Pediatric emergency medicine trisk 0522 0522
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TABLE 22.3
OTHER CONSIDERATIONS FOR VOMITING ALONE
Diabetic ketoacidosis
Increased intracranial pressure
Otitis media
Heart failure
Obstruction (e.g., pyloric stenosis)
Urinary tract infection
Ingestion
Age of the child, nutritional status, and type of dehydration may also affect
clinical assessment, which is critical to effective management of the acutely
dehydrated child. In general, older children show signs of dehydration sooner
than babies do because of their lower levels of extracellular water. Babies with
excess subcutaneous fat may look less dehydrated than they really are, whereas
severely malnourished babies may appear to be more dehydrated secondary to
wasted supporting tissues. Signs of dehydration may be less evident or appear
later in hypernatremic dehydration. Excessive irritability with increased muscle
tone, and doughy or smooth and velvety skin, often are noted with this type of
dehydration. Conversely, signs of dehydration may be more pronounced or appear
sooner in hyponatremic dehydration. Keeping these observations in mind,
particular attention should be paid to the overall appearance, mental status, eyes,
and skin on physical examination. Patients with obvious burns or diseases that
disrupt the integument in the same way (e.g., scalded skin syndrome) are
presumed to have become dehydrated through transudation of fluid through the
skin. Additional considerations are listed in Table 22.1 . The mildly dehydrated
child usually appears well or may be tired, have decreased tearing, and a slightly
dry mouth. Dry mucous membranes are an early sign of dehydration, but this
finding is affected by rapid breathing and ingestion of fluids. Conversely, the
severely dehydrated baby classically appears quite ill with lethargy or irritability,
a dry mouth, sunken fontanel, and absent tears. Moderate states of dehydration,
however, require careful evaluation. One of the more objective measures of
dehydration is assessment of skin perfusion by measuring capillary refill time.
Although the child’s body temperature does not predictably affect capillary refill
time, it may be falsely prolonged when measured on the foot or in a cool room.
