Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Vomiting, Acute
The forceful ejection of stomach contents through the esophagus and mouth; a common symptom throughout infancy and childhood.
I. Etiology
A. Associated with a variety of illnesses, infections, and emotional stress.
B. Often indicative of an abnormality or infection of the gastrointestinal tract, urinary tract, or central nervous system.
C. Etiology varies according to age group.
II. Incidence: One of the most common symptoms throughout infancy and childhood
III. Subjective data
A. Is nausea associated with vomiting?
B. Does child appear ill?
C. Duration of vomiting: Acute or chronic
D. Frequency of vomiting
E. Character of vomitus: Undigested food, bile, fecal material, blood
F. Relation to intake
G. Projectile vomiting or “spitting up”
H. Associated temperature elevation
I. Diarrhea or constipation
J. Exposure to similar illness
K. Any weight loss or last accurate weight
L. Decrease in urinary output
M. Detailed dietary history
N. Ingestion of drugs or other substances
O. Stress or changes—family, school
P. Associated symptoms
1. Pulling at ears or complaints of ear pain
2. Sore throat or distress when swallowing
3. Stiff neck
4. Cough
5. Abdominal pain
6. Headache
7. Changes in vision
8. High-pitched cry
9. Convulsions
Q. History of injury (e.g., fall on head)
IV. Objective data
A. Physical examination should encompass other systems to rule out other infectious processes.
1. Ears
2. Throat
3. Adenopathy
4. Chest
5. CNS for signs of meningeal irritation
a. Nuchal rigidity
b. Fontanelle
c. Kernig’s sign
d. Brudzinski’s sign
e. Irritability, especially paradoxical
f. Level of sensorium
6. Abdomen for distention, visible peristalsis, bowel sounds, tenderness, spasm, organomegaly, masses
7. State of hydration (see Appendix H, p. 534)
8. Weight, head circumference, pulse, blood pressure, temperature
B. Laboratory tests
1. Urinalysis; include specific gravity to assess state of hydration
2. Urine culture to R/O UTI
3. CBC, electrolytes, and BUN to assess for infectious process and hydration status.
V. Assessment
A. Type of vomiting
1. Projectile
a. Etiology: Upper gastrointestinal tract or increased intracranial pressure
b. Refer to physician.
2. Vomiting without nausea
a. Etiology: Probable increased intracranial pressure
b. Refer to physician.
3. Vomiting with nausea: Etiology is infection or toxicity.
B. Vomiting in infants (neonates to toddlers 2 years of age)
1. Most acute vomiting in this age group is in conjunction with infection. The following causes must also be considered:
a. Overfeeding
b. Poor feeding techniques (e.g., failure to burp baby, propping of bottle)
c. Congenital anomalies
(1) Gastrointestinal lesions
(a) Pyloric stenosis: Onset of vomiting at 2 to 3 weeks of age; progresses to projectile vomiting
(b) Chalasia: Vomiting or regurgitation after feedings
(c) Intussusception: Currant jelly stools, distention, visible peristalsis, bile-stained vomitus
(d) Volvulus/obstruction: Bile-stained emesis
(e) Hirshsprung’s disease: Non-bilious emesis, constipation
(2) Hydrocephalus: Increased head circumference, bulging fontanelle
2. Infections: Almost any disease with fever at onset
a. Gastroenteritis
b. Urinary tract infection
c. Meningitis
d. Pneumonia
e. Otitis media
3. Poisoning
C. Vomiting in children (2 years of age and older): Infection is also the most common etiology in acute vomiting in children over the age of
2 years, but ingestion of toxic substances becomes of increasing importance in this age group. The following are important causes to be considered in this age group:
1. Acute infection
a. Gastroenteritis
b. Urinary tract infection
c. Meningitis
d. Pneumonia
e. Pharyngitis
f. Otitis media
g. Acute glomerulonephritis
h. Hepatitis
2. Appendicitis
3. Central nervous system
a. Increased intracranial pressure due to brain tumor, hydrocephalus
b. Migraine headaches
4. Poisoning
a. Lead
b. Medications, drugs, salicylates
c. Poisons
VI. Plan
A. Acute vomiting due to infectious cause
1. Rehydration Phase: First 4 hours
a. Continue breastfeeding.
b. ORS: Ricelyte, Pedialyte, Lytren; 1 tsp every 1 to 5 minutes
c. After cessation of vomiting, increase amounts and decrease frequency to avoid overstimulating gastrocolic reflex and causing diarrhea. Give 1 to 2 oz every 15 to 30 minutes.
d. If vomiting recurs, resume 1 tsp every 1 to 5 minutes until tolerated, and again gradually increase amounts.
e. Intractable vomiting after 4 hours of therapy: Refer for parenteral fluid therapy. Administer 50 mL/kg for mild dehydration, and 100 mL/kg for moderate dehydration.
2. Second phase: Once vomiting has ceased for 4 hours
a. Gradually resume age-appropriate diet with small, frequent feedings.
b. Avoid foods high in fat, roughage, simple sugars, and complex carbohydrates as well as strong-flavored foods.
c. BRAT diet is no longer recommended, but rather diet that is palatable to child.
B. Treatment for concurrent infectious processes must be instituted. Initially antibiotics may have to be given parenterally.
VII. Education
A. Set timer and give 1 tsp of clear liquids every 1 to 5 minutes.
1. Some children will not take ORS readily; try Pedialyte pops or sports drinks.
2. Vomiting resolves as fluid repletion occurs and tissue acidosis is corrected.
3. If 5 mL (1 tsp) of ORS is given every minute, rehydration will generally occur with the total 300 mL delivered in 1 hour.
B. Monitor temperature, intake, and output.
C. Support and encourage parent; this treatment is time-consuming but is the most effective way to treat vomiting and prevent dehydration.
D. Give parent specific instructions, written if possible, and stress importance of strict adherence to regimen.
E. If clear liquids are used for more than 48 hours, child may have reactive loose stools or starvation stools.
F. Stress hygiene and proper handwashing technique to prevent spread if vomiting due to infectious process.
G. Use tepid baths for temperature control if indicated.
H. Antiemetics are contraindicated in child with acute vomiting.
VIII. Follow-up
A. Telephone contact at least every 2 to 4 hours while child is vomiting. Call immediately if any symptoms of dehydration.
B. Check weight in 24 hours.
C. Follow-up for other infectious process per protocol.
IX. Complications: The most important complication of acute vomiting due to infection is dehydration.
X. Consultation/referral
A. Infant younger than 6 months
B. Child of any age who appears toxic
C. Any signs or symptoms of dehydration
D. Child with projectile vomiting
E. Blood, fecal material, or bile in vomitus
F. Vomiting persisting more than 12 hours in neonate, more than 24 hours for a child under 2 years of age, and more than 48 hours for a child over 2 years of age
G. Child with any positive findings on abdominal examination