Approach to Acute Diarrhea

and Shock in the ED 13

Figure 13.1: Severe dehydration responds dramatically to IV fluid therapy (Courtesy: Dr Mullai Baalaaji and Dr Gunda Srinivas)

Learning Objectives
1. Recognition of severity of dehydration and shock 2. How fluids are administered using the pull push
using the modified rapid cardiopulmonary cerebral technique?
assessment and the pediatric assessment triangle. 3. Recognition of coexisting septic shock in a child
presenting with diarrhea and hypovolemic shock.

INTRODUCTION CASE SCENARIO

Acute diarrhea with or without shock is the commonest A 10-year-old girl is rushed into the ED following sev-
emergency encountered in day to day practice (Figure 13.1). eral episodes of diarrhea and vomiting. She is drowsy.
This chapter is predominantly based on the WHO recom-
mendations—20051 for the management of acute diarrhea.
The PEMC approach helps the novice physician to
identify the severity of fluid loss using the rapid cardiopul-
monary cerebral assessment and the pediatric assessment
triangle and match fluid resuscitation.
This approach also emphasizes that altered mental sta-
tus (lethargy), in the background of severe dehydration
may be secondary to hypovolemic shock.
This observation is based on the fact that loss exceed-
ing 25% of effective circulating volume leads to decreased
cerebral perfusion and fall in level of consciousness. Se- Figure 13.2: Note the sunken eyes in this child, who presented
vere dehydration is attributed to loss of 10% circulating with hypovolemic shock. Two intravenous lines have been
volume. However, altered mental status in children with secured. Pull push technique is being used to administer RL
severe dehydration may also result from dyselectrolytemia boluses (Note O2 being given through NRM and BP cuff tied for
or hypoglycemia. BP monitoring) (Courtesy: Dr Gunda Srinivas).
 130 Section V n Circulation

Figure 13.4: The 3-way stopcock is turned to close the patient

end and facilitate withdrawal of fluid from the reservoir
Figure 13.3 Physiological status: Airway stable/effortless (Courtesy: Dr Gunda Srinivas).
tachypnea/hypotensive shock/with altered mental status and
severe dehydration.

Management (Figure 13.2 to 13.8)

●● Provide oxygen using the non-rebreathing mask.
●● Secure 2 IV lines and infuse RL 20 mL/kg using push-
pull technique.
●● Until BP normalizes for age.
●● Remember systolic BP less than or equal to 90 mm Hg
should be considered as hypotension in children aged
10 years or more.
●● Check Dextrostix and correct documented hypoglyce­mia.
●● Repeat rapid cardiopulmonary cerebral assessment af- .
ter every fluid bolus. Figure 13.5: The 3-way stopcock is now turned such that fluids
●● Send blood for electrolytes, urea, creatinine. can be pushed into the intravenous line (Courtesy: Dr Gunda
●● Avoid antibiotics, since most diarrheal episodes are Srinivas).
secondary to viral infections.
●● If acute gastroenteritis is due to giardiasis or the child is The pull push method described above is one of the
having dysentery or less than 6 months of age or has sys- fastest methods of administering large volumes of fluids in
temic illness or has proven or sus­picion of shigellosis. the shortest period of time.
Ù
Cholera: Oral Doxycycline
Dedicate one team member to:

Dose: 4–5 years 100 mg stat,
2–4 years: 50 mg stat single dose.
Shigellosis: Ciprofloxacin
Dose: 1 month to 18 years 20 mg/kg (max 750 mg) twice
daily.
Giardiasis: Oral Metronidazole
1–3 years : 500 mg OD for 3 days
3–7 years : 600–800 mg OD for 3 days
Child 7–10 years : 1 g OD for 3 days
10–18 years : 2 g OD for 3 days.
●● Keep track of the number of boluses that are being ad-
ministered.
●● Perform the rapid cardiopulmonary cerebral assess-
ment after each intervention.
●● Document the findings and response to treatment.
Ù
Do not stop fluid boluses on the basis of normalization
of BP. All the therapeutic goals should be achieved. If
shock persists, plan to continue fluid therapy.
Dehydration may persist after shock correction.
 Chapter 13 n Approach to Acute Diarrhea and Shock in the ED 131

CASE SCENARIO CONTINUED ●● Discontinue oxygen therapy.

●● If the patient can drink, begin giving oral rehydration
Following three rapid boluses of 20 mL/kg, her repeat salts (ORS) solution by mouth.
assessment was as follows:
Children > 1 year
●● 30 mL/kg as rapidly as possible (within 30 minutes);
then 70 mL/kg in the next 2 hours.
Children < 1 year
●● 30 mL/kg in the 1st hour; then.
●● 70 mL/kg in the next 5 hours.

CASE SCENARIO CONTINUED

Following RL 100 mL/kg over 6 hours, her repeat assess­
ment revealed.

Figure 13.6 Physiological status: Airway stable/tachypnea/

tachycardia with normotensive shock with severe
dehydration.

Management
●● Continue O2 administration using the non-rebreathing
mask.
●● Infuse RL 20 mL/kg over 20 minutes.

CASE SCENARIO CONTINUED

Following the 4th bolus of 20 mL/kg, her repeat as­ Figure 13.8 Physiological status: Cardiopulmonary cerebral
sessment revealed. status is normal, tachycardia has also resolved. She has features
of ‘some dehydration’.

●● Advice ORS 75 mL/kg for 4 hours and review.

●● ORS ad lib in the older child.
●● When hydration becomes normal: Advice ORS 10 mL/
kg for every loose stool.

CONTRAINDICATIONS
TO ORAL REHYDRATION
●● Signs of shock.
●● Ileus or intestinal obstruction (proven or suspected).
●● Comatose or unconscious.
●● Unable to tolerate oral/NGT rehydration (persistent
vomiting).
Figure 13.7 Physiological status: Airway stable/breathing ●● Often, children presenting with hypovolemic shock
normal/shock has resolved, but she has dehydration as have elevated renal parameters due to prerenal failure.
evidenced by sunken eyes and loss of skin turgor. Persistent Decision to withhold fluids will have disastrous con-
tachycardia is a sign of dehydration, since shock as resolved. sequences.
 132 Section V n Circulation
Refer Protocol 13.1.
Ù
Correct shock and re-evaluate renal parameters in
previously normal children.
Key Points
ü
1. Repeat cardiopulmonary cerebral assessment after
every fluid order. Recurrence of diarrheal episodes
and vomiting can alter the physiological status.
2. Attempt to shift the pediatric assessment triangle
from hypotensive shock to the normal triangle.
3. Inotropes and intubation are rarely needed in the
management of uncomplicated hypovolemic shock.
4. Evidence of warm shock (wide pulse pressure),
tachy­cardia and tachypnea fulfilling the SIRS
criteria, in a dehydrated child should alert the to
the possibility of coexisting GI sepsis. Evidence of
respiratory distress in a shocked child with diarrhea,
but without respiratory symptoms is hallmark of
cardiogenic or non-cardiogenic pulmonary edema
in GI sepsis.
common errors
û
1. Failure to recognize shock and treat as severe
dehydration!
2. Failure to anticipate that hypovolemic shock may
co­exist with septic shock secondary to GI sepsis.
3. Initiating dopamine for shock persisting after
adminis­tration of 60 mL/kg of fluids.
4. Using GNS or other glucose containing fluids to
cor­rect shock.
5. Withholding fluids in shocked children in view of
elevated urea and creatinine.
6. Failure to correct metabolic abnormalities after
resolving shock and dehydration.
7. Failure to anticipate that failure in improvement in
tone and posture after correction of shock could be
due to persistent hypokalemia.
REFERENCE
1. “The Treatment Of Diarrhea, A manual for physicians and
other senior health workers”: WHO-2005.
Protocol 13.1: PEMC approach: Recognition of the severity of dehydration and presence of septic shock in children
presenting with diarrhea Chapter 13 n Approach to Acute Diarrhea and Shock in the ED
133