Diarrhea

07/01/20 • 50 min

Traditional Approach: Secretory -- poisoned mucosal villi -- "the sieve" Cytotoxic -- destroyed mucosal villi -- "the shred" Osmotic -- malabsorption -- "the pull" Inflammatory -- edema, motility -- "the push" Lots of overlap, difficult to apply to clinical signs and symptoms. Bedside Approach: Fever/No Fever, Bloody/No Blood Non-bloody, febrile -- most likely viral Non-bloody, afebrile -- may be viral Bloody, febrile -- likely bacterial Non-bloody, afebrile -- full stop. Eval for Hemolytic Uremic Syndrome Workup

Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc.

Admit sick children, but most go home, so...

Non-bloody, febrile -- no workup necessary; precautionary advice Non-bloody, afebrile -- be more skeptical, but generally same as above Bloody, febrile -- stool culture, follow up; do not treat empirically unless septic and admitted. Culture will dictate treat/no treat/how. Bloody, afebrile -- evaluate for hemolytic uremic syndrome, especially if under 5 years old: CBC, chemistries, UA, stool culture Evaluate Hydration Status

Selected References

Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18

Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641.

Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.

Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc.

Admit sick children, but most go home, so...

Selected References

Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18

Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641.

Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.

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Heat-Related Illness

A spectrum — but will you recognize the blurry signposts? Temperature (core) Presentation Management Miliaria Crystallina Normal Salt-colored tiny papules, easily burst; not pruritic Modify environment; light clothing; hydration Miliaria Rubra Normal Discrimiate, red papules, not assocaited with follicles; pruritic Above plus cool compresses; calamine lotion; symptomatic tx for pruritis Miliaria Profunda Normal Confluent flesh-colored, “lumpy-bumpy”; burning Same as rubra Miliaria Pustulosa Normal May resemble rubra and/or crustallina, but pustular; h/o previous dermatitis Same as above, but may may need antibiotic if no improvement over time Heat edema Normal Swelling of feet, ankles, and/or lower legs Modify environment; elevate legs Heat syncope Normal Dizziness, orthostatic hypotension, and syncope after exertion with rapid return to normal mental status when supine Modify environment; rehydration; monitoring Heat cramps May be elevated to 40°C (104°F) Exercise-induced cramping in large muscle groups, especially legs Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently Heat tetany May be elevated to 40°C (104°F) Hyperventilation with paresthesia, carpopedal spasm Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2 Heat exhaustion Elevated up to 40°C (104°F) Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities Cool environment; hydration; consider labs with severe symptoms, or if not improved Heat Stroke >40 to 40.5°C (104 to 105°F) Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission Miliaria Crystallina Miliaria Crystallina — Infant Miliaria Crystallina — Older Child Miliaria Rubra — Infant Miliaria Rubra — Infant Miliaria Rubra — Toddler Miliaria Rubra — Adolescent Miliaria Profunda

Selected References

Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741.

Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553.

DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37.

Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992.

Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.