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Pediatric Emergency Update: Cyclic Vomiting Syndrome
PEDIATRIC UPDATE
PEDIATRIC EMERGENCY UPDATE: CYCLIC VOMITING SYNDROME Author: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, Boston, MA Section Editors: Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P, and Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN.
Earn Up to 8.5 CE Hours. See page 269.
omiting is a common chief complaint in the pediatric ED population. Emergency nurses should develop a systematic approach that is age and developmentally appropriate to evaluate the child with vomiting to identify life-threatening emergencies. Vomiting is a symptom that can indicate a vast array of medical problems from catastrophic to benign. Some children have chronic recurrent vomiting episodes, diagnosed as cyclic vomiting syndrome. Emergency nurses caring for pediatric patients must be objective and open to all differential diagnoses that vomiting could represent. Misdiagnosis of children with the chief complaint of vomiting is not uncommon. It is important to look at each body system of a child brought to the emergency department with recurrent vomiting. The following case report of a 4-month-old infant brought to the pediatric emergency department for frequent vomiting can serve as an example. The child was beautiful, well developed, chubby, awake, and alert, being evaluated in the outpatient setting by both his pediatrician and a gastroenterologist for recurrent vomiting. The child’s primary nurse in the pediatric emergency department noted that a complete workup was ordered, which included blood tests, urine tests, radiographs, and a computed tomography (CT) scan of the head. The child’s mother was concerned that he kept spitting up (vomiting) for no apparent reason. Part of the complete workup for this infant involved
V
Patricia A. Normandin, Member, Massachusetts ENA Beacon Chapter, is Emergency Department Staff Nurse, Tufts Medical Center and Northeastern University, Boston, MA; Adjunct Nursing Faculty, Brigham & Women’s Hospital and Massachusetts General Hospital, Institute of Health Professions, Boston, MA; and Term Lecturer and Site Clinical Instructor, Boston Children’s Hospital, Boston, MA. For correspondence, write: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, 7 Bowl Rd, Chelmsford, MA 01824; E-mail: [email protected]. J Emerg Nurs 2015;41:260-2. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.03.003
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obtaining a straight catheter urine specimen. When the diaper was removed to obtain this specimen, abnormal urine flow was noted. The child’s urine stream would start and stop and then repeat this pattern. Documentation of this was placed in his medical record, and the ED pediatrician was notified. A brain tumor was identified on CT scan. Fortunately, during this pediatric emergency visit, this child with a history of recurrent vomiting was evaluated objectively, using a systematic format. The child was admitted with the newly diagnosed brain tumor for further evaluation and treatment. When all differential diagnoses—both life-threatening and benign—that may cause the child’s vomiting are eliminated, cyclic vomiting syndrome can be diagnosed. Cyclic vomiting syndrome is a chronic gastrointestinal condition identified in children as long ago as in the 1800s. The description of cyclic vomiting syndrome includes the following: the child has 3 or more distinct episodes of recurrent severe vomiting, with completely normal health between episodes, and the child’s vomiting occurs with similar timing, symptoms, and duration. The vomiting episodes of children diagnosed with cyclic vomiting syndrome have variable duration from hours to days, with no exact cause identified. The exact pathophysiology of recurrent cyclic vomiting is unknown. Emergency nurses who care for pediatric patients need to ensure that all potential life-threatening differential diagnoses are eliminated before labeling pediatric patients as having cyclic vomiting syndrome. 1,2 Before any child is diagnosed with chronic cyclic vomiting syndrome, the nurse must complete a swift, organized, age-appropriate physical assessment. The child’s developmental age can help to predict potential catastrophic diagnoses that the symptom of vomiting may represent but that might not yet have been identified. Possible system-related causes of vomiting in children include neurologic conditions, central nervous system dysfunction, mitochondrial disease, autonomic nervous system dysfunction, migraines, and metabolic and endocrine problems. Other system-related causes of vomiting in
VOLUME 41 • ISSUE 3
May 2015
Normandin/PEDIATRIC UPDATE
children include respiratory, cardiac, or gastrointestinal disorders; renal, urinary tract, hepatic, pancreatic, or congenital anomalies; and autoimmune or infectious processes. Some possible external causes of vomiting in children include accidental or nonaccidental trauma; shaken baby syndrome; toxic ingestion of poisons; and environmental exposures, such as carbon monoxide exposure. Adolescents should be questioned regarding chronic cannabis (marijuana) use because of its association with cyclic vomiting syndrome. 3 Ingestion of other illegal substances or alcohol and sexually transmitted infections are differential considerations in the adolescent. Vomiting in children might indicate infectious processes. Children with vomiting might have sepsis, meningitis, viral infections, congenitally acquired infections, bacterial infections, urinary tract infections, pyelonephritis, gastrointestinal infections, blood infections, respiratory infections, or chronic sinusitis. Emergency nurses should advocate for head CT scans of all infants and children who present with repeated episodes of vomiting to rule out any life-threatening brain lesion or intracranial hemorrhage. Psychosocial considerations such as anxiety; depression; mood disorders; eating disorders, including anorexia nervosa and bulimia; and stress can also cause vomiting in children. Assessing infants and children with vomiting in the emergency department can be a challenge. Normal assessment findings would include an anterior fontanelle that is not bulging or depressed in children younger than 2 years, a capillary refill time of less than 2 seconds, intact skin turgor, a moist mouth, tears with crying, a pink color, and a normal voiding pattern as reported by the parent or child. A thorough evaluation should include a complete blood count with differential testing, electrolyte levels, chemistry profiles, blood cultures if a fever is noted, urinalysis, a urine culture, radiographs, cultures for respiratory viruses, rapid influenza swabs, CT scans, magnetic resonance imaging, and lumbar punctures, to name a few. Children with cyclic vomiting syndrome might appear pale, appear listless, be unable to walk, be unable to talk, have severe vomiting, and appear as though they are in shock. If all diagnostic testing results are negative in the emergency department, the child with cyclic vomiting symptoms should be referred to a gastroenterologist. 1 To improve the diagnosis and treatment of cyclic vomiting syndrome, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) developed a position statement that includes the criterion that the number of vomiting episodes should be equal to or greater than 5 total episodes or should be at least 3 episodes over a period of 6 months. These episodic vomiting episodes may last 1 hour to 10 days and
May 2015
VOLUME 41 • ISSUE 3
are usually greater than 1 week apart. These children have a stereotypical pattern of vomiting and symptoms. They vomit 4 or more times in 1 hour. They return to baseline health between vomiting episodes, and no other disorder is identified as the cause for vomiting. Laboratory values, including levels of glucose, electrolytes, blood urea nitrogen, and creatinine, as well as upper gastrointestinal radiographs, should be obtained. If all laboratory results are normal and the child does not have any life-threatening conditions, then he or she is treated for cyclic vomiting syndrome. 1 If the child shows any signs and symptoms of a life-threatening condition, such as gastrointestinal bilious vomiting, abdominal tenderness, or severe abdominal pain, further gastrointestinal testing should be performed. Further diagnostic testing would include abdominal ultrasonography and assessment of serum alanine transaminase, γ-glutamyltransferase, and lipase levels. Metabolic life-threatening concerns may be episodes triggered by illness, a high-protein meal, or fasting. If metabolic concerns are present, further metabolic testing should be performed, including assessment of levels of serum lactic acid, ammonia, amino acids, carnitine, urine ketones, and organic acids. If neurologic life-threatening symptoms, such as abnormal eye movements, papilledema, motor asymmetry, or abnormal gait, are present, then neurologic tests and brain magnetic resonance imaging with contrast should be performed. If any test results are positive, the appropriate specialist should be consulted, such as a gastroenterologist, neurologist, metabolic specialist, endocrinologist, or surgeon. If all test results are normal, then the child is treated for cyclic vomiting syndrome. 1 Treatment for cyclic vomiting syndrome may include intravenous hydration in the emergency department, medications given to stop the vomiting episode, rescue medications during an acute episode, and stress-reduction teachings. The NASPGHAN organization consensus statement recommends that if the child in the emergency department is dehydrated, rehydration should be performed with an initial fluid bolus of 10 mL/kg of normal saline solution, repeated as clinically indicated. Maintenance intravenous fluid to infuse at 1.5 times the maintenance dose can be administered to replace fluid losses and energy. It is recommended that pediatric emergency departments establish emergency and hospital protocols to treat cyclic vomiting syndrome. Emergency departments should provide quiet, darkened rooms for patients with cyclic vomiting syndrome. Vital signs should be taken at least every 4 to 6 hours and more frequently if indicated. Typical emergency protocols for cyclic vomiting syndrome may include antiemetics, such as ondansetron to reduce the vomiting. Analgesics should be given to control severe pain.
WWW.JENONLINE.ORG
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PEDIATRIC UPDATE/Normandin
Intravenous lorazepam is recommended for comfort. If the child has moderate to severe abdominal pain, administration of intravenous ketorolac can be performed. A pediatric emergency patient with cyclic vomiting syndrome who is 5% dehydrated and has no urine output in greater than 12 hours should be admitted. Other admission criteria are a serum sodium level lower than 130 mEq/L, an anion gap greater than 18 mEq/L, and an inability to stop vomiting. The child should be allowed oral fluid intake as tolerated. 1 Emergency nurses need to recognize that cyclic vomiting syndrome is a potential differential diagnosis for children who present with vomiting. A systematic approach incorporating the child’s developmental age should be considered when ruling out life-threatening diagnoses. Interventions for cyclic vomiting syndrome include providing support to the child with cyclic vomiting syndrome and her or his family, teaching stress-reduction measures as appropriate, and referring the child to a gastroenterologist. It is important for emergency nurses to be aware that infections, psychological stressors, and even usually positive events (holidays, birthdays, vacation) can trigger a cyclic vomiting syndrome episode. Emergency nurses should be aware that infectious triggers for cyclic vomiting syndrome are upper respiratory infections and chronic sinusitis.
262
JOURNAL OF EMERGENCY NURSING
Patient teachings provided to the child and family should include avoidance of known common triggers of cyclic vomiting syndrome such as chocolate, aged cheese, and monosodium glutamate; changes in caffeine intake; physical exhaustion; and menses. The Cyclic Vomiting Syndrome Association, at www.cvsaonline.org, has excellent information for patients and their families. 1 REFERENCES 1. Li B, Williams SE. Cyclic vomiting syndrome clinical features and comorbidities. Contemp Pediatr. 2012;29(9):34-46. 2. Bullard J, Page NE. Cyclic vomiting syndrome: a disease in disguise. Pediatr Nurs. 2005;31(1):27-29. 3. Pattathan MB, Hejazi RA, McCallum RW. Association of marijuana use and cyclic vomiting syndrome. Pharmaceuticals (Basel). 2012;5(7):719-726.
Submissions to this column are encouraged and may be sent to Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P [email protected] or Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN [email protected]
VOLUME 41 • ISSUE 3
May 2015
PEDIATRIC EMERGENCY UPDATE: CYCLIC VOMITING SYNDROME Author: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, Boston, MA Section Editors: Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P, and Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN.
Earn Up to 8.5 CE Hours. See page 269.
omiting is a common chief complaint in the pediatric ED population. Emergency nurses should develop a systematic approach that is age and developmentally appropriate to evaluate the child with vomiting to identify life-threatening emergencies. Vomiting is a symptom that can indicate a vast array of medical problems from catastrophic to benign. Some children have chronic recurrent vomiting episodes, diagnosed as cyclic vomiting syndrome. Emergency nurses caring for pediatric patients must be objective and open to all differential diagnoses that vomiting could represent. Misdiagnosis of children with the chief complaint of vomiting is not uncommon. It is important to look at each body system of a child brought to the emergency department with recurrent vomiting. The following case report of a 4-month-old infant brought to the pediatric emergency department for frequent vomiting can serve as an example. The child was beautiful, well developed, chubby, awake, and alert, being evaluated in the outpatient setting by both his pediatrician and a gastroenterologist for recurrent vomiting. The child’s primary nurse in the pediatric emergency department noted that a complete workup was ordered, which included blood tests, urine tests, radiographs, and a computed tomography (CT) scan of the head. The child’s mother was concerned that he kept spitting up (vomiting) for no apparent reason. Part of the complete workup for this infant involved
V
Patricia A. Normandin, Member, Massachusetts ENA Beacon Chapter, is Emergency Department Staff Nurse, Tufts Medical Center and Northeastern University, Boston, MA; Adjunct Nursing Faculty, Brigham & Women’s Hospital and Massachusetts General Hospital, Institute of Health Professions, Boston, MA; and Term Lecturer and Site Clinical Instructor, Boston Children’s Hospital, Boston, MA. For correspondence, write: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, 7 Bowl Rd, Chelmsford, MA 01824; E-mail: [email protected]. J Emerg Nurs 2015;41:260-2. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.03.003
260
JOURNAL OF EMERGENCY NURSING
obtaining a straight catheter urine specimen. When the diaper was removed to obtain this specimen, abnormal urine flow was noted. The child’s urine stream would start and stop and then repeat this pattern. Documentation of this was placed in his medical record, and the ED pediatrician was notified. A brain tumor was identified on CT scan. Fortunately, during this pediatric emergency visit, this child with a history of recurrent vomiting was evaluated objectively, using a systematic format. The child was admitted with the newly diagnosed brain tumor for further evaluation and treatment. When all differential diagnoses—both life-threatening and benign—that may cause the child’s vomiting are eliminated, cyclic vomiting syndrome can be diagnosed. Cyclic vomiting syndrome is a chronic gastrointestinal condition identified in children as long ago as in the 1800s. The description of cyclic vomiting syndrome includes the following: the child has 3 or more distinct episodes of recurrent severe vomiting, with completely normal health between episodes, and the child’s vomiting occurs with similar timing, symptoms, and duration. The vomiting episodes of children diagnosed with cyclic vomiting syndrome have variable duration from hours to days, with no exact cause identified. The exact pathophysiology of recurrent cyclic vomiting is unknown. Emergency nurses who care for pediatric patients need to ensure that all potential life-threatening differential diagnoses are eliminated before labeling pediatric patients as having cyclic vomiting syndrome. 1,2 Before any child is diagnosed with chronic cyclic vomiting syndrome, the nurse must complete a swift, organized, age-appropriate physical assessment. The child’s developmental age can help to predict potential catastrophic diagnoses that the symptom of vomiting may represent but that might not yet have been identified. Possible system-related causes of vomiting in children include neurologic conditions, central nervous system dysfunction, mitochondrial disease, autonomic nervous system dysfunction, migraines, and metabolic and endocrine problems. Other system-related causes of vomiting in
VOLUME 41 • ISSUE 3
May 2015
Normandin/PEDIATRIC UPDATE
children include respiratory, cardiac, or gastrointestinal disorders; renal, urinary tract, hepatic, pancreatic, or congenital anomalies; and autoimmune or infectious processes. Some possible external causes of vomiting in children include accidental or nonaccidental trauma; shaken baby syndrome; toxic ingestion of poisons; and environmental exposures, such as carbon monoxide exposure. Adolescents should be questioned regarding chronic cannabis (marijuana) use because of its association with cyclic vomiting syndrome. 3 Ingestion of other illegal substances or alcohol and sexually transmitted infections are differential considerations in the adolescent. Vomiting in children might indicate infectious processes. Children with vomiting might have sepsis, meningitis, viral infections, congenitally acquired infections, bacterial infections, urinary tract infections, pyelonephritis, gastrointestinal infections, blood infections, respiratory infections, or chronic sinusitis. Emergency nurses should advocate for head CT scans of all infants and children who present with repeated episodes of vomiting to rule out any life-threatening brain lesion or intracranial hemorrhage. Psychosocial considerations such as anxiety; depression; mood disorders; eating disorders, including anorexia nervosa and bulimia; and stress can also cause vomiting in children. Assessing infants and children with vomiting in the emergency department can be a challenge. Normal assessment findings would include an anterior fontanelle that is not bulging or depressed in children younger than 2 years, a capillary refill time of less than 2 seconds, intact skin turgor, a moist mouth, tears with crying, a pink color, and a normal voiding pattern as reported by the parent or child. A thorough evaluation should include a complete blood count with differential testing, electrolyte levels, chemistry profiles, blood cultures if a fever is noted, urinalysis, a urine culture, radiographs, cultures for respiratory viruses, rapid influenza swabs, CT scans, magnetic resonance imaging, and lumbar punctures, to name a few. Children with cyclic vomiting syndrome might appear pale, appear listless, be unable to walk, be unable to talk, have severe vomiting, and appear as though they are in shock. If all diagnostic testing results are negative in the emergency department, the child with cyclic vomiting symptoms should be referred to a gastroenterologist. 1 To improve the diagnosis and treatment of cyclic vomiting syndrome, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) developed a position statement that includes the criterion that the number of vomiting episodes should be equal to or greater than 5 total episodes or should be at least 3 episodes over a period of 6 months. These episodic vomiting episodes may last 1 hour to 10 days and
May 2015
VOLUME 41 • ISSUE 3
are usually greater than 1 week apart. These children have a stereotypical pattern of vomiting and symptoms. They vomit 4 or more times in 1 hour. They return to baseline health between vomiting episodes, and no other disorder is identified as the cause for vomiting. Laboratory values, including levels of glucose, electrolytes, blood urea nitrogen, and creatinine, as well as upper gastrointestinal radiographs, should be obtained. If all laboratory results are normal and the child does not have any life-threatening conditions, then he or she is treated for cyclic vomiting syndrome. 1 If the child shows any signs and symptoms of a life-threatening condition, such as gastrointestinal bilious vomiting, abdominal tenderness, or severe abdominal pain, further gastrointestinal testing should be performed. Further diagnostic testing would include abdominal ultrasonography and assessment of serum alanine transaminase, γ-glutamyltransferase, and lipase levels. Metabolic life-threatening concerns may be episodes triggered by illness, a high-protein meal, or fasting. If metabolic concerns are present, further metabolic testing should be performed, including assessment of levels of serum lactic acid, ammonia, amino acids, carnitine, urine ketones, and organic acids. If neurologic life-threatening symptoms, such as abnormal eye movements, papilledema, motor asymmetry, or abnormal gait, are present, then neurologic tests and brain magnetic resonance imaging with contrast should be performed. If any test results are positive, the appropriate specialist should be consulted, such as a gastroenterologist, neurologist, metabolic specialist, endocrinologist, or surgeon. If all test results are normal, then the child is treated for cyclic vomiting syndrome. 1 Treatment for cyclic vomiting syndrome may include intravenous hydration in the emergency department, medications given to stop the vomiting episode, rescue medications during an acute episode, and stress-reduction teachings. The NASPGHAN organization consensus statement recommends that if the child in the emergency department is dehydrated, rehydration should be performed with an initial fluid bolus of 10 mL/kg of normal saline solution, repeated as clinically indicated. Maintenance intravenous fluid to infuse at 1.5 times the maintenance dose can be administered to replace fluid losses and energy. It is recommended that pediatric emergency departments establish emergency and hospital protocols to treat cyclic vomiting syndrome. Emergency departments should provide quiet, darkened rooms for patients with cyclic vomiting syndrome. Vital signs should be taken at least every 4 to 6 hours and more frequently if indicated. Typical emergency protocols for cyclic vomiting syndrome may include antiemetics, such as ondansetron to reduce the vomiting. Analgesics should be given to control severe pain.
WWW.JENONLINE.ORG
261
PEDIATRIC UPDATE/Normandin
Intravenous lorazepam is recommended for comfort. If the child has moderate to severe abdominal pain, administration of intravenous ketorolac can be performed. A pediatric emergency patient with cyclic vomiting syndrome who is 5% dehydrated and has no urine output in greater than 12 hours should be admitted. Other admission criteria are a serum sodium level lower than 130 mEq/L, an anion gap greater than 18 mEq/L, and an inability to stop vomiting. The child should be allowed oral fluid intake as tolerated. 1 Emergency nurses need to recognize that cyclic vomiting syndrome is a potential differential diagnosis for children who present with vomiting. A systematic approach incorporating the child’s developmental age should be considered when ruling out life-threatening diagnoses. Interventions for cyclic vomiting syndrome include providing support to the child with cyclic vomiting syndrome and her or his family, teaching stress-reduction measures as appropriate, and referring the child to a gastroenterologist. It is important for emergency nurses to be aware that infections, psychological stressors, and even usually positive events (holidays, birthdays, vacation) can trigger a cyclic vomiting syndrome episode. Emergency nurses should be aware that infectious triggers for cyclic vomiting syndrome are upper respiratory infections and chronic sinusitis.
262
JOURNAL OF EMERGENCY NURSING
Patient teachings provided to the child and family should include avoidance of known common triggers of cyclic vomiting syndrome such as chocolate, aged cheese, and monosodium glutamate; changes in caffeine intake; physical exhaustion; and menses. The Cyclic Vomiting Syndrome Association, at www.cvsaonline.org, has excellent information for patients and their families. 1 REFERENCES 1. Li B, Williams SE. Cyclic vomiting syndrome clinical features and comorbidities. Contemp Pediatr. 2012;29(9):34-46. 2. Bullard J, Page NE. Cyclic vomiting syndrome: a disease in disguise. Pediatr Nurs. 2005;31(1):27-29. 3. Pattathan MB, Hejazi RA, McCallum RW. Association of marijuana use and cyclic vomiting syndrome. Pharmaceuticals (Basel). 2012;5(7):719-726.
Submissions to this column are encouraged and may be sent to Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P [email protected] or Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN [email protected]
VOLUME 41 • ISSUE 3
May 2015