Pediatric emergency medicine trisk 398

Peptic ulcer disease
Pancreatitis
Peritonitis
Paralytic ileus
Crohn disease
Neurologic
Intracranial mass lesions (brain tumors, other)
Cerebral edema
Migraine
Motion sickness
Concussion
Seizures
Renal
Obstructive uropathy
Renal insufficiency/uremia
Renal tubular acidosis
Infectious
Meningitis
Urinary tract infection
Hepatitis
Upper respiratory infection (postnasal drip)
Metabolic
Diabetic ketoacidosis
Reye syndrome
Adrenal insufficiency
Inborn error of metabolism (urea cycle or fatty acid oxidation defect; acute,
intermittent porphyria)
Toxins and drugs
Aspirin
Ipecac
Digoxin

Iron
Lead (chronic)
Respiratory (posttussive)


Asthma exacerbation
Infectious respiratory disease (pneumonia, bronchiolitis)
Foreign body
Other
Pregnancy
Cyclic vomiting


TABLE 81.2
LIFE-THREATENING CAUSES OF VOMITING
Newborn (birth to 2 wks)
Anatomic anomalies—esophageal stenosis/atresia; intestinal obstructions (
Table 81.1 ), especially malrotation and volvulus; Hirschsprung disease
Other gastrointestinal (GI) causes
Necrotizing enterocolitis
Peritonitis
Neurologic—kernicterus, mass lesions, hydrocephalus
Renal—obstructive anomalies, uremia
Infectious—sepsis, meningitis
Metabolism—inborn errors, especially congenital adrenal hyperplasia
Older infant (2 wks to 12 mo)
Intestinal obstruction ( Table 81.1 ), especially pyloric stenosis,
intussusception, incarcerated hernia, malrotation with volvulus
Other GI causes, especially gastroenteritis (with dehydration)
Neurologic—mass lesions, hydrocephalus

Renal—obstruction, uremia
Infectious—sepsis, meningitis, pertussis
Metabolic—inborn errors of metabolism
Toxins, drugs
Older child (older than 12 mo)
GI obstruction, especially intussusception ( Table 81.1 )
Other GI causes, especially appendicitis, peptic ulcer disease
Neurologic—mass lesions
Renal—uremia
Infectious—meningitis, sepsis
Metabolic—diabetic ketoacidosis, adrenal insufficiency, inborn errors of
metabolism
Toxins, drugs
The diverse nature of causes for vomiting makes a routine laboratory or
radiologic screen impossible. The history and physical examination must guide
the approach in individual patients. Certain well-defined clinical pictures demand


urgent radiologic workup. For example, abdominal pain and bilious vomiting in
an infant requires supine and upright plain films, as well as a limited upper GI
series for evaluation of congenital obstructive anomalies such as malrotation. A
child with paroxysms of colicky abdominal pain and grossly bloody stools
requires immediate ultrasound for rapid diagnosis of intussusception, or in clearcut cases should proceed directly to an air-contrast enema for both diagnosis and
reduction of the intussusception. Other situations require no imaging studies (e.g.,
a typical case of viral gastroenteritis). In many cases, cultures or serum chemical
analyses are essential for making a diagnosis (e.g., meningitis, aspirin toxicity,
urinary tract infection [UTI], pregnancy) or for guiding management (e.g., degree
of metabolic derangement in severe dehydration, pyloric stenosis, diabetic
ketoacidosis). For most straightforward, common illnesses (e.g., gastroenteritis,
respiratory infections with posttussive emesis), laboratory investigation is

unwarranted.