Peds 15 Flashcards
What is rehydration management plan for a moderately dehydrated 4 year old patient?
Begin oral rehydration (50-100mL/kg given over 2-4 hours) with a commercially prepared solution while monitoring the patient in the pediatric clinic
How do you correct for ongoing losses via diarrhea or emesis?
10 ml/kg of oral rehydration solution administered for each watery stool
2 ml/kg for each episode of emesis
You determine an 8 month old infant with pyloric stenosis is severely dehydrated. What is your rehydration (and overall) plan?
- IV boluses NS 20mL/kg until clinical improvement
- Consult pediatric surgery
- Maintenance IV fluids (D5NS + 20KCl) after surgery
Ben is an 8-week-old formula-fed baby boy with a one-week history of repeated, non-bilious, now blood-streaked emesis, with fatigue and weight loss. He’s had no fever or diarrhea, but urine output is decreased. BMP shows hypochloremic, hypokalemic metabolic alkalosis. What would you expect to see diagnostic studies?
Abdominal/pyloric ultrasound - pyloric hypertrophy
Upper GI contrast study - very narrow pyloric channel (the “string sign”), indentation of the hypertrophied pylorus on the antrum of the stomach, and delayed gastric emptying
What is the treatment for pyloric stenosis?
Consult pediatric surgery, who will perform a laparoscopic pyloromyotomy
A 25-month-old male presents to the ED with a 2-day history of vomiting and diarrhea. The patient’s father relays a history of abrupt onset of vomiting that started yesterday around 1 pm. He has had 6 episodes of emesis since yesterday and 3 episodes of diarrhea. The emesis is non-bilious and the diarrhea is described as watery. There are no sick contacts in the home. Vital signs: T 37.1, P 102, R 20, BP 90/60. Physical examination is normal and he has still been tolerating some PO feeds without instant vomiting. What is the most immediate intervention for this patient?
A. CT scan and surgical consult B. IV bolus with 0.9% saline C. IV bolus with D5W D. No immediate intervention is necessary E. Random glucose test
D. No immediate intervention is necessary
A 5-week-old infant presents to clinic with 4 days of repeated, non-bilious, non-bloody vomiting with non-bloody diarrhea. He has 8 to 9 episodes of vomiting per day immediately following breastfeeding. The episodes started 4 days after the entire family suffered from severe viral gastroenteritis. His birth history is uncomplicated (full term, NSVD, unremarkable 30-week ultrasound) and birth weight was 3.6 kg (50th percentile). On exam, his vitals are: T 36.7°C, HR 185, BP 85/45, RR 36, Wt 4.1 kg (25th percentile). On exam, his eyes are moderately sunken without production of tears, his lips are cracked, and his throat is without erythema. His capillary refill is ~3 seconds, and his pulse is thready. He appears lethargic. What is your first step in management?
A. Administer 75 mL/kg of oral rehydration solution over 3-4 hours and 60-120 mL of oral rehydration solution for every episode of vomiting.
B. Close observation in the office for 6 hours and encourage PO intake until vitals normalize.
C. Intravenous 20 mL/kg boluses of ¼ normal saline solution until baseline clinical status is achieved, then closely monitor vitals for 6 hours while encouraging PO formula intake.
D. Intravenous lactated Ringer’s solution of 20mL/kg boluses until baseline clinical status is achieved, then either oral hydration or IV fluid hydration if not tolerating PO. E. Observe for 6 hours with normal PO intake and administer 60-120 mL of oral rehydration solution for every episode of vomiting.
E. Observe for 6 hours with normal PO intake and administer 60-120 mL of oral rehydration solution for every episode of vomiting.
D. Intravenous lactated Ringer’s solution of 20mL/kg boluses until baseline clinical status is achieved, then either oral hydration or IV fluid hydration if not tolerating PO. E. Observe for 6 hours with normal PO intake and administer 60-120 mL of oral rehydration solution for every episode of vomiting.
This patient has severe dehydration and. should be treated with Lactated Ringer’s solution or normal saline in up to three 20ml/kg boluses until clinical baseline is achieved (normal pulse, perfusion and mental status). Once stabilized, oral rehydration may be attempted. If the patient still cannot take PO, then IV hydration with 5% dextrose and normal saline may be administered. Providers should also factor in replacement of ongoing losses.
A 6-month-old infant comes to clinic because of several weeks of vomiting after large feedings. The vomiting has become blood-streaked, which is when the mom became concerned and brought him in. The baby’s PO intake has decreased and he has been losing weight. Abdominal exam is normal, with no masses palpated. What is the most likely diagnosis?
A. Gastroenteritis B. GERD with esophagitis C. Intussusception D. Pyloric stenosis E. Volvulus
B. GERD with esophagitis
A 1-month-old infant who is < 3rd percentile for weight presents to the clinic. He is breastfed every 2 hours and latches on well. However, he has frequent non-bilious episodes of vomiting that have been increasing over the past week despite his mother instituting “reflux precautions.” He does not have mucus or blood in his stool. Physical exam reveals a small, olive-sized mass in his abdomen. What is the most likely diagnosis?
A. Cleft palate B. Cystic fibrosis C. Munchausen syndrome by proxy D. Non-organic failure to thrive E. Pyloric stenosis
E. Pyloric stenosis
A 15-month-old boy presents to the ED with a 3-day history of vomiting and diarrhea. His current weight is 11 kg. He was born at 39 weeks, without any perinatal complications. There is no significant history of travel, sick contacts, or recent changes in diet. The mother notes that he has had only 2 urine diapers over the last day. Physical exam is remarkable for an irritable but consolable infant with tachycardia and normal blood pressure. He is crying with minimal tears and his mucous membranes are dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds. He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the following statements is true?
A. The patient is minimally dehydrated and should be managed with adequate fluid and age appropriate diet
B. The patient is moderately dehydrated and should be bolused with 220 ccs of D5 ½ normal saline for emergency phase correction, to ensure hemodynamic stability.
C. The patient is moderately dehydrated and should be managed with 50-100ml/kg of oral rehydrating solution over 2-4 hours.
D. The patient should be rehydrated with clear liquids and then transitioned to a lactose-free diet until his diarrhea resolves.
C. The patient is moderately dehydrated and should be managed with 50-100ml/kg of oral rehydrating solution over 2-4 hours.
What are the 3 steps of fluid management?
- Deficit replacement - 20mL/kg fluid boluses replaced over 24-48 hours
- mIVF
- Per day: 100, 50, 20 mL/kg/day
- Per hour: 4, 2, 1, mL/kg/hour - Replace ongoing losses (vomiting, diarrhea, NG tube output, other insensible losses)
You estimate a child’s fluid deficit to be about 9% (severe dehydration). His current weight is 5.2kg. You don’t have a pre-illness weight. He’s gotten 60mL/kg in repeated 20mL/kg boluses x3. At what rate should his mIVF be run at (mL/hr)? What is your choice of IV fluids?
0.09% (5.2kg) = 468 mL fluid deficit total
60mL/kg x 5.2kg = 312 mL already given via boluses
468 mL - 312 mL = 156 mL deficit left
156 mL / 24 hours = 6.5 mL/hr to replace fluid deficit
mIVF (w/o considering dehydration), using 4, 2, 1 rule: 4mL/kg/hr x 5.2 kg = 20.8 mL/hr
final answer: 6.5 mL/hr + 20.8 mL/hr = 27.3 mL/hr D5NS + 20KCl
