NursePractitioner

ClinicalProtocol
Diarrhoea+/vomiting

ChildandAdolescentHealthService
PrincessMargaretHospitalforChildren

Diarrhoea+/vomiting

NursePractitioner
ClinicalProtocol
EmergencyDepartment

Backgroundand
practicenotes
Scope
Assessmentand
initialintervention

Clinicalprotocolauthorship
andapproval
References
Acknowledgement
Disclaimer

Workingdiagnosis
andinvestigations
Management
Patienteducationand
dischargeinformation

Medications
Managementflowchart
Associateddocuments
Clinicalaudit
Definitionofterms

Backgroundandpracticenotes
MostchildrenpresentingtotheEmergencyDepartment(ED)withgastroenteritisandnocomorbiditieswillnotrequireany
interventionotherthanparentalreassuranceandeducation.Mildcasesofgastroenteritisareusuallyselflimitingandmay
cause mild dehydration, which can be treated or prevented by continued feeding and drinking appropriate amounts of
fluids. Breastfeeding of affected babies should continue even during oral rehydration1,8,11 as it is thought that this may
reduce stool output and shorten duration of diarrhoea.1 Parameters of severity of dehydration vary widely in the
literature.6,8,9Forthepurposeofthisclinicalprotocol,thefollowingdiagnosticcriteriaofmildandmoderatedehydrationwill
beused.8
Nodehydration
Mildtomoderatedehydration
(<3%weightloss)

(38%weightloss)

Nosigns

Drymucousmembranes
Reducedurineoutput

Sunkeneyes
Minimalornotears
Diminishedskinturgor(pinchtest12secs)

Useoforalrehydrationsolutionistherecommendedfirstlinetherapyfortreatingmildtomoderatedehydrationinchildren
with gastroenteritis.2,11 Enteral (oral or nasogastric) rehydration is a much safer means of rehydration compared with
intravenous rehydration because it avoids the risks associated with rapid fluid and electrolyte shifts.8 Diarrhoea and
vomitingsettlesmorequicklyandappetitereturnsearlierwithuseoforalrehydrationtherapy.8Oralrehydrationtherapy
hasbeenshowntobeaseffectiveasintravenoustherapyintreatingmildtomoderatedehydrationinacutegastroenteritis.2
The use of antiemetics for children with gastroenteritis who are vomiting are not routinely indicated, however this issue
remains controversial.3,4 Ondansetron has been shown to reduce the frequency of vomiting, improve the success and
compliancewithoralrehydrationtherapy2,4,5andreducetheneedforintravenoustherapyinsomecases.2Therehavebeen
reports of increased frequency of diarrhoea after its usage, however this is usually transient and well tolerated.2 Some
workplacepracticesupportsOndansetronuseinchildrenwithgastroenteritisbutisreservedasasingleoraldoseforthose
9
1,8
withpersistentvomiting. Antidiarrhoealsshouldnotbeusedforacutediarrhoeainchildren. Theydonotreducefluidand
1
electrolyteloss,maydelayexpulsionoforganismsandmaycauseadverseeffects.
Featuressuggestiveofadiagnosisotherthangastroenteritisinclude:abdominalpainwithsignificanttenderness,distension,
mass or guarding, hepatomegaly, vomiting of blood or bile, bloody diarrhoea, red current jelly stools, pallor, jaundice,
8
systemicallyunwelloutofproportiontothedegreeofdehydration,shockandaneonatewithdiarrhoea. Vomitingalone
8
shouldnotbediagnosedasgastroenteritis. Thefollowingconditionsshouldbeexcludedastheymayhavesimilarfeatures:
appendicitis, antibiotic associated diarrhoea, meningitis, haemolytic uraemic syndrome, urinary tract infection and other
gastrointestinalsurgicalconditionssuchasintussusceptionandpartialbowelobstruction.
NursePractitionerClinicalProtocol
DateIssued:October2011
Diarrhoea+/vomiting
DateRevised:January2012
EmergencyDepartment
ReviewDate:October2013
PrincessMargaretHospital
Authorisedby:PMHEmergencyDepartment
Perth,WesternAustralia
ReviewTeam:PMHEmergencyDepartment
Thisdocumentshouldbereadinconjunctionwithdisclaimerinthisclinicalprotocol

Page1of10

EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Scope

Outcomes

NursePractitioner

MedicalPractitioner+/
NursePractitioner

Childrenolderthan12monthsofagewithacute
onsetofdiarrhoea+/nausea,vomiting,fever,
abdominalpain

Identifypatientssuitablefor
EmergencyNurse
Practitioner(ENP)clinical
protocol
Identifypatientsnotsuitable
Infantslessthan12monthsofage
forENPclinicalprotocoland
Underlyingsignificantmedicalpathology
refertoSeniorMedical
eg:previousgastrointestinalsurgery,metabolic
Practitioner(SMP)
disorders,inflammatoryboweldisease

Evidenceoffailuretothrive
Childrenpresentingwithhistoryofvomitingbileor However,patientcanbe
managedbyENPin
blood,redcurrentjellystoolsormalenaorpale,
consultationwithSMPif
floppyepisodes
appropriate
Unwelllookingorsepticappearance
Evidenceofshockorseveredehydration
Cardiovascularinstability
Severeabdominalpain
Vomitingwithoutdiarrhoea
Historyofdiarrhoeaforgreaterthan10days+/
vomitingforgreaterthan7days

Assessmentandinitialintervention
Primarysurvey

History

Outcomes

Airway
Breathing
Circulation
Disability
Exposure
Signsandsymptomsofcurrentillness:frequency
andnatureofstoolsandvomits
Oralintake,volumeandfluidtype
Urineoutput,numberofwetnappies
Abdominalpain
Urinarysymptoms
Levelofactivity
Riskfactors;recenttravel,knowninfectious
contacts,antibioticrelateddiarrhoea
Pastmedicalhistory
Allergies,immunisationstatus,medications

Abnormalprimarysurvey
identifiedexitENPclinical
protocolandrefertoSMP

Identifypatientsnotsuitable
forENPclinicalprotocoland
refertoSMP

Abnormalexamination
Vitalsigns
outsidedefinedscoperefer
Urinalysisifappropriate(eg:unsettled,poor
toSMP
feeding,vomitingwithoutdiarrhoea)
Generalexamination
Abdominalexamination
Hydrationstatus;mentalstatus,capillaryrefill
time,skinturgor,mucousmembranes,fontanelle,
presenceoftears,+/eyessunken
Weight(bareif<12monthsofage);comparison
withpreillnessandposttreatmentifavailable
(goldstandard7)

Examination

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EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Assessmentandinitialintervention(continued)

Outcomes

Painassessment

Useappropriatepainassessmenttool

Analgesia

Administrationofanalgesiaasrequired Reliefofpain
(refertoPainManagementandProcedural
SedationENPClinicalProtocol)
Notroutinelyindicated

Determineneedforand
typeofanalgesia

Workingdiagnosisandinvestigations
Meetsinclusioncriteria.Historyandexaminationfindingssupportworkingdiagnosisofgastroenteritis.
Imaging

Notroutinelyindicated

Pathology

Stoolculturerequiredforthefollowing:8
Bloodinstool
Suspectedepidemicforfoodpoisoning
Severeorprolongeddiarrhoea(>2weeks)
Recentoverseastravel
Childresidinginaninstitution
Campylobacter,Cryptosporidium,Shigella,
Salmonellaandrotavirusarenotifiablediseases12
Bloodtestsarenotroutinelyindicatedbutmaybe
clinicallyusefulinthefollowingcircumstances:8
Bloodydiarrhoeaconsiderfullbloodcount
(FBC),urea,creatinine
Dehydrationwithdoughyfeeltoskinthat
mightindicatehypernatraemia
Dehydratedchildrenwherehistoryandclinical
examinationareinconsistentwithstraight
forwarddiarrhoealepisode
Anychildreceivingintravenous(IV)rehydration
shouldhavescreeningtestspriortotherapy
includingFBC,ureaandelectrolytes

Appropriatefollowupof
stoolcultureorbloodtestsif
specimentakenduring
presentation

Anychildrequiringablood
testmustbediscussedwith
SMPprior

Page3of10

EmergencyDepartment
PrincessMargaretHospitalforChildren

Management

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Outcomes

Antiemeticsandantidiarrhoealsarenotroutinelyindicatedforchildrenwithacutediarrhoea+/vomiting.1,8,11
Noormilddehydration

Moderatedehydration

Severedehydration

ENPwithviewtodischargehome
Advisesmallfrequentfluidsandfeeds
Continuebreastfeedingifapplicable
ProvidefactsheetGastroenteritisHealthFacts
Discussrepresentationcriteria
Commenceoralfluidtrialusingappropriate
departmentaldocumentation
Oralfluidtrialshouldconsistoforalrehydration
solutionorwater1ml/kgevery5minsandreview
in1hour
Provideparentalsupportandreassuranceduring
thistime
ConsideruseofsingleoraldoseofOndansetron
forchildrenwithpersistentvomitinganddifficulty
toleratingoral/nasogastric(NG)fluidrehydration

Improvementinhydrationstatus
Preparefordischarge
Advisesmallfrequentfluidsandfeeds
Continuebreastfeedingifapplicable
ProvidefactsheetGastroenteritisHealthFacts
Discussrepresentationcriteria

Noorpartialimprovement
DiscusswithandpatientreviewbySMP
ConsiderNGrehydrationat50ml/kgover4hours
IVfluidsmaybeconsideredifolderchildandhas
difficultytoleratingNGtube
Ifrequired0.9%SodiumChlorideand5%Glucose
istheIVrehydrationfluidofchoiceinchildren
(unlesshypernatraemicorhypovolaemicshock,in
whichcaseSodiumChloride0.9%ispreferred)
Refertomedicationsectionofthisprotocolfor
calculationofIVfluidrequirements
AdmittoShortStayUnit
Regularreassessmentofhydrationstatusduring
thistime,weighpatientpostrehydrationand
compareweightwithprehydrationweight
Ifconditionimproves,preparefordischargein
consultationwithSMP
Advisesmallfrequentfluidsandfeeds
Continuebreastfeedingifapplicable
ProvidefactsheetGastroenteritisHealthFacts
Discussrepresentationcriteria
Deteriorationincondition
RefertoSMP

Patientidentifiedassuitable
forENPclinicalprotocoland
dischargedhome

Patientidentifiedassuitable
forENPclinicalprotocoland
dischargedhome

ConsultationwithSMPifno
orminimalimprovementor
ifconditiondeteriorates

ExitENPclinicalprotocol
andrefertoSMP
Page4of10

EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Management(continued)
Recommendationsfor
admission

Acutereferral

Outcomes
Thosechildrenwhoseparentsarenotableto
managethechildsconditionathome
Childrenathigherriskofbecomingdehydrated
maybeobservedforatleast4hourstoensure
adequatemaintenanceofhydrationeg:youngage,
highfrequencyofwaterystoolsandvomits,
childrenwithdisabilityorfeedingissues
Childrenwithseveredehydration
NoorpartialimprovementwithEDregimen
Referralasappropriateto:
Interpreter
Alliedhealth
AboriginalLiaisonOfficer

Patienteducationanddischargeinformation
Dischargecriteria

Treatmentinstructions

Medicationinstructions
Followup/referral

Representationcriteria

Documentation

Expectedoutcome

Appropriatepatient
admission

Patient/parentunderstands
referralprocess

Outcomes

Toleratingoralfluids
Improvementinhydration(isnomorethanmildly
dehydrated)
Nosignsofsepsisorlikelyalternatediagnosis
Considertimeofday,distancefrommedicalcare,
parentconfidenceandunderstanding
Verbalandwritteninstructionsregardingfluid
regimen,breastfeeding,diet,medicationuseand
infectioncontrolmeasures
Identifylikelyprogressionoftheillness,expected
outcome,representationcriteriaandreferrals
VerbalinstructionsgivenbyENP
Simpleanalgesiashorttermifrequired
Notroutinelyrequiredunlessspecificconcerns
AdviseGPfollowupwithin24hoursifconcerned
orotherriskfactorseg:youngerthan12months,
significantlosses(waterystools+/vomits)
Seekfurthermedicaladviceifnotimproving
Verbalandwritteninstructionsasappropriate
Nottoleratingoralfluids
Significantincreaseinlosses
Significantlyreducedurineoutput,increased
lethargy,generallymoreunwell
Parentalconcern
ParenteducationGastroenteritisHealthFacts
GPletterifapplicable
Medicalcertificate/certificateofattendance
Patientmedicalrecord
Appropriatefluidorderdocumentation
Adequatehydrationstatusachievedpriorto
dischargefromED
Hydrationstatusmaintainedfollowingdischarge
Gradualresolutionofsymptomsandreturntopre
illnessbowelhabitswithin710days

Patientsuitablefor
discharge

Patient/parentunderstands
instructionsgiven

Patient/parentunderstands
instructionsgiven
Patient/parentunderstands
followuparrangement

Patient/parentunderstands
criteriaforrepresentation
andisdischargedhome

Appropriatedocumentation
completed

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EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Medications
Preparation

Powderfororalliquidinsachets
Oralliquid

Route/administration

Oralornasogastricuseonly

Dose

Oralfluidtrial:1ml/kgevery5minsfor1hour8
NGrapidrehydration:50ml/kgover4hours8

Pharmacology

Providesfluid,electrolyteandglucosereplacement

Pharmacodynamics

Welltolerated

Indication

Moderatedehydrationcorrectionoffluidandelectrolyteloss
associatedwithdiarrhoea+/vomiting

Contraindications
forENPuse

Childrenwithhistoryofdiabetes,hypertension,renaldisease,
phenylketonuria
Knownhypersensitivitytoanyingredientinoralrehydration
salts

Interactions

Nonereported

Paediatric
considerations

Replacementsolutionsmaybebettertoleratediffrozenand
presentedasaniceblock

Adverseeffects

Nonereported

Patienteducation

Followadministrationdirectionsprovidedandrefertoproduct
information
Donotreconstitutewithdiluentsotherthanwater

Usefullinks

ForfullprescribinginformationrefertoAMHonline

Route/administration

Intravenous

Dose

CalculationofIVfluidrequirements8
100ml/kgper24hoursforfirst10kgofbodyweight
Add50ml/kgper24hoursfornext10kgofbodyweight
Add20ml/kgper24hoursforremainingkgofbodyweight

8
Estimationofdeficitvolume
Thisisbasedontheestimatedpercentageofdehydration
%dehydrationxbodyweight(kg)x10
Administerdeficitvolumeover24hoursseenotebelow

Note:deficitvolumeistobeaddedtomaintenancerequirement
andongoinglossesover24hours;givehalfofthistotalvolumein
thefirst8hoursthenrestoverremaining16hours

Indication

IVrehydrationforchildrenwithmoderatedehydration
correctionoffluidandelectrolytelossassociatedwith
diarrhoea+/vomiting

Contraindications
forENPuse

Childrenwithhypernatraemiaorhypovolaemicshock
Childrenwithdiabetes

Oralrehydration
solution
Unscheduled

Intravenousfluids

0.9%SodiumChloride
with5%Glucose
Unscheduled

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EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Medications(continued)
Preparation

Wafer4mg,8mg
Liquid,each5mlcontains4mgOndansetron

Route/administration

Oral/sublingualuse

Dose

0.15mg/kg/dosetobegivenasasingledoseonly

Pharmacology

Centralandperipheral5HT3receptorblockade
Precisemodeofactioninthecontrolofnauseaandvomitingis
notknown

Pharmacokinetics

Tablet,waferandoralliquidformulationsarebioequivalent
Peakplasmaconcentrationsareachievedinapproximately1.5
hours
Volumeofdistributionis1.8L/kg
MetabolisedbyP450enzymes
Plasmaproteinbindingis7070%
Eliminationhalflifeis411hours

Indication

Persistentnauseaand/orvomitingassociatedwithacute
gastroenteritis

Contraindicationsfor
ENPuse

Childrenwithhistoryofliverimpairment,cardiacdisease(can
causeQTprolongation;usuallytransientandclinically
insignificant),phenylketonuria(waferscontainaspartame)
Childrenyoungerthan2yearsofage
Hypersensitivitytootherselective5HT3receptorantagonists

Interactions

Phenytoin,carbamazepine,rifampicin,tramadol

Adverseeffects

Rarebutmayincludeconstipation,headache,dizziness,
transientriseinaminotransferases,ECGchanges(rare;is
predominantlyassociatedwithintravenousinfusion)

Paediatric
considerations

SeekadvicefromSMPforuseinchildrenyoungerthan2years
ofage
Calculateleanbodyweightwherechildisoverweight

Practicepoints

Ondansetronmaybeusefultoimprovesuccessandcompliance
withoralrehydrationtherapy2,4,5

Usefullinks

ForfullprescribinginformationrefertoAMHonline

Ondansetron
Poisonschedule4

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EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Managementflowchart

Gastroenteritismanagementflowchart

Diarrhoea+/nausea,vomiting,feverand
abdominalpain

Yes

Childyoungerthan12months
Underlyingrelevantmedicalpathology
Systemicallyunwellorevidenceofshock
Cardiovascularinstability
Septicappearance
Bloodinvomitand/orbilestainedvomit
Malenaorredcurrentjellystools
Hxdiarrhoea>10days+/vomitingfor>7days
Vomitingwithoutdiarrhoea

Yes

DiscusswithSMP

No

No

Workingdiagnosisofgastroenteritis

RefertoSMP

Yes
Yes

Severedehydration

RefertoSMP

No
Yes

Moderatedehydration

Commenceoralfluidtrial
Observechildovernexthour

No

Condition
improved

Yes

Partialorno
improvement

Condition
deteriorated

DiscusswithSMP
ConsideradmissionandNG
rehydration/ IVrehydration

RefertoSMP

Yes

Noormilddehydration
Yes
Yes

Meetsdischargecriteria

Providedischargeadvice
Dischargehome

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EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

Associateddocuments
GastroenteritisPMHEmergencyDepartmentClinicalPracticeGuideline2010
PainManagementandProceduralSedationENPClinicalProtocol
Clinicalaudit
Unexpectedrepresentation

EmergencyDepartmentInformationSystemandENPclinicallog

Definitionofterms
EmergencyNursePractitioner
EmergencyDepartment
GeneralPractitioner
AustralianMedicinesHandbook
Intravenous
Nasogastric

ENP
ED
GP
AMH
IV
NG

Clinicalprotocolauthorshipandapproval
Clinicalprotocolauthor

JemmaBatesSmith
ActingNursePractitioner
EmergencyDepartment
Datewritten

October2011

Dateforreview

October2013

Page9of10

EmergencyDepartment
PrincessMargaretHospitalforChildren

NursePractitioner
ClinicalProtocol
Diarrhoea+/vomiting

References
1.

2.
3.

4.

5.
6.

7.

8.
9.
10.
11.
12.

AustralianMedicinesHandbook(online).2011Jul.[cited2011Sept6]. Availablefrom:
http://www.amh.net.au.pklibresources.health.wa.gov.au/online/view.php?page=chapter12/treatdiarrhoea.t.html#d
iarrhoea.t
ChowC,LeungA,HonK.Acutegastroenteritis:fromguidelinestoreallife.ClinicalandExperimental
Gastroenterology.2010;3:97112.
FedorowiczZ,JagannathVA,CarterB.Antiemeticsforreducingvomitingrelatedtoacutegastroenteritisinchildren
andadolescents.CochraneDatabaseofSystematicReviews.2011,Issue9.ArtNo:CD005506.
DOI:10.1002/14651858.CD005506.pub5.
FreedmanSB,SteinerMJ,ChanKJ.Oralondansetronadministrationinemergencydepartmentstochildrenwith
gastroenteritis:Aneconomicanalysis.PLoSMedicine.2010Oct;7(10):e1000350.
doi:10.1371/journal.pmed.1000350.
FreedmanSB,AlderM,SeshadriR,PowellE.Oralondansetronforgastroenteritisinapediatricemergency
department.TheNewEnglandJournalofMedicine.2006Apr;354(16):16981705.
HartlingL,BellemareS,WiebeN,RussellKF,KlassenTP,CraigWR.Oralversusintravenousrehydrationfortreating
dehydrationduetogastroenteritisinchildren(Review).CochraneDatabaseofSystematicReviews.2006,Issue3.Art
No:CD004390.DOI:10.1002/14651858.CD004390.pub2.
MoyerVA,ElliottEJ.Evidencebasedpediatricsandchildhealth[internet].London:BMJPublishingGroup;2004.
Chapter37,AcuteGastroenteritis;p37589.[cited2011Sept12].Availablefrom:
http://books.google.com.au/books?id=V0axOhNjq_QC&pg=PA381&lpg=PA381&dq=gold+standard+weighing+childre
n+with+dehydration&source=bl&ots=GtOVyNiRjv&sig=A
CuDWWnPe3ZRD3zOWtSlNvgsB0&hl=en#v=onepage&q&f=false
PrincessMargaretHospitalforChildren,Perth,WesternAustralia.2010.EmergencyDepartmentClinicalPractice
Guideline,Gastroenteritis.
TheRoyalChildrensHospital,Melbourne,Australia.2009.ClinicalPracticeGuidelines,Gastroenteritis.
TheRoyalChildrensHospital,Melbourne,Australia.2004.NursePractitionerClinicalPracticeGuideline,Diarrhoea
+/vomiting.
TherapeuticGuidelinesonline(eTG).Infectiousdiarrhoea:fluidandelectrolytetherapy(rehydration).2011Feb.
[Cited22Aug2011].Availablefrom:http://online.tg.org.au.pklibresources.health.wa.gov.au/ip/
WesternAustralia,DepartmentofHealth.Notifiablediseases.[cited2011Sept12].Availablefrom:
http://www.public.health.wa.gov.au/3/284/2/notifiable_communicable_diseases.pm

Acknowledgement
PrincessMargaretHospitalwishestoacknowledgeTheRoyalChildrensHospitalinMelbourne,JoondalupHealthCampus
andtheDepartmentofHealth,WesternAustraliafortheirvaluedadviceandsupportwithregardstothecreationofthis
clinicalprotocol.

Disclaimer/Statementofintent
ThisclinicalprotocolisintendedforusebyEmergencyNursePractitioners(ENPs)workingintheEmergencyDepartmentat
PrincessMargaretHospitalforChildreninthemanagementofchildrenpresentingwithsignsandsymptomssuggestiveof
gastroenteritis.
Standardsofcarearedeterminedonthebasisofclinicaldataavailableandaresubjecttochangeasscientificknowledge
and technology advance and patterns of care evolve. The clinical protocols detail diagnostic criteria and appropriate
managementoptions.Departmentalclinicalpracticeguidelinesareavailabletoguidemedicalclinicaldecisionmaking.They
formthefoundationfortheENPclinicalprotocolsandensurethatthepracticeoftheENPisconsistent,safeandthatthe
boundaries of ENP practice are well defined. It should be noted that clinical protocols provide a framework but do not
attempt to take the place of sound clinical judgement. Nurse Practitioners may be responsible for clinical decisions not
adequately defined by clinical protocols and under these circumstances collaboration with a Senior Medical Practitioner
(SMP)willensurethatdecisionsareappropriate.ASMPwillbetheEDConsultantoraSeniorRegistrardelegatedbytheED
Consultant.
NursePractitionerClinicalProtocol
DateIssued:October2011
Diarrhoea+/vomiting
DateRevised:January2012
EmergencyDepartment
ReviewDate:October2013
PrincessMargaretHospital
Authorisedby:PMHEmergencyDepartment
Perth,WesternAustralia
ReviewTeam:PMHEmergencyDepartment
Thisdocumentshouldbereadinconjunctionwithdisclaimerinthisclinicalprotocol

Page10of10