Meckel diverticulum. Surgical resection is curative.

Transfusion may be necessary in cases of significant blood

loss.

Malrotation and volvulus. Emergent surgical repair is

essential to minimize bowel necrosis.

Constipation. Treatments range from mild (laxatives

for home use) to invasive (enema, disimpaction). Rarely,

children require admission for continued enemas and

nasogastric administration of laxatives.

DISPOSITION

..... Admission

Children with surgical or suspected surgical causes of

abdominal pain should be admitted to the hospital under

the care of a surgeon. To prevent exposure to ionizing

radiation, children with equivocal examinations or

ultrasound findings may be admitted for serial abdominal

examinations. Intussusception has up to a lOo/o recurrence

risk in the first 24 hours after reduction. Most often children are admitted after reduction, but the potential exists

for discharge from the ED with thorough instructions on

when to return.

..... Discharge

Children with medical causes of abdominal pain (pharyngitis, urinary tract infection, pneumonia, gastroenteritis)

who tolerate oral fluids can be discharged home with

close follow-up. The first presentation of etiologies of

abdominal pain such as appendicitis or intussusception

may be misinterpreted as viral illness. Therefore, very

specific return instructions must be provided to the caregivers on discharge. These include bilious vomiting, worsening pain, localization to the right lower quadrant, and

inability to tolerate oral fluids.

SUGGESTED READING

Bachur RG. Abdominal emergencies. In Fleischer GR, Ludwig S.

Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia,

PA: Lippincott Williams & Wilkins, 20 10, pp. 1515-1 538.

Kharbanda AK, Sawaya RD. Acute abdominal pain in children.

In: Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7tb ed. New York, NY: McGraw-Hill, New York, 2011,

839-848.

Ross S, LeLeiko NS. Acute abdominal pain. Pediatr Rev.

2010;3 1:135-144.

Rothrock SG, Pagane J. Acute appendicitis in children: Emergency

department diagnosis and management. Ann Emerg Med.

2000;36:39-5 1.

Dehydration

Kristi ne Cieslak, MD

Key Points

• Dehydration is not a disease; the underlying cause must

be identified and treated.

• Severity of dehydration can be classified using clinical

assessment.

• Management priorities in the emergency department

are stabil ization of vita l signs, replacement of

INTRODUCTION

Acute evaluation and treatment of children presenting

with dehydration represents one of the most common

situations in the pediatric emergency department (ED).

Dehydration in sick children is often a combination of

refusing to eat or drink and losing fluid from vomiting,

diarrhea, or fever. In children with vomiting and diarrhea,

the underlying problem is actually intravascular volume

depletion, not dehydration. Volume depletion represents

an equal loss of water and solutes (mainly sodium) from

the blood plasma, whereas dehydration denotes a disproportional loss of plasma free water.

Children have higher morbidity and mortality rates

associated with dehydration than adults due to a higher

turnover of fluids and solutes (higher metabolic rates,

increased body surface area/mass index, larger total body

water content, immature kidneys with relative inability to

produce concentrated urine, reliance on caregivers for basic

needs). In clinical practice, the clinician attempts to determine the degree of volume depletion and the underlying

cause of dehydration to initiate proper treatment.

Gastroenteritis is the most common cause of dehydra ­

tion and is due to viruses in 80% of cases (rotavirus

30-50%). The clinical diagnosis of gastroenteritis by defi ­

nition requires the presence of diarrhea. However, many

intravascu lar volume deficit and ongoing losses, and

correction of electrolyte abnormal ities.

• Frequent reassessment of clinical status is necessary to

mon itor the response to treatment.

infants with viral gastroenteritis present with isolated diarrhea or isolated vomiting. Rotavirus infections are responsible for approximately 3 million cases of diarrhea and

55,000 hospitalizations for diarrhea and dehydration in

children <5 years of age each year in the United States. The

majority of children with dehydration presenting to the

ED have a benign etiology; however, there are serious

causes for dehydration that should be considered.

Consider appendicitis, intussusception, volvulus, pyloric

stenosis, urinary tract infection, hydrocephalus, brain

tumors, and diabetes mellitus as potential underlying conditions in the pediatric patient who presents with

dehydration. Other causes of dehydration include

gastrointestinal (hepatitis, liver failure, drug toxicity), endocrine (congenital adrenal hyperplasia, Addisonian crisis),

renal (pyelonephritis, renal tubular acidosis, thyrotoxicosis),

poor oral intake (pharyngitis, stomatitis), and insensible

losses (fever, burns, sweating, pulmonary processes).

CLINICAL PRESENTATION

..... History