II. Pathophysiology
- See Vomiting (includes definitions)
III. Causes
IV. History
- See Vomiting History for clinical clues (geared toward adults)
- Prenatal and Birth History
- Prenatal conditions
- Did infant pass meconium and how long after birth?
- Systemic Symptoms and Signs
-
Emesis Characteristics
- Onset of Vomiting
- Timing between food or milk and Emesis
- Projectile Emesis
- Evaluate for Pyloric Stenosis in the young infant
- Emesis appearance or color
- Undigested food or milk or yellow color (Stomach contents)
- Hematemesis (Upper GI Bleeding)
- Bilious Emesis (e.g. Small Bowel Obstruction from mid-gut Volvulus in infants)
- Gastrointestinal Symptoms or Signs
- Abdominal Pain before Vomiting (red flag)
- Gastrointestinal Bleeding (Hematemesis, Melana)
- Dysphagia
- Constipation
- Diarrhea
- Diarrhea that follows Vomiting is consistent with Gastroenteritis
- Vomiting that follows Diarrhea is consistent with enteritis (or Urinary Tract Infection in girls, women)
- Jaundice
- Genitourinary Symptoms
- Urine Output
- At least three times daily in infants and twice daily in children and older
- Dysuria
- Urgency or frequency
- Hematuria
- Urine Output
- Associated Conditions
- Neurologic Symptoms and Signs
- Altered Level of Consciousness (GCS, mental status)
- Consider Non-accidental Trauma
- Altered Level of Consciousness (GCS, mental status)
V. History: Red Flags
- Weight loss or failure to gain weight
- Projectile Emesis in the young infant
- Evaluate for Pyloric Stenosis
-
Bilious Emesis in newborn
- Evaluate for malrotation and Volvulus (emergent management needed)
- Bloody stools, Abdominal Distention and Emesis in a newborn
- Evaluate for necrotizing entercolitis
- Refractory Vomiting in a benign Abdomen, possible Altered Level of Consciousness
- Evaluate for Non-accidental Trauma, brain mass
VI. Examination
- Observe for dehydration
- Weight loss since prior exam
- Decreased skin turgur
- Dry mucus membranes (or not making tears in children)
- Sinus Tachycardia
- Orthostatic Hypotension
- Decreased Capillary Refill
- Other systemic signs of serious illness
- Abdominal examination
- Abdominal Distention
- Abdominal wall Hernia
- Peritoneal signs (abdominal guarding, Rebound Tenderness)
- Abdominal Trauma (e.g. Bruising)
- Abdominal tenderness to palpation
- Right lower quadrant pain: Appendicitis (esp. with Psoas Sign, Rosving's sign)
- Flank Pain: Pyelonephritis or Uretolithiasis
- Bowel sounds
- Hyperactive suggests Gastroenteritis
- High pitched suggests Small Bowel Obstruction
- Absent or decreased suggests ileus
- Genitourinary exam
- Inguinal Hernia
- Testicular Torsion (testicular tenderness, swelling, absent Cremasteric Reflex)
- Ovarian Torsion
- Neurologic Examination
- Skin
VII. Differential Diagnosis
- See Vomiting Causes
- Ptyalism (Excessive Salivation)
- Gastroesophageal Reflux Disease (Acid Reflux) or Spitting Up in an infant
- Forceful Coughing
- Post-nasal drainage
- Asthma, Bronchitis or Bronchiolitis
- Pneumonia
- Undigested Food Regurgitation
- Esophageal Obstruction
- Esophageal Diverticulum
- Overfilled Stomach
- Delayed Gastric Emptying or Gastroparesis
VIII. Labs
- Precautions
- Most children will not need lab testing
- Labs should be directed by history and exam
- Fingerstick Glucose (for Hypoglycemia, DKA)
- Complete Blood Count
- Comprehensive metabolic panel (Electrolytes, Renal Function tests, Liver Function Tests)
- Urinalysis
- Additional labs to consider in Sepsis
- Additional labs/measures to consider in newborns
- Ammonia (Inborn Errors of Metabolism)
- Attempt passage of oral Gastric Tube
IX. Evaluation
X. Imaging
- Abdominal Ultrasound
- Abdominal XRay (flat and upright, or in infants, a left lateral decubitus image)
- Malrotation
- Small Bowel Obstruction
-
Chest XRay
- Abdominal free air
- Pneumonia
XI. Management
- See Vomiting Management in Children
- Always consider Nonaccidental Trauma
- Urgent surgical Consultation indications
- Empiric Management
- See Vomiting Management in Children
- Treat Pediatric Dehydration as needed
- Antiemetic followed by oral liquid trial
- Ondansetron 0.15 mg/kg up to 4-8 mg (age >6 months)
- Avoid Promethazine (Phenergan) in children (FDA black box warning)
XII. References
- (2017) Crit Dec Emerg Med 31(4): 19-25