Dehydration secondary to gastroenteritis

Abstract

An 18-month-old child presented at a community hospital emergency room at 18:00 with a history of “vomiting and diarrhea all day”. No attempt was made to quantify or semiquantify the number of stools or vomiting episodes, and there is no record regarding the passage of urine. The child’s weight was 9 kg and body temperature 37.7°C, but the pulse, blood pressure and respiratory rate were not recorded. The child was given 12.5 mg of Gravol (CarterHorner, Canada) intramuscularly and sent home on oral Gravol (2.5 cc every 4 h for two doses). At the inquest, the mother recalled that she was told only “to give clear fluids”. The physician involved stated that he “gave an order for fluids to be given over the next day”. He was unable to recall which fluids and had made no notation in this regard. The child returned to the emergency room 25 h after discharge. The triage nurse noted that his “lips were blue and eyes sunken”. His temperature was 38.4°C and, once again, no other vital signs were recorded. A physician assessed the child 30 min later and, confirming the nurses observation, ordered an immediate complete blood cell count and electrolytes to be drawn. While this was being attempted 50 min after presentation, the child arrested. Attempts at starting an intravenous infusion were unsuccessful, and an intraosseous line was not established until 10 min after the child arrested. An autopsy determined the cause of death to be dehydration secondary to gastroenteritis. The Pediatric Death Review Committee of Ontario made the following recommendations. A full set of vital signs is crucial in the assessment of a child who is potentially dehydrated. If vital signs have not been recorded by the nursing staff, the physician has a responsibility to ensure that vital signs are taken and recorded. Oral rehydration therapy (ORT) was probably the appropriate response during the child’s first presentation at the hospital. Printed handouts for parents about oral rehydration are far more effective than verbal advice. Furthermore, it is easier to note that “ORT handout given” than it is to note the verbal advice that may have been provided. The child was clearly in shock during the second presentation, at which point immediate volume expansion with normal saline or Ringer lactate should have taken priority over laboratory investigations. Oxygen administration would have been valuable. These may appear to be simple, basic and unnecessary recommendations; however, Ontario’s Pediatric Death Review Committee continues to review the deaths of children from dehydration in urban Canada in the 21st century. Paediatricians have an obligation to educate their family physician and emergency medicine colleagues in the ABC’s of the management of gastroenteritis.