Table 6.

Pediatric emergency department protocol for patients with recurrent vomiting regardless of an established diagnosis of Cyclic Vomiting Syndrome (CVS).

Medical history and physical examination

- individuate the presence of warning signs/symptoms (Table 2)

- evaluate for the presence of clinical criteria for CVS (Table 1)

- evaluate the change in the typical vomiting pattern (if previous CVS diagnosis)

- evaluate previously performed investigations

Emergency Department management

1. Clinical assessment: pulse rate, temperature, breathing rate, blood pressure, level of consciousness, state of hydration, and body weight

2. Investigations for all patients:

• complete blood count, electrolytes, glucose, blood urea nitrogen, creatinine, arterial-blood gas test, urinalysis

• upper gastrointestinal tract series to evaluate for malrotation (if not done before)

3.Other laboratories and diagnostic imaging guided by warning symptoms/signs at discretion of attending physician:

• Attack with bilious vomiting, severe abdominal pain, abdomen tenderness, hematemesis

∘ At any time

▪ ultrasound of abdomen and pelvis, lipase/amylase, EGDS

∘ During the attack

▪ Amylase and lipase, alanine aminotransferase and g-glutamyltransferase

▪ Upper GI endoscopy if large hematemesis

• Attack precipitated by fasting, intercurrent illness, high protein meal

∘ Before IV fluid

▪ glucose, electrolytes for anion gap, lactate, pyruvate, ammonia, serum amino acid, urine organic acid, urine ketones, plasma carnitine, acylcarnitine

• Abnormal neurological exam (severe altered mental status, abnormal eye movement, papilledema, motor asymmetry, gait abnormality)

▪ Brain MRI, Brain CT

▪ EEG

4.Reassess after treatment for emetic phase of CVS (see treatment) or for complications of vomiting

• Treatment failure: intensify treatment as indicated (see treatment) or admit patient

• Positive treatment response: discharge with treatment advice and eventually referral to specialist

This ED protocol represents a sample template and should be tailored based on individual needs.