Today’s Morning Report comes from our Save of the Month recipient Dr. Melton!
“Please evaluate for projectile vomiting”
A 17 day old baby boy with no significant birth history is sent in by his pediatrician for evaluation of projectile vomiting. Mom states that the vomiting began 4 days prior to presentation. Mom reports a great appetite but multiple episodes of vomiting that have become more forceful.
Pyloric Stenosis and Metabolic Derangements
Pyloric stenosis is caused by an increase in the musculature of the pylorus. Seen
in about 1 in 1000 live births. More common in first born males. Seen between
2 and 8 weeks of life (median, 5 weeks).
Symptoms:
- Non-bilious projectile vomiting
- Dehydration
- Metabolic derangements: hyponatremia, hypokalemic, hypochloremic metabolic alkalosis
Exam:
- General appearance on a spectrum from well appearing to lethargic
- May find “olive shaped mass” in the RUQ.
- May see abdominal peristaltic waves.
- Evidence of dehydration: poor skin turgor, sunken eyes, sunken fontanelle
Everything is chaos: mom is crying, baby looks terrible, the nurse yells the baby is bradycardic! You assess disagree with the nurse but note that the baby has become more lethargic:
- ABCs
- IV, O2, monitor, fingerstick, Labs, ABG, UA, UCx, CXR, temperature
- Resuscitation
Initial treatment:
- 20 cc/kg bolus NS
- Monitor UOP
Hypoglycemia and Pediatrics
Plasma glucose level of <45 milligrams/dL in any symptomatic patient or <35 milligrams/dL in an asymptomatic neonate.
Hypoglycemia in the neonate or infant may result from inadequate oral intake, excess insulin, deficient hyperglycemic hormones, disorders of metabolism, acidurias, or systemic infection (sepsis). Infants of diabetic mothers are at risk for hypoglycemia due to excess fetal insulin level, premature infants or those small for gestational age are at risk due to inadequate glycogen stores.
The dose of dextrose is 0.5 to 1.0 gram/kg regardless of the route of administration. Newborns should receive 5 mL/kg of 10% dextrose (D10), whereas infants and children should receive 2 mL/kg of 25% dextrose.
The younger guys receive the less concentrated dextrose in order to prevent sclerosis of the peripheral veins.
Provide maintenance dextrose at a rate of 6 to 8 milligrams/kg/min with D10, which is 1.5 times the normal maintenance rate for infants and children.
| Age | Dextrose bolus | Dextrose Maintenance | Other Modalities |
| Neonate | D10 5 mL/kg PO/NG/IV/IO | 6 mL/kg/h D10 | Glucagon, 0.3 milligram/kg IM
Hydrocortisone, 25 grams PO/IM/IV/IO |
| Infant | D10 5 mL/kg PO/NG/IV/IO or D25 2 mL/kg | 6 mL/kg/h D10 | Glucagon, 0.3 milligram/kg IM
Hydrocortisone, 25 grams PO/IM/IV/IO |
| Child | D25 2 mL/kg PO/NG/IV/IO | 6 mL/kg/h D10 for the first 10 kg + 3 mL/kg/h for 11–20 kg + 1.5 mL/kg/h for each additional kg >20 kg | Glucagon, 0.3 milligram/kg/IM
Hydrocortisone, 50 grams PO/IM/IV/IO |
| Adolescent | — | 6 mL/kg/h D10 for the first 10 kg + 3 mL/kg/h for 11–20 kg + 1.5 mL/kg/h for each additional kg >20 kg | Glucagon, 0.3 milligram/kg IM
Hydrocortisone, 100 grams PO/IM/IV/IO |
Keep in your back pocket glucagon and hydrocortisone for refractory hypoglycemia.
ED Management of pyloric stenosis:
- Initiate IVF rehydration
- Begin correcting metabolic derangements
- Pediatric surgery and PICU
- Abdominal U/S
Thanks Jay!
Jay Khadpe MD
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