistory Allergies,immunisationstatus,medications

History

Identifypatientsnotsuitable forENPclinicalprotocoland refertoSMP

Examination

Abnormalexamination Vitalsigns outsidedefinedscoperefer Urinalysisifappropriate(eg:unsettled,poor toSMP feeding,vomitingwithoutdiarrhoea) Generalexamination Abdominalexamination Hydrationstatus;mentalstatus,capillaryrefill time,skinturgor,mucousmembranes,fontanelle, presenceoftears,+/eyessunken Weight(bareif<12monthsofage);comparison withpreillnessandposttreatmentifavailable (goldstandard7)
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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Assessmentandinitialintervention(continued) Painassessment Analgesia Useappropriatepainassessmenttool

Outcomes Determineneedforand typeofanalgesia

Administrationofanalgesiaasrequired Reliefofpain (refertoPainManagementandProcedural SedationENPClinicalProtocol) Notroutinelyindicated

Workingdiagnosisandinvestigations Meetsinclusioncriteria.Historyandexaminationfindingssupportworkingdiagnosisofgastroenteritis. Imaging Pathology Notroutinelyindicated Stoolculturerequiredforthefollowing:8 Bloodinstool Suspectedepidemicforfoodpoisoning Severeorprolongeddiarrhoea(>2weeks) Recentoverseastravel Childresidinginaninstitution Campylobacter,Cryptosporidium,Shigella, Salmonellaandrotavirusarenotifiablediseases12 Bloodtestsarenotroutinelyindicatedbutmaybe clinicallyusefulinthefollowingcircumstances:8 Bloodydiarrhoeaconsiderfullbloodcount (FBC),urea,creatinine Dehydrationwithdoughyfeeltoskinthat mightindicatehypernatraemia Dehydratedchildrenwherehistoryandclinical examinationareinconsistentwithstraight forwarddiarrhoealepisode Anychildreceivingintravenous(IV)rehydration shouldhavescreeningtestspriortotherapy includingFBC,ureaandelectrolytes Appropriatefollowupof stoolcultureorbloodtestsif specimentakenduring presentation Anychildrequiringablood testmustbediscussedwith SMPprior

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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Management Noormilddehydration

ENPwithviewtodischargehome Advisesmallfrequentfluidsandfeeds Continuebreastfeedingifapplicable ProvidefactsheetGastroenteritisHealthFacts Discussrepresentationcriteria Commenceoralfluidtrialusingappropriate departmentaldocumentation Oralfluidtrialshouldconsistoforalrehydration solutionorwater1ml/kgevery5minsandreview in1hour Provideparentalsupportandreassuranceduring thistime ConsideruseofsingleoraldoseofOndansetron forchildrenwithpersistentvomitinganddifficulty toleratingoral/nasogastric(NG)fluidrehydration Improvementinhydrationstatus Preparefordischarge Advisesmallfrequentfluidsandfeeds Continuebreastfeedingifapplicable ProvidefactsheetGastroenteritisHealthFacts Discussrepresentationcriteria Noorpartialimprovement DiscusswithandpatientreviewbySMP ConsiderNGrehydrationat50ml/kgover4hours IVfluidsmaybeconsideredifolderchildandhas difficultytoleratingNGtube Ifrequired0.9%SodiumChlorideand5%Glucose istheIVrehydrationfluidofchoiceinchildren (unlesshypernatraemicorhypovolaemicshock,in whichcaseSodiumChloride0.9%ispreferred) Refertomedicationsectionofthisprotocolfor calculationofIVfluidrequirements AdmittoShortStayUnit Regularreassessmentofhydrationstatusduring thistime,weighpatientpostrehydrationand compareweightwithprehydrationweight Ifconditionimproves,preparefordischargein consultationwithSMP Advisesmallfrequentfluidsandfeeds Continuebreastfeedingifapplicable ProvidefactsheetGastroenteritisHealthFacts Discussrepresentationcriteria Deteriorationincondition RefertoSMP

Outcomes Patientidentifiedassuitable forENPclinicalprotocoland dischargedhome Patientidentifiedassuitable forENPclinicalprotocoland dischargedhome ConsultationwithSMPifno orminimalimprovementor ifconditiondeteriorates

Antiemeticsandantidiarrhoealsarenotroutinelyindicatedforchildrenwithacutediarrhoea+/vomiting.1,8,11

Moderatedehydration

Severedehydration

ExitENPclinicalprotocol andrefertoSMP
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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Management(continued) Recommendationsfor admission Thosechildrenwhoseparentsarenotableto managethechildsconditionathome Childrenathigherriskofbecomingdehydrated maybeobservedforatleast4hourstoensure adequatemaintenanceofhydrationeg:youngage, highfrequencyofwaterystoolsandvomits, childrenwithdisabilityorfeedingissues Childrenwithseveredehydration NoorpartialimprovementwithEDregimen Referralasappropriateto: Interpreter Alliedhealth AboriginalLiaisonOfficer Toleratingoralfluids Improvementinhydration(isnomorethanmildly dehydrated) Nosignsofsepsisorlikelyalternatediagnosis Considertimeofday,distancefrommedicalcare, parentconfidenceandunderstanding Verbalandwritteninstructionsregardingfluid regimen,breastfeeding,diet,medicationuseand infectioncontrolmeasures Identifylikelyprogressionoftheillness,expected outcome,representationcriteriaandreferrals VerbalinstructionsgivenbyENP Simpleanalgesiashorttermifrequired Notroutinelyrequiredunlessspecificconcerns AdviseGPfollowupwithin24hoursifconcerned orotherriskfactorseg:youngerthan12months, significantlosses(waterystools+/vomits) Seekfurthermedicaladviceifnotimproving Verbalandwritteninstructionsasappropriate Nottoleratingoralfluids Significantincreaseinlosses Significantlyreducedurineoutput,increased lethargy,generallymoreunwell Parentalconcern ParenteducationGastroenteritisHealthFacts GPletterifapplicable Medicalcertificate/certificateofattendance Patientmedicalrecord Appropriatefluidorderdocumentation Adequatehydrationstatusachievedpriorto dischargefromED Hydrationstatusmaintainedfollowingdischarge Gradualresolutionofsymptomsandreturntopre illnessbowelhabitswithin710days

Outcomes Appropriatepatient admission

Acutereferral

Patient/parentunderstands referralprocess

Patienteducationanddischargeinformation Dischargecriteria

Outcomes Patientsuitablefor discharge

Treatmentinstructions

Patient/parentunderstands instructionsgiven

Medicationinstructions Followup/referral

Patient/parentunderstands instructionsgiven Patient/parentunderstands followuparrangement

Representationcriteria

Patient/parentunderstands criteriaforrepresentation andisdischargedhome

Documentation

Appropriatedocumentation completed

Expectedoutcome

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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Medications

Oralrehydration solution
Unscheduled

Preparation

Powderfororalliquidinsachets Oralliquid Oralornasogastricuseonly Oralfluidtrial:1ml/kgevery5minsfor1hour8 NGrapidrehydration:50ml/kgover4hours8 Providesfluid,electrolyteandglucosereplacement Welltolerated Moderatedehydrationcorrectionoffluidandelectrolyteloss associatedwithdiarrhoea+/vomiting Childrenwithhistoryofdiabetes,hypertension,renaldisease, phenylketonuria Knownhypersensitivitytoanyingredientinoralrehydration salts Nonereported Replacementsolutionsmaybebettertoleratediffrozenand presentedasaniceblock Nonereported Followadministrationdirectionsprovidedandrefertoproduct information Donotreconstitutewithdiluentsotherthanwater ForfullprescribinginformationrefertoAMHonline

Route/administration Dose Pharmacology Pharmacodynamics Indication Contraindications forENPuse

Interactions Paediatric considerations Adverseeffects Patienteducation

Intravenousfluids

Usefullinks

0.9%SodiumChloride with5%Glucose
Unscheduled

Route/administration Dose

Intravenous CalculationofIVfluidrequirements8 100ml/kgper24hoursforfirst10kgofbodyweight Add50ml/kgper24hoursfornext10kgofbodyweight Add20ml/kgper24hoursforremainingkgofbodyweight 8 Estimationofdeficitvolume Thisisbasedontheestimatedpercentageofdehydration %dehydrationxbodyweight(kg)x10 Administerdeficitvolumeover24hoursseenotebelow Note:deficitvolumeistobeaddedtomaintenancerequirement andongoinglossesover24hours;givehalfofthistotalvolumein thefirst8hoursthenrestoverremaining16hours IVrehydrationforchildrenwithmoderatedehydration correctionoffluidandelectrolytelossassociatedwith diarrhoea+/vomiting Childrenwithhypernatraemiaorhypovolaemicshock Childrenwithdiabetes

Indication

Contraindications forENPuse

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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Medications(continued)

Ondansetron
Poisonschedule4

Preparation Route/administration Dose Pharmacology

Wafer4mg,8mg Liquid,each5mlcontains4mgOndansetron Oral/sublingualuse 0.15mg/kg/dosetobegivenasasingledoseonly Centralandperipheral5HT3receptorblockade Precisemodeofactioninthecontrolofnauseaandvomitingis notknown Tablet,waferandoralliquidformulationsarebioequivalent Peakplasmaconcentrationsareachievedinapproximately1.5 hours Volumeofdistributionis1.8L/kg MetabolisedbyP450enzymes Plasmaproteinbindingis7070% Eliminationhalflifeis411hours Persistentnauseaand/orvomitingassociatedwithacute gastroenteritis Childrenwithhistoryofliverimpairment,cardiacdisease(can causeQTprolongation;usuallytransientandclinically insignificant),phenylketonuria(waferscontainaspartame) Childrenyoungerthan2yearsofage Hypersensitivitytootherselective5HT3receptorantagonists Phenytoin,carbamazepine,rifampicin,tramadol Rarebutmayincludeconstipation,headache,dizziness, transientriseinaminotransferases,ECGchanges(rare;is predominantlyassociatedwithintravenousinfusion) SeekadvicefromSMPforuseinchildrenyoungerthan2years ofage Calculateleanbodyweightwherechildisoverweight Ondansetronmaybeusefultoimprovesuccessandcompliance withoralrehydrationtherapy2,4,5 ForfullprescribinginformationrefertoAMHonline

Pharmacokinetics

Indication Contraindicationsfor ENPuse

Interactions Adverseeffects

Paediatric considerations Practicepoints Usefullinks

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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Managementflowchart

Gastroenteritismanagementflowchart
Diarrhoea+/nausea,vomiting,feverand abdominalpain

Yes

Childyoungerthan12months Underlyingrelevantmedicalpathology Systemicallyunwellorevidenceofshock Cardiovascularinstability Septicappearance Bloodinvomitand/orbilestainedvomit Malenaorredcurrentjellystools Hxdiarrhoea>10days+/vomitingfor>7days Vomitingwithoutdiarrhoea

Yes

DiscusswithSMP

No

Workingdiagnosisofgastroenteritis
Yes

No

RefertoSMP

Severedehydration

Yes

RefertoSMP

No Yes

Moderatedehydration

Commenceoralfluidtrial Observechildovernexthour

No

Condition improved

Partialorno improvement

Condition deteriorated

Yes

DiscusswithSMP ConsideradmissionandNG rehydration/ IVrehydration

RefertoSMP

Yes

Noormilddehydration
Yes

Meetsdischargecriteria

Yes

Providedischargeadvice Dischargehome

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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

Associateddocuments GastroenteritisPMHEmergencyDepartmentClinicalPracticeGuideline2010 PainManagementandProceduralSedationENPClinicalProtocol Clinicalaudit Unexpectedrepresentation Definitionofterms ENP ED GP AMH IV NG EmergencyNursePractitioner EmergencyDepartment GeneralPractitioner AustralianMedicinesHandbook Intravenous Nasogastric EmergencyDepartmentInformationSystemandENPclinicallog

Clinicalprotocolauthorshipandapproval Clinicalprotocolauthor JemmaBatesSmith ActingNursePractitioner EmergencyDepartment Datewritten Dateforreview

October2011 October2013

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EmergencyDepartment PrincessMargaretHospitalforChildren

NursePractitioner ClinicalProtocol Diarrhoea+/vomiting

References
1. AustralianMedicinesHandbook(online).2011Jul.[cited2011Sept6]. Availablefrom: http://www.amh.net.au.pklibresources.health.wa.gov.au/online/view.php?page=chapter12/treatdiarrhoea.t.html#d iarrhoea.t ChowC,LeungA,HonK.Acutegastroenteritis:fromguidelinestoreallife.ClinicalandExperimental Gastroenterology.2010;3:97112. FedorowiczZ,JagannathVA,CarterB.Antiemeticsforreducingvomitingrelatedtoacutegastroenteritisinchildren andadolescents.CochraneDatabaseofSystematicReviews.2011,Issue9.ArtNo:CD005506. DOI:10.1002/14651858.CD005506.pub5. FreedmanSB,SteinerMJ,ChanKJ.Oralondansetronadministrationinemergencydepartmentstochildrenwith gastroenteritis:Aneconomicanalysis.PLoSMedicine.2010Oct;7(10):e1000350. doi:10.1371/journal.pmed.1000350. FreedmanSB,AlderM,SeshadriR,PowellE.Oralondansetronforgastroenteritisinapediatricemergency department.TheNewEnglandJournalofMedicine.2006Apr;354(16):16981705. HartlingL,BellemareS,WiebeN,RussellKF,KlassenTP,CraigWR.Oralversusintravenousrehydrationfortreating dehydrationduetogastroenteritisinchildren(Review).CochraneDatabaseofSystematicReviews.2006,Issue3.Art No:CD004390.DOI:10.1002/14651858.CD004390.pub2. MoyerVA,ElliottEJ.Evidencebasedpediatricsandchildhealth[internet].London:BMJPublishingGroup;2004. Chapter37,AcuteGastroenteritis;p37589.[cited2011Sept12].Availablefrom: http://books.google.com.au/books?id=V0axOhNjq_QC&pg=PA381&lpg=PA381&dq=gold+standard+weighing+childre n+with+dehydration&source=bl&ots=GtOVyNiRjv&sig=A CuDWWnPe3ZRD3zOWtSlNvgsB0&hl=en#v=onepage&q&f=false PrincessMargaretHospitalforChildren,Perth,WesternAustralia.2010.EmergencyDepartmentClinicalPractice Guideline,Gastroenteritis. TheRoyalChildrensHospital,Melbourne,Australia.2009.ClinicalPracticeGuidelines,Gastroenteritis. TheRoyalChildrensHospital,Melbourne,Australia.2004.NursePractitionerClinicalPracticeGuideline,Diarrhoea +/vomiting. TherapeuticGuidelinesonline(eTG).Infectiousdiarrhoea:fluidandelectrolytetherapy(rehydration).2011Feb. [Cited22Aug2011].Availablefrom:http://online.tg.org.au.pklibresources.health.wa.gov.au/ip/ WesternAustralia,DepartmentofHealth.Notifiablediseases.[cited2011Sept12].Availablefrom: http://www.public.health.wa.gov.au/3/284/2/notifiable_communicable_diseases.pm

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Acknowledgement
PrincessMargaretHospitalwishestoacknowledgeTheRoyalChildrensHospitalinMelbourne,JoondalupHealthCampus andtheDepartmentofHealth,WesternAustraliafortheirvaluedadviceandsupportwithregardstothecreationofthis clinicalprotocol.

Disclaimer/Statementofintent
ThisclinicalprotocolisintendedforusebyEmergencyNursePractitioners(ENPs)workingintheEmergencyDepartmentat PrincessMargaretHospitalforChildreninthemanagementofchildrenpresentingwithsignsandsymptomssuggestiveof gastroenteritis. Standardsofcarearedeterminedonthebasisofclinicaldataavailableandaresubjecttochangeasscientificknowledge and technology advance and patterns of care evolve. The clinical protocols detail diagnostic criteria and appropriate managementoptions.Departmentalclinicalpracticeguidelinesareavailabletoguidemedicalclinicaldecisionmaking.They formthefoundationfortheENPclinicalprotocolsandensurethatthepracticeoftheENPisconsistent,safeandthatthe boundaries of ENP practice are well defined. It should be noted that clinical protocols provide a framework but do not attempt to take the place of sound clinical judgement. Nurse Practitioners may be responsible for clinical decisions not adequately defined by clinical protocols and under these circumstances collaboration with a Senior Medical Practitioner (SMP)willensurethatdecisionsareappropriate.ASMPwillbetheEDConsultantoraSeniorRegistrardelegatedbytheED Consultant.
NursePractitionerClinicalProtocol DateIssued:October2011 Diarrhoea+/vomiting DateRevised:January2012 EmergencyDepartment ReviewDate:October2013 PrincessMargaretHospital Authorisedby:PMHEmergencyDepartment Perth,WesternAustralia ReviewTeam:PMHEmergencyDepartment Thisdocumentshouldbereadinconjunctionwithdisclaimerinthisclinicalprotocol

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