Vomiting In The ChildAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

553 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx70

Approach to the critical patient

›Initial context

›Time of last normal

›Pre arrival events

›Triage acuity trigger

HPI overview

›Symptom summary

›Primary symptom

›Time course pattern

›Prior similar episodes

OPQRST Onset

›Onset details

›Sudden

›Gradual

›Time since onset

OPQRST Provocation or palliation

›Modifiers

›Triggered by intake

›Triggered by motion

›Triggered by pain

›Relieved by antiemetic

OPQRST Quality

›Emesis characterization

›Non bilious

›Bilious

›Projectile

›Coffee ground appearance

›Hematemesis

OPQRST Region or radiation

›Pain association

›No abdominal pain

›Epigastric

›Periumbilical

›Right lower quadrant

›Flank

OPQRST Severity

›Burden

›Number of episodes

›Inability to keep fluids down

›Degree of dehydration concern

OPQRST Timing

›Temporal pattern

›Post prandial

›Nocturnal awakening

›Cyclic pattern

›Progressive worsening

Associated symptoms

›Symptom cluster

›Fever

›Diarrhea

›Constipation

›Abdominal distension

›Blood in stool

›Headache

›Neck pain

›Photophobia

›Dizziness or syncope

›Dysuria

›Rash

›Cough or rhinorrhea

Hydration and intake

›Volume status history

›Oral intake tolerance

›Urine output change

›Wet diaper count

›Tears present

›Weight change

Infectious exposure and outbreak context

›Exposure history

›Sick contacts

›Daycare or school outbreak

›Recent travel

›Foodborne exposure

Age specific history

›Neonate and infant considerations

›Feeding difficulty

›Lethargy

›Bulging fontanelle concern

›Older child considerations

›Migraine history

›Cannabis exposure

›Eating disorder behaviors

02Alarm Features/alarm32

Immediate escalation triggers

›Resuscitation triggers

›Altered mental status

›Shock physiology

›Respiratory distress

›Persistent bilious emesis

›Concern for surgical abdomen

Vital sign danger thresholds

›High risk vitals

›Hypotension for age

›Tachycardia out of proportion to fever

›Tachypnea with metabolic compensation concern

›Hypoxia

›Temperature 38.0 C in infant under 3 months

High risk vomit characteristics

›Concerning content

›Bilious

›Hematemesis

›Coffee ground material

›Feculent appearance

High risk abdominal features

›Surgical abdomen features

›Peritoneal signs

›Abdominal distension with pain

›Severe localized right lower quadrant pain

›Palpable mass

High risk neurologic features

›Raised intracranial pressure concern

›Morning vomiting

›Headache with vomiting

›Focal neurologic deficit

›Papilledema

High risk metabolic features

›Endocrine and toxin concern

›Hypoglycemia

›Hyperglycemia with dehydration

›Kussmaul breathing

›Severe lethargy without fever

03Medications/meds21

Current medication list

›Home medications

›Prescription medications

›Recent antibiotic exposure

›Recent corticosteroid exposure

OTC exposures

›Non prescription agents

›Acetaminophen exposure

›Ibuprofen exposure

›Bismuth exposure

Antiemetic use

›Prior antiemetics

›Ondansetron

›Dimenhydrinate

›Promethazine exposure

High risk medication classes

›Medication adverse effect risk

›Opioids

›Iron products

›Digoxin

›GLP 1 receptor agonists

Contraindications and interaction traps

›Common conflicts

›QT prolonging medications

›Serotonergic medications

›Anticholinergic burden

04Diet/diet16

Recent intake pattern

›Intake changes

›Poor oral intake duration

›Breastfeeding tolerance

›Formula changes

Hydration indicators

›Fluid status markers

›Refusal of fluids

›Excess free water intake

›Oral rehydration solution use

Trigger exposures

›Dietary triggers

›High fat meal

›New foods

›Suspect spoiled food

Substance exposure

›Relevant ingestions

›Caffeine or energy drinks

›Alcohol exposure

›Cannabis exposure

05Review of Systems/ros25

General

›Constitutional

›Fever

›Weight loss

›Fatigue or lethargy

›Gastrointestinal

›Abdominal pain

›Diarrhea

›Constipation

›Hematochezia

›Melena

›Genitourinary

›Dysuria

›Urinary frequency

›Flank pain

Respiratory

›Airway and lungs

›Cough

›Dyspnea

›Wheeze

Neuro

›Neurologic

›Headache

›Neck stiffness

›Seizure

Skin

›Dermatologic

›Rash

›Petechiae or purpura

06Collateral History and Family History/chafh16

Collateral source

›Reliability

›Parent or guardian report

›School or daycare report

›EMS report

Family history

›Inherited and recurrent patterns

›Migraine

›Cyclic vomiting syndrome

›Metabolic disorders

Household exposures

›Shared illness risk

›Sick contacts

›Recent gastroenteritis cluster

›Food preparation exposures

Supervision and safety

›Home context

›Medication access at home

›Substance access at home

›Ability to monitor intake and output

07Risk Factors/rf20

Age and developmental risk

›Vulnerable groups

›Infant under 3 months

›Prematurity history

›Developmental delay affecting hydration

Exposure risks

›Infection and toxin risks

›Daycare exposure

›Recent travel

›Reptile exposure

Surgical and anatomic risks

›Obstruction risk

›Prior abdominal surgery

›Hernia history

›Known malrotation

Metabolic and endocrine risks

›Decompensation risks

›Type 1 diabetes mellitus (E10.9)

›Adrenal insufficiency (E27.1)

›Inborn errors of metabolism

Immunocompromise

›Severe infection risk

›Chemotherapy

›Transplant

›Primary immunodeficiency

08Differential Diagnosis/ddx58

Life threatening

›Cannot miss etiologies

›Midgut volvulus with malrotation (K56.2)

›Bilious vomiting

›Rapid progression to shock

›Intussusception (K56.1)

›Intermittent colicky pain

›Lethargy out of proportion

›Bloody stool or currant jelly stool

›Appendicitis with perforation (K35.32)

›Right lower quadrant pain

›Guarding or rebound

›Diabetic ketoacidosis (E10.10)

›Polyuria or polydipsia

›Tachypnea

›Abdominal pain

›Sepsis or meningitis

›Fever with toxicity

›Neck stiffness

›Altered mental status

›Toxic ingestion

›Unsupervised access history

›Unexplained bradycardia or tachyarrhythmia

Common

›High probability etiologies

›Viral gastroenteritis (A08.4)

›Sick contacts

›Diarrhea

›Dehydration (E86.0)

›Reduced urine output

›Dry mucosa

›Constipation (K59.00)

›Hard stools

›Stool withholding behaviors

›UTI or pyelonephritis (N39.0)

›Dysuria

›Fever without source

›Foodborne illness

›Shared meal exposure

›Rapid onset vomiting

Less common

›Lower probability etiologies

›Cyclic vomiting syndrome (G43.A0)

›Stereotyped episodes

›Symptom free intervals

›Migraine associated vomiting (G43.909)

›Headache history

›Photophobia

›Gastritis or peptic disease (K29.70)

›Epigastric pain

›NSAID exposure

›Pneumonia (J18.9)

›Cough

›Tachypnea

›Intracranial mass effect

›Morning vomiting

›New headache pattern

Mimics and pitfalls

›Diagnostic traps

›Early appendicitis with minimal tenderness

›DKA misattributed to gastroenteritis

›Bilious vomiting mislabeled as reflux

09Past Medical History/pmh14

Chronic conditions

›Baseline conditions

›Gastroesophageal reflux disease (K21.9)

›Chronic constipation (K59.00)

›Diabetes mellitus

Prior similar episodes

›Recurrence pattern

›Prior ED visits for vomiting

›Prior admissions for dehydration

Surgical history

›Relevant surgeries

›Abdominal surgery

›Hernia repair

Baseline function

›Functional status

›Baseline oral intake

›Baseline urine output

›Weight trajectory

10Physical Exam/exam35

General and vitals interpretation

›Appearance

›Toxic appearance

›Consolability

›Level of alertness

›Vitals pattern

›Tachycardia with dehydration

›Fever pattern

Hydration assessment

›Dehydration markers

›Mucous membranes dry

›Tears absent

›Capillary refill prolonged

›Skin turgor reduced

›Sunken eyes

HEENT

›Head and neck

›Fontanelle status

›Signs of otitis media

›Neck stiffness

Cardiopulmonary

›Heart and lungs

›Perfusion quality

›Work of breathing

›Focal lung findings

Abdominal exam

›Abdominal findings

›Distension

›Tenderness location

›Guarding

›Rebound

›Palpable mass

Skin

›Cutaneous findings

›Rash pattern

›Petechiae

›Signs of dehydration

Neuro

›Neurologic status

›Gait if age appropriate

›Focal deficit

›Papilledema concern

11Lab Studies/labs39

Point of care tests

›Rapid bedside tests

›Glucose

›Hypoglycemia threshold local protocol dependent

›Hyperglycemia with dehydration prompt ketone testing

›Capillary ketones

›Elevated ketones prompt DKA evaluation

›Starvation ketosis possible with prolonged poor intake

Basic labs for moderate or severe illness

›Core evaluation

›Electrolytes

›Sodium abnormalities with dehydration

›Potassium abnormalities with vomiting

›Urea and creatinine

›Prerenal azotemia support dehydration

›Baseline kidney disease consideration

Acid base and DKA evaluation

›Metabolic assessment

›Venous blood gas

›Acidosis with Kussmaul breathing concern

›Interpretation with clinical context

›Beta hydroxybutyrate

›High level supports DKA

›Lower level possible starvation ketosis

Infection evaluation when indicated

›Infection focused tests

›CBC

›Leukocytosis non specific

›Neutrophil predominance support bacterial pattern

›CRP or ESR

›Adjunct for appendicitis pathways

›Not rule out test

Urine testing

›Genitourinary evaluation

›Urinalysis

›Leukocyte esterase and nitrites support UTI

›Ketones support dehydration or ketosis

›Urine culture

›Febrile UTI pathway

›Prior antibiotic exposure reduces yield

Pregnancy related testing

›Post menarche evaluation

›Beta hCG

›Ectopic pregnancy risk with pain

›Hyperemesis gravidarum consideration

12Imaging/img42

Scoring Systems

›Risk tools

›Pediatric Appendicitis Score

›Migration of pain

›Anorexia

›Nausea or vomiting

›Right lower quadrant tenderness

›Cough percussion hopping tenderness

›Fever

›Leukocytosis

›Neutrophilia

›Pediatric Appendicitis Risk Calculator

›Age and sex inputs

›Symptom duration inputs

›Exam findings inputs

›Lab inputs

›Clinical Dehydration Scale

›General appearance

›Eyes

›Mucous membranes

›Tears

MRI

›MRI abdomen pelvis

›Appendicitis evaluation when ultrasound nondiagnostic

›Avoid ionizing radiation when feasible

›Limitations

›Availability and sedation needs

›Time to imaging

›CT abdomen pelvis

›Suspected appendicitis with nondiagnostic ultrasound and high risk features

›Suspected obstruction with unclear diagnosis

›Contrast considerations

›Allergy history

›Kidney function concern

›Radiation considerations

›Use pediatric dose protocols

›Shared decision making with caregivers

Ultrasound

›Abdominal ultrasound

›First line for suspected appendicitis in many pediatric pathways

›Intussusception evaluation

›Pyloric stenosis evaluation in young infants

›Pitfalls

›Operator dependence

›Nonvisualized appendix does not exclude appendicitis

13Special Tests/spec26

Bedside and procedural diagnostics

›Focused bedside tests

›Stool occult blood testing

›Bloody diarrhea differential support

›Interpretation limited by diet and perianal irritation

›Nasogastric aspirate consideration

›Persistent hematemesis evaluation pathway dependent

›Specialist input recommended

Toxicology testing when indicated

›Ingestion evaluation

›Acetaminophen level time based interpretation

›Use nomogram when single acute ingestion

›Unknown timing increases risk

›Salicylate level

›Mixed acid base disturbance pattern

›Symptoms may be delayed

Infectious stool testing when indicated

›Stool studies

›Stool PCR panels local protocol dependent

›Ova and parasites

›Travel exposure

›Prolonged diarrhea

Metabolic testing when indicated

›Expanded evaluation

›Ammonia

›Unexplained encephalopathy

›Sample handling pitfalls

›Lactate

›Shock physiology marker

›Nonspecific elevation

14ECG/ecg11

Indications

›ECG triggers

›Syncope with vomiting

›Significant electrolyte abnormality concern

›QT risk medications

High risk findings

›Dangerous patterns

›QT prolongation

›Ventricular ectopy

›Conduction block

Serial timing

›Repeat strategy

›After electrolyte correction if QT prolonged

›After high risk antiemetic exposure if symptoms develop

15Assessment/ax28

Problem representation

›Working syndromes

›Acute vomiting with dehydration (E86.0)

›Poor intake

›Reduced urine output

›Suspected gastroenteritis (A08.4)

›Sick contacts

›Diarrhea present

Severity stratification

›Dehydration severity

›Mild

›Thirst with normal perfusion

›Normal mental status

›Moderate

›Tachycardia

›Delayed cap refill

›Severe

›Hypotension for age

›Altered mental status

Alternate diagnoses to actively exclude

›High consequence exclusions

›Bilious vomiting obstruction pathway

›Malrotation with volvulus concern

›Immediate surgical consultation trigger

›DKA pathway

›Hyperglycemia

›Acidosis

Diagnostic uncertainty

›Reassessment targets

›Evolution of abdominal tenderness

›Response to fluids and antiemetic

›New neurologic findings

16Plan/plan39

First 5 minutes workflow

›Stabilization priorities

›Continuous monitoring for ill appearing child

›IV access criteria

›Moderate or severe dehydration

›Failure of oral rehydration

›Bedside glucose target within minutes for altered mental status

Fluids and rehydration

›Rehydration strategy

›Oral rehydration solution

›Small frequent volumes

›Re dose after emesis episodes

›IV isotonic fluids for moderate or severe dehydration

›20 mL per kg bolus local protocol dependent

›Repeat bolus based on perfusion and vitals

Antiemetics

›Ondansetron

›Oral dose 0.15 mg per kg

›Maximum single dose 8 mg

›Avoid in

›Congenital long QT syndrome

›Significant electrolyte abnormalities until corrected

›Dimenhydrinate

›Dose local protocol dependent

›Avoid in

›Significant sedation risk

›Anticholinergic toxidrome concern

Analgesia when pain present

›Pain control

›Acetaminophen weight based dosing local protocol dependent

›Ibuprofen weight based dosing local protocol dependent

Diagnostic sequencing

›Testing logic

›If bilious emesis then urgent imaging pathway

›If focal right lower quadrant pain then appendicitis pathway

›If fever without source then urine testing pathway

Monitoring and reassessment loop

›Reassessment cadence

›Repeat vitals after fluids

›Repeat abdominal exam after analgesia and hydration

›Oral challenge after antiemetic

Consultation

›Specialty triggers

›Surgery for bilious emesis or peritoneal signs

›Pediatrics for infant under 3 months with vomiting and fever

›Toxicology for suspected ingestion

17Disposition/dispo21

ICU criteria

›Critical care triggers

›Shock requiring repeated boluses with ongoing instability

›Severe metabolic acidosis

›Altered mental status not rapidly reversible

Inpatient admission criteria

›Admission triggers

›Persistent inability to tolerate oral fluids

›Moderate or severe dehydration needing ongoing IV fluids

›Suspected surgical diagnosis

›Social reliability concerns for monitoring

Observation pathway criteria

›Short stay criteria

›Improved vitals after rehydration

›Needs reassessment of abdominal findings

›Uncertain diagnosis requiring serial exams

Discharge criteria

›Safe discharge features

›Tolerating oral fluids

›Normal mental status

›Improving vitals and perfusion

›Caregivers able to monitor intake and urine output

Follow up timing

›Outpatient plan

›Primary care within 24 to 48 hours if persistent symptoms

›Return evaluation same day if worsening

18Discharge Instructions/di23

Copy discharge instructions

›You were seen for vomiting

›Most causes are viral and improve with time

›The most important treatment is keeping up with fluids

›Fluids

›Give small amounts often

›Use oral rehydration solution if available

›Medicines

›Use the prescribed anti nausea medicine only as directed

›Do not use other anti nausea medicines unless instructed

›Eating

›Resume light foods when hungry

›Avoid very greasy foods until better

›Return to the emergency department now if any of these happen

›Green vomiting

›Blood in vomit

›Severe belly pain

›Sleepy or hard to wake

›Trouble breathing

›No urine for a long time

›Signs of dehydration getting worse

›Follow up

›See your doctor in 1 to 2 days if not improving

›Come back sooner if symptoms worsen

19References/r17

Guidelines and evidence

›American Academy of Pediatrics acute gastroenteritis guidance local protocol dependent

›Oral rehydration therapy as first line

›Antiemetic use varies by pathway

›NICE guideline gastroenteritis in children 2009 updated local protocol dependent

›Dehydration assessment framework

›Rehydration recommendations

›CDC acute gastroenteritis and dehydration resources local protocol dependent

›Oral rehydration solution principles

›Red flag features

›American College of Radiology appropriateness criteria suspected appendicitis child local protocol dependent

›Ultrasound first pathways

›CT and MRI second line considerations

›Pediatric Appendicitis Score validation studies local protocol dependent

›Risk stratification support

›Not a stand alone rule out tool

›Project instructions file

›Formatting and structure rules

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Vomiting In The ChildAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

553 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx70

Approach to the critical patient

›Initial context

›Time of last normal

›Pre arrival events

›Triage acuity trigger

HPI overview

›Symptom summary

›Primary symptom

›Time course pattern

›Prior similar episodes

OPQRST Onset

›Onset details

›Sudden

›Gradual

›Time since onset

OPQRST Provocation or palliation

›Modifiers

›Triggered by intake

›Triggered by motion

›Triggered by pain

›Relieved by antiemetic

OPQRST Quality

›Emesis characterization

›Non bilious

›Bilious

›Projectile

›Coffee ground appearance

›Hematemesis

OPQRST Region or radiation

›Pain association

›No abdominal pain

›Epigastric

›Periumbilical

›Right lower quadrant

›Flank

OPQRST Severity

›Burden

›Number of episodes

›Inability to keep fluids down

›Degree of dehydration concern

OPQRST Timing

›Temporal pattern

›Post prandial

›Nocturnal awakening

›Cyclic pattern

›Progressive worsening

Associated symptoms

›Symptom cluster

›Fever

›Diarrhea

›Constipation

›Abdominal distension

›Blood in stool

›Headache

›Neck pain

›Photophobia

›Dizziness or syncope

›Dysuria

›Rash

›Cough or rhinorrhea

Hydration and intake

›Volume status history

›Oral intake tolerance

›Urine output change

›Wet diaper count

›Tears present

›Weight change

Infectious exposure and outbreak context

›Exposure history

›Sick contacts

›Daycare or school outbreak

›Recent travel

›Foodborne exposure

Age specific history

›Neonate and infant considerations

›Feeding difficulty

›Lethargy

›Bulging fontanelle concern

›Older child considerations

›Migraine history

›Cannabis exposure

›Eating disorder behaviors

02Alarm Features/alarm32

Immediate escalation triggers

›Resuscitation triggers

›Altered mental status

›Shock physiology

›Respiratory distress

›Persistent bilious emesis

›Concern for surgical abdomen

Vital sign danger thresholds

›High risk vitals

›Hypotension for age

›Tachycardia out of proportion to fever

›Tachypnea with metabolic compensation concern

›Hypoxia

›Temperature 38.0 C in infant under 3 months

High risk vomit characteristics

›Concerning content

›Bilious

›Hematemesis

›Coffee ground material

›Feculent appearance

High risk abdominal features

›Surgical abdomen features

›Peritoneal signs

›Abdominal distension with pain

›Severe localized right lower quadrant pain

›Palpable mass

High risk neurologic features

›Raised intracranial pressure concern

›Morning vomiting

›Headache with vomiting

›Focal neurologic deficit

›Papilledema

High risk metabolic features

›Endocrine and toxin concern

›Hypoglycemia

›Hyperglycemia with dehydration

›Kussmaul breathing

›Severe lethargy without fever

03Medications/meds21

Current medication list

›Home medications

›Prescription medications

›Recent antibiotic exposure

›Recent corticosteroid exposure

OTC exposures

›Non prescription agents

›Acetaminophen exposure

›Ibuprofen exposure

›Bismuth exposure

Antiemetic use

›Prior antiemetics

›Ondansetron

›Dimenhydrinate

›Promethazine exposure

High risk medication classes

›Medication adverse effect risk

›Opioids

›Iron products

›Digoxin

›GLP 1 receptor agonists

Contraindications and interaction traps

›Common conflicts

›QT prolonging medications

›Serotonergic medications

›Anticholinergic burden

04Diet/diet16

Recent intake pattern

›Intake changes

›Poor oral intake duration

›Breastfeeding tolerance

›Formula changes

Hydration indicators

›Fluid status markers

›Refusal of fluids

›Excess free water intake

›Oral rehydration solution use

Trigger exposures

›Dietary triggers

›High fat meal

›New foods

›Suspect spoiled food

Substance exposure

›Relevant ingestions

›Caffeine or energy drinks

›Alcohol exposure

›Cannabis exposure

05Review of Systems/ros25

General

›Constitutional

›Fever

›Weight loss

›Fatigue or lethargy

›Gastrointestinal

›Abdominal pain

›Diarrhea

›Constipation

›Hematochezia

›Melena

›Genitourinary

›Dysuria

›Urinary frequency

›Flank pain

Respiratory

›Airway and lungs

›Cough

›Dyspnea

›Wheeze

Neuro

›Neurologic

›Headache

›Neck stiffness

›Seizure

Skin

›Dermatologic

›Rash

›Petechiae or purpura

06Collateral History and Family History/chafh16

Collateral source

›Reliability

›Parent or guardian report

›School or daycare report

›EMS report

Family history

›Inherited and recurrent patterns

›Migraine

›Cyclic vomiting syndrome

›Metabolic disorders

Household exposures

›Shared illness risk

›Sick contacts

›Recent gastroenteritis cluster

›Food preparation exposures

Supervision and safety

›Home context

›Medication access at home

›Substance access at home

›Ability to monitor intake and output

07Risk Factors/rf20

Age and developmental risk

›Vulnerable groups

›Infant under 3 months

›Prematurity history

›Developmental delay affecting hydration

Exposure risks

›Infection and toxin risks

›Daycare exposure

›Recent travel

›Reptile exposure

Surgical and anatomic risks

›Obstruction risk

›Prior abdominal surgery

›Hernia history

›Known malrotation

Metabolic and endocrine risks

›Decompensation risks

›Type 1 diabetes mellitus (E10.9)

›Adrenal insufficiency (E27.1)

›Inborn errors of metabolism

Immunocompromise

›Severe infection risk

›Chemotherapy

›Transplant

›Primary immunodeficiency

08Differential Diagnosis/ddx58

Life threatening

›Cannot miss etiologies

›Midgut volvulus with malrotation (K56.2)

›Bilious vomiting

›Rapid progression to shock

›Intussusception (K56.1)

›Intermittent colicky pain

›Lethargy out of proportion

›Bloody stool or currant jelly stool

›Appendicitis with perforation (K35.32)

›Right lower quadrant pain

›Guarding or rebound

›Diabetic ketoacidosis (E10.10)

›Polyuria or polydipsia

›Tachypnea

›Abdominal pain

›Sepsis or meningitis

›Fever with toxicity

›Neck stiffness

›Altered mental status

›Toxic ingestion

›Unsupervised access history

›Unexplained bradycardia or tachyarrhythmia

Common

›High probability etiologies

›Viral gastroenteritis (A08.4)

›Sick contacts

›Diarrhea

›Dehydration (E86.0)

›Reduced urine output

›Dry mucosa

›Constipation (K59.00)

›Hard stools

›Stool withholding behaviors

›UTI or pyelonephritis (N39.0)

›Dysuria

›Fever without source

›Foodborne illness

›Shared meal exposure

›Rapid onset vomiting

Less common

›Lower probability etiologies

›Cyclic vomiting syndrome (G43.A0)

›Stereotyped episodes

›Symptom free intervals

›Migraine associated vomiting (G43.909)

›Headache history

›Photophobia

›Gastritis or peptic disease (K29.70)

›Epigastric pain

›NSAID exposure

›Pneumonia (J18.9)

›Cough

›Tachypnea

›Intracranial mass effect

›Morning vomiting

›New headache pattern

Mimics and pitfalls

›Diagnostic traps

›Early appendicitis with minimal tenderness

›DKA misattributed to gastroenteritis

›Bilious vomiting mislabeled as reflux

09Past Medical History/pmh14

Chronic conditions

›Baseline conditions

›Gastroesophageal reflux disease (K21.9)

›Chronic constipation (K59.00)

›Diabetes mellitus

Prior similar episodes

›Recurrence pattern

›Prior ED visits for vomiting

›Prior admissions for dehydration

Surgical history

›Relevant surgeries

›Abdominal surgery

›Hernia repair

Baseline function

›Functional status

›Baseline oral intake

›Baseline urine output

›Weight trajectory

10Physical Exam/exam35

General and vitals interpretation

›Appearance

›Toxic appearance

›Consolability

›Level of alertness

›Vitals pattern

›Tachycardia with dehydration

›Fever pattern

Hydration assessment

›Dehydration markers

›Mucous membranes dry

›Tears absent

›Capillary refill prolonged

›Skin turgor reduced

›Sunken eyes

HEENT

›Head and neck

›Fontanelle status

›Signs of otitis media

›Neck stiffness

Cardiopulmonary

›Heart and lungs

›Perfusion quality

›Work of breathing

›Focal lung findings

Abdominal exam

›Abdominal findings

›Distension

›Tenderness location

›Guarding

›Rebound

›Palpable mass

Skin

›Cutaneous findings

›Rash pattern

›Petechiae

›Signs of dehydration

Neuro

›Neurologic status

›Gait if age appropriate

›Focal deficit

›Papilledema concern

11Lab Studies/labs39

Point of care tests

›Rapid bedside tests

›Glucose

›Hypoglycemia threshold local protocol dependent

›Hyperglycemia with dehydration prompt ketone testing

›Capillary ketones

›Elevated ketones prompt DKA evaluation

›Starvation ketosis possible with prolonged poor intake

Basic labs for moderate or severe illness

›Core evaluation

›Electrolytes

›Sodium abnormalities with dehydration

›Potassium abnormalities with vomiting

›Urea and creatinine

›Prerenal azotemia support dehydration

›Baseline kidney disease consideration

Acid base and DKA evaluation

›Metabolic assessment

›Venous blood gas

›Acidosis with Kussmaul breathing concern

›Interpretation with clinical context

›Beta hydroxybutyrate

›High level supports DKA

›Lower level possible starvation ketosis

Infection evaluation when indicated

›Infection focused tests

›CBC

›Leukocytosis non specific

›Neutrophil predominance support bacterial pattern

›CRP or ESR

›Adjunct for appendicitis pathways

›Not rule out test

Urine testing

›Genitourinary evaluation

›Urinalysis

›Leukocyte esterase and nitrites support UTI

›Ketones support dehydration or ketosis

›Urine culture

›Febrile UTI pathway

›Prior antibiotic exposure reduces yield

Pregnancy related testing

›Post menarche evaluation

›Beta hCG

›Ectopic pregnancy risk with pain

›Hyperemesis gravidarum consideration

12Imaging/img42

Scoring Systems

›Risk tools

›Pediatric Appendicitis Score

›Migration of pain

›Anorexia

›Nausea or vomiting

›Right lower quadrant tenderness

›Cough percussion hopping tenderness

›Fever

›Leukocytosis

›Neutrophilia

›Pediatric Appendicitis Risk Calculator

›Age and sex inputs

›Symptom duration inputs

›Exam findings inputs

›Lab inputs

›Clinical Dehydration Scale

›General appearance

›Eyes

›Mucous membranes

›Tears

MRI

›MRI abdomen pelvis

›Appendicitis evaluation when ultrasound nondiagnostic

›Avoid ionizing radiation when feasible

›Limitations

›Availability and sedation needs

›Time to imaging

›CT abdomen pelvis

›Suspected appendicitis with nondiagnostic ultrasound and high risk features

›Suspected obstruction with unclear diagnosis

›Contrast considerations

›Allergy history

›Kidney function concern

›Radiation considerations

›Use pediatric dose protocols

›Shared decision making with caregivers

Ultrasound

›Abdominal ultrasound

›First line for suspected appendicitis in many pediatric pathways

›Intussusception evaluation

›Pyloric stenosis evaluation in young infants

›Pitfalls

›Operator dependence

›Nonvisualized appendix does not exclude appendicitis

13Special Tests/spec26

Bedside and procedural diagnostics

›Focused bedside tests

›Stool occult blood testing

›Bloody diarrhea differential support

›Interpretation limited by diet and perianal irritation

›Nasogastric aspirate consideration

›Persistent hematemesis evaluation pathway dependent

›Specialist input recommended

Toxicology testing when indicated

›Ingestion evaluation

›Acetaminophen level time based interpretation

›Use nomogram when single acute ingestion

›Unknown timing increases risk

›Salicylate level

›Mixed acid base disturbance pattern

›Symptoms may be delayed

Infectious stool testing when indicated

›Stool studies

›Stool PCR panels local protocol dependent

›Ova and parasites

›Travel exposure

›Prolonged diarrhea

Metabolic testing when indicated

›Expanded evaluation

›Ammonia

›Unexplained encephalopathy

›Sample handling pitfalls

›Lactate

›Shock physiology marker

›Nonspecific elevation

14ECG/ecg11

Indications

›ECG triggers

›Syncope with vomiting

›Significant electrolyte abnormality concern

›QT risk medications

High risk findings

›Dangerous patterns

›QT prolongation

›Ventricular ectopy

›Conduction block

Serial timing

›Repeat strategy

›After electrolyte correction if QT prolonged

›After high risk antiemetic exposure if symptoms develop

15Assessment/ax28

Problem representation

›Working syndromes

›Acute vomiting with dehydration (E86.0)

›Poor intake

›Reduced urine output

›Suspected gastroenteritis (A08.4)

›Sick contacts

›Diarrhea present

Severity stratification

›Dehydration severity

›Mild

›Thirst with normal perfusion

›Normal mental status

›Moderate

›Tachycardia

›Delayed cap refill

›Severe

›Hypotension for age

›Altered mental status

Alternate diagnoses to actively exclude

›High consequence exclusions

›Bilious vomiting obstruction pathway

›Malrotation with volvulus concern

›Immediate surgical consultation trigger

›DKA pathway

›Hyperglycemia

›Acidosis

Diagnostic uncertainty

›Reassessment targets

›Evolution of abdominal tenderness

›Response to fluids and antiemetic

›New neurologic findings

16Plan/plan39

First 5 minutes workflow

›Stabilization priorities

›Continuous monitoring for ill appearing child

›IV access criteria

›Moderate or severe dehydration

›Failure of oral rehydration

›Bedside glucose target within minutes for altered mental status

Fluids and rehydration

›Rehydration strategy

›Oral rehydration solution

›Small frequent volumes

›Re dose after emesis episodes

›IV isotonic fluids for moderate or severe dehydration

›20 mL per kg bolus local protocol dependent

›Repeat bolus based on perfusion and vitals

Antiemetics

›Ondansetron

›Oral dose 0.15 mg per kg

›Maximum single dose 8 mg

›Avoid in

›Congenital long QT syndrome

›Significant electrolyte abnormalities until corrected

›Dimenhydrinate

›Dose local protocol dependent

›Avoid in

›Significant sedation risk

›Anticholinergic toxidrome concern

Analgesia when pain present

›Pain control

›Acetaminophen weight based dosing local protocol dependent

›Ibuprofen weight based dosing local protocol dependent

Diagnostic sequencing

›Testing logic

›If bilious emesis then urgent imaging pathway

›If focal right lower quadrant pain then appendicitis pathway

›If fever without source then urine testing pathway

Monitoring and reassessment loop

›Reassessment cadence

›Repeat vitals after fluids

›Repeat abdominal exam after analgesia and hydration

›Oral challenge after antiemetic

Consultation

›Specialty triggers

›Surgery for bilious emesis or peritoneal signs

›Pediatrics for infant under 3 months with vomiting and fever

›Toxicology for suspected ingestion

17Disposition/dispo21

ICU criteria

›Critical care triggers

›Shock requiring repeated boluses with ongoing instability

›Severe metabolic acidosis

›Altered mental status not rapidly reversible

Inpatient admission criteria

›Admission triggers

›Persistent inability to tolerate oral fluids

›Moderate or severe dehydration needing ongoing IV fluids

›Suspected surgical diagnosis

›Social reliability concerns for monitoring

Observation pathway criteria

›Short stay criteria

›Improved vitals after rehydration

›Needs reassessment of abdominal findings

›Uncertain diagnosis requiring serial exams

Discharge criteria

›Safe discharge features

›Tolerating oral fluids

›Normal mental status

›Improving vitals and perfusion

›Caregivers able to monitor intake and urine output

Follow up timing

›Outpatient plan

›Primary care within 24 to 48 hours if persistent symptoms

›Return evaluation same day if worsening

18Discharge Instructions/di23

Copy discharge instructions

›You were seen for vomiting

›Most causes are viral and improve with time

›The most important treatment is keeping up with fluids

›Fluids

›Give small amounts often

›Use oral rehydration solution if available

›Medicines

›Use the prescribed anti nausea medicine only as directed

›Do not use other anti nausea medicines unless instructed

›Eating

›Resume light foods when hungry

›Avoid very greasy foods until better

›Return to the emergency department now if any of these happen

›Green vomiting

›Blood in vomit

›Severe belly pain

›Sleepy or hard to wake

›Trouble breathing

›No urine for a long time

›Signs of dehydration getting worse

›Follow up

›See your doctor in 1 to 2 days if not improving

›Come back sooner if symptoms worsen

19References/r17

Guidelines and evidence

›American Academy of Pediatrics acute gastroenteritis guidance local protocol dependent

›Oral rehydration therapy as first line

›Antiemetic use varies by pathway

›NICE guideline gastroenteritis in children 2009 updated local protocol dependent

›Dehydration assessment framework

›Rehydration recommendations

›CDC acute gastroenteritis and dehydration resources local protocol dependent

›Oral rehydration solution principles

›Red flag features

›American College of Radiology appropriateness criteria suspected appendicitis child local protocol dependent

›Ultrasound first pathways

›CT and MRI second line considerations

›Pediatric Appendicitis Score validation studies local protocol dependent

›Risk stratification support

›Not a stand alone rule out tool

›Project instructions file

›Formatting and structure rules

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.