Consider Blood Glucose Advice from Lead ED / Paediatrician-On-Call* should be sought and/or a clear management plan agreed with parents. Begin management of clinical dehydration algorithm [see Fig 3] See [Fig 4] for Stool sample microscopy indications Immediate Paediatric Assessment If clinical shock suspected or confirmed follow management plan [see Fig 1] See [Fig 4] for Stool sample microscopy indications Amber Action Urgent Action Green Action For all patients, continue monitoring following PEWS Chart recommendation This guidance is written in the following context: This document was arrived at after careful consideration of the evidence available including but not exclusively NICE, SIGN, EBM data and NHS evidence, as applicable. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer. Fig 3 Management of Clinical Dehydration • Increase oral fluid intake to 2 mls/kg every 10 mins with an oral rehydration solution (ORS) aiming for 50 ml/kg over 4 hours • Continue breast / bottle feeding, little and often is best • Give ORS via nasogastric tube if the child is unable to drink or vomits persistently • A&E - Refer to Paediatrics if after 2 hours and child is still amber • Consider use of Ondansetron as per local policy Clinical Findings Green - low risk Amber - intermediate risk Red - high risk Age Behaviour Over 3 months old • Responds normally to social cues • Content / smiles • Stays awake / awakens quickly • Strong normal crying / not crying Under 3 months old • Altered response to social cues • No smile • Decreased activity • Irritable • Lethargic • Appears unwell • No response to social cues • Unable to rouse or if roused does not stay awake • Appears ill to a healthcare professional • Weak, high pitched or continuous cry Skin Hydration • Normal skin colour • Normal turgor • Warm extremities • Not dehydrated • CRT < 2 secs • Moist mucous membranes (except after a drink) • Normal urine output • Fontanelle normal • Normal skin colour • Warm extremities • Reduced skin turgor • Clinically dehydrated • CRT 2-3 secs • Dry mucous membranes (except for mouth breather) • History of reduced urine output or fewer wet nappies than usual • Sunken fontanelle • Pale / mottled / ashen blue • Cold extremities • Clinical Shock • CRT> 3 secs • History of significant reduction in output or dry nappies > 18 hours • Markedly sunken fontanelle Respiratory Measured at rest for 30 seconds • Normal breathing pattern and rate** • Normal breathing pattern and rate** • Abnormal breathing / tachypnoea** Heart Rate • Heart rate normal • Peripheral pulses normal • Mild tachycardia* • Peripheral pulses normal • Severe tachycardia* Blood pressure • Normal* • Normal* • Hypotensive* Eyes • Normal Eyes • Not sunken • Sunken Eyes Sunken eyes First Draft Version: May 2011 Subsequent Versions have been published in Nov 2013, Jan 2015 and May 2015. Date of this Refreshed Version: Dec 2016 Review Date: Dec 2018 Triage Assessment (PEWS Score) Temp, Heart Rate, RR, CRT, O 2 Sats BP, Blood Glucose (if indicated) Consider Stool Microscopy [Fig 4] Nursing Assessment -History Hydration Antipyretics Oral Rehydration Solution (ORS) 1 ml / kg every 10 minutes and/or continue breastfeeding Try to isolate to limit cross infection Consider any of the following as possible indicators of diagnoses other than gastroenteritis [See Table 3 overleaf]: • Sepsis • Fever: Temperature of > 38°C (younger than 3 months) • Temperature of > 39°C (3 months or older) • Shortness of breath or tachypnoea • Altered state of consciousness • Consider a diagnosis of diabetes • Neck stiffness • Bulging fontanelle in infants • Non blanching rash • Blood and/or mucous in stool • Bilious (green) or blood-stained vomit • Projectile vomiting • Vomiting alone • Head Injury • Severe localised abdominal pain • Abdominal distension or rebound tenderness • History/Suspicion of poisoning e.g. Carbon Monoxide Discuss with Lead ED / Paediatric Doctor Fig 1 Management when clinical shock suspected • Give 20 ml/kg 0.9% Sodium Chloride First Bolus Reassess Give 20 ml/kg 0.9% Sodium Chloride as First Bolus and alert Paediatric Emergency Service Fig 2 IV Fluid Therapy Only use IV fluid therapy if in shock or red flag patient and deteriorates despite ORS or persistently vomits ORS therapy. Always use isotonic solutions. Use maintenance plus replacement 50 – 100 mls/kg over 48 hours dependent on severity. If you need language support or translation please inform the member of staff to whom you are speaking. To feedback or for further information including how to obtain more copies of this document (Please Quote Ref: DV1) we have one mailbox for these queries on behalf of the South East Clinical Networks area (Kent, Surrey and Sussex). Please email: [email protected] Some useful phone numbers (You may want to add some numbers on here too) Self Care Using the advice overleaf you can provide the care your child needs at home If none of the above features are present, most children with Diarrhoea and / or Vomiting can be safely managed at home. (Please note that children younger than 1 year or those who were born with a low birth weight may be more prone to become dehydrated. If your child appears otherwise well, but you still have concerns please contact your GP surgery or call NHS 111). How is your child? (traffic light advice) You need to contact a doctor or nurse today Please ring your GP surgery or call NHS 111- dial 111 If your child: seems dehydrated: ie. dry mouth, sunken eyes, no tears, sunken fontanelle (soft spot on baby’s head), drowsy or passing less urine than normal has blood in the stool (poo) or constant tummy pain has stopped drinking or breastfeeding and / or is unable to keep down drinks / tolerate oral fluids during this illness becomes irritable or lethargic their breathing is rapid or deep has cold feet and hands with no mottling of skin blood in the vomit is under 3 months old You need urgent help please phone 999 or go to the nearest Hospital Emergency (A&E) Department If your child is / has: becomes difficult to rouse / unresponsive becomes pale and floppy finding it difficult to breathe Diabetes cold feet and hands with mottled skin No wet nappies or wees for > 18 hours Further advice / Follow up Name of Child Age Date / Time advice given Name of Professional Signature of Professional Red Amber Green Diarrhoea and/or Vomiting Advice Sheet (Gastroenteritis) - Advice for parents and carers of children younger than 5 years Most children with diarrhoea and / or vomiting get better very quickly, but some children can get worse. You need to regularly check your child and follow the advice given to you by your healthcare professional and / or as listed on this sheet. For online advice: NHS Choiceswww.nhs.uk (available 24 hrs - 7 days a week) Family Information Service: All areas have an online service providing useful information for Families set up by local councils GP Surgery (make a note of number here) ............................................... NHS 111 dial 111 (available 24 hrs - 7 days a week) School Nurse / Health Visiting Team (make a note of number here) ............................................... ............................................... December 2016 Kent, Surrey & Sussex Version Children and Young People South East Clinical Networks Patient presents with or has a history of diarrhoea & / or vomiting Diarrhoea and/or Vomiting (Gastroenteritis) Pathway Clinical Assessment / Management Tool for Children Younger than 5 years with suspected Gastroenteritis Management - Acute Setting (APLS † ) < 1 year 1-2 years > 2-5 years Respiratory Rate at rest: [b/min] 30 - 40 25 - 35 25 - 30 Heart Rate [bpm] 110 - 160 100 - 150 95 - 140 Table 2 Normal Paediatric Values: Systolic Blood Pressure [mmHg] 70 - 90 80 - 95 80 - 100 Table 1 Do the symptoms and/or signs suggest an immediately life threatening (high risk) illness? Complete PEWS for all patients Alert Paediatric Emergency Service following local hospital referral pathway Move to Resuscitation Area [see Fig 1] Resus Call (“2222”) for Paediatric Arrest Yes Think Sepsis To avoid dehydration (see patient advice sheet) Continue with breast and / or bottle feeding Encourage fluid intake, little and often Children at increased risk of dehydration [see Fig 5 overleaf] Confirm they are comfortable with the decisions / advice given and then think “Safeguarding” before sending home. See [Fig 4] for Stool sample microscopy indications December 2016 Kent, Surrey & Sussex Version Children and Young People South East Clinical Networks * Please see Normal Paediatric Values in Table 2 above. † Advanced Paediatric Life Support The Practical Approach Fifth Edition Advanced Life Support Group Edited by Martin Samuels; Susan Wieteska Wiley-Blackwell / 2011 BMJ Books. Record your findings. GMC Best Practice recommendation http://bit.ly/1DPXl2b Fig 4 Stool Microscopy perform if: • Suspected septicaemia • Or immunocompromised • Or blood / mucous in stools • Or history of travel abroad • Or no improvement in diarrhoea after 7 days