SYMPOSIUM ON PGIMER MANAGEMENT PROTOCOLS IN GASTROINTESTINAL EMERGENCIES Management of a Child with Vomiting Sunit C. Singhi & Ravi Shah & Arun Bansal & M. Jayashree Received: 10 August 2012 / Accepted: 28 December 2012 / Published online: 23 January 2013 # Dr. K C Chaudhuri Foundation 2013 Abstract Vomiting is a protective reflex that results in force- ful ejection of stomach contents up to and out of the mouth. It is a common complaint and may be the presenting symptom of several life-threatening conditions. It can be caused by a variety of organic and nonorganic disorders; gastrointestinal (GI) or outside of GI. Acute gastritis and gastroenteritis (AGE) are the leading cause of acute vomiting in children. Important life threatening causes in infancy include congenital intestinal obstruction, atresia, malrotation with volvulus, necrotizing enterocolitis, pyloric stenosis, intussusception, shaken baby syndrome, hydrocephalus, inborn errors of metabolism, con- genital adrenal hypoplasia, obstructive uropathy, sepsis, men- ingitis and encephalitis, and severe gastroenteritis, and in older children appendicitis, intracranial mass lesion, diabetic ketoacidosis, Reye’ s syndrome, toxic ingestions, uremia, and meningitis. Initial evaluation is directed at assessment of airway, breathing and circulation, assessment of hydration status and red flag signs (bilious or bloody vomiting, altered sensorium, toxic/septic/apprehensive look, inconsolable cry or excessive irritability, severe dehydration, concern for symp- tomatic hypoglycemia, severe wasting, Bent-over posture). The history and physical examination guides the approach in an individual patient. The diverse nature of causes of vomiting makes a “routine” laboratory or radiologic screen impossible. Investigations (Serum electrolytes and blood gases,renal and liver functions and radiological studies) are required in any child with dehydration or red flag signs, to diagnose surgical causes. Management priorities include treatment of dehydra- tion, stoppage of oral fluids/feeds and decompression of the stomach with nasogastric tube in patients with bilious vomit- ing. Antiemetic ondansetron(0.2 mg/kg oral; parenteral 0.15 mg/kg; maximum 4 mg) is indicated in children unable to take orally due to persistent vomiting, post-operative vom- iting, chemotherapy induced vomiting, cyclic vomiting syn- drome and acute mountain sickness. Keywords Children . Vomiting . Antiemetic Introduction Vomiting is a very common complaint in infants and chil- dren who present to the emergency department (ED). A large percentage of infants and children with vomiting have a non-serious etiology for their symptoms and have a self- limiting illness. However, vomiting may be the presenting symptom in several life-threatening conditions. The ED management is primarily tailored to identify and manage those with a serious underlying cause, and provide symp- tomatic relief to others. Terminology Vomiting is a complex behavior. It is usually composed of three linked activities: nausea, retching and expulsion of stomach contents. Nausea is a sensation of impending emesis and is fre- quently accompanied by autonomic changes, such as in- creased heart rate and salivation. Vomiting can occur without preceding nausea, for e.g., projectile vomiting in individuals with increased intracranial pressure. Retching is defined as strong, involuntary efforts to vomit but without expelling material from the mouth, which may be seen as preparatory manoeuvres to vomiting. Vomiting is a protective reflex and is defined as forceful ejection of stomach contents up to and out of the mouth [1]. S. C. Singhi (*) : R. Shah : A. Bansal : M. Jayashree Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh 160012, India e-mail: sunit.singhi@gmail.com Indian J Pediatr (April 2013) 80(4):318–325 DOI 10.1007/s12098-012-0959-6