Download Diarrhoea and Vomiting

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Guideline ID
CG10
Version
1.0
Title
Diarrhoea and Vomiting
Approved by
Clinical Effectiveness Group
Date Issued
01/01/2013
Review Date
31/12/2016
Directorate
Clinical
Authorised Staff
Clinical
Publication
Category
Ambulance Care Assistant
Emergency Care Assistant
Student Paramedic
Advanced Technician
Paramedic (non-ECP)
Nurse (non-ECP)
ECP
Doctor
Guidance (Green) - Deviation permissible;
Apply clinical judgement
1.Scope
1.1
This guideline details the assessment and management of patients experiencing
diarrhoea and vomiting.
2.
Background and Definitions
2.1Norovirus
2.1.1 Norovirus is the most common cause of infectious gastroenteritis (diarrhoea and
vomiting) in England and Wales. The illness is generally mild and people usually
recover fully within 2-3 days; there are no long term effects that result from
being infected. Infections can occur at any age. The virus is easily transmitted
from one person to another. The infectious dose is very low, swallowing as few
as 10 - 100 virus particles may be enough to cause illness.
2.1.2 The incubation period is usually 12 to 48 hours, and the infected person
commonly presents with sudden onset of nausea, followed by projectile
vomiting and watery diarrhoea. Some affected individuals have a raised
temperature, headache and aching limbs. The illness is self-limiting and the
symptoms will last for 12 to 60 hours, although the person will be infectious for up
to 48hrs after the symptoms have fully resolved.
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2.2
Clostridium Difficile
2.2.1 Clostridium difficile is a spore forming bacterium which is present as one of
the normal bacteria in the gut of up to 3% of healthy adults. It is much more
common in babies, with up to two thirds of infants having it in their gut, where
it rarely causes problems. People over the age of 65 are more susceptible to
contracting the infection.
2.2.2 It is usually kept under control by other bacteria that live in the gut that are
essential for maintaining good health. The infection often occurs after someone
has taken antibiotics to treat another illness. The medication disturbs the
bacteria normally found in the gut and allows Clostridium difficile to multiply. It
produces poisons (toxins) which can lead to diarrhoea and severe inflammation
of the bowel.
2.3
Other Causes
2.3.1 Food poisoning is caused by someone eating food which may be contaminated
with a range of infection causing bugs. Some gastrointestinal infections, such as
Campylobacter, can also be caught from pets and other animals.
3.Guidance
3.1Assessment
3.1.1 When assessing the severity of illness consider:
▲▲ Frequency and consistency of stools;
▲▲ The presence of blood in stools;
▲▲ Frequency of vomiting;
▲▲ Ability to eat and drink.
3.1.2 Perform an appropriate examination:
▲▲ Check conscious level, respiratory rates, pulse rate, blood glucose, blood
pressure and temperature using an CABCD approach;
▲▲ Assess for abdominal tenderness;
▲▲ Assess for features of dehydration.
3.1.3 Investigate potential causes or contributing factors:
▲▲ Recent contact with someone with acute diarrhoea and/or vomiting;
▲▲ Exposure to a known source of enteric infection (possibly contaminated
water or food);
▲▲ Recent travel abroad;
▲▲ Recent antibiotics or hospital admission within the last 8 weeks (suspect
infection with Clostridium difficile).
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3.2
Clinical Features of Dehydration
3.2.1 Table 1 details the signs and symptoms of different degrees of dehydration.
3.2.2 Table 1 - Dehydration
Mild
Moderate
Severe
Lassitude (feeling of
weariness, diminished
energy).
Apathy/tiredness.
Profound apathy.
Anorexia, nausea.
Dizziness.
Weakness.
Light headedness.
Muscle cramps.
Confusion, leading to
coma.
Postural hypotension.
Pinched face.
Shock.
Usually no signs.
Dry tongue or sunken eyes.
Tachycardia.
Reduced skin elasticity.
Marked peripheral
vasoconstriction.
Postural hypotension (systolic
blood pressure > 90 mmHg).
Systolic blood pressure
< 90 mmHg.
Tachycardia.
Oliguria or anuria (low
or no urine output).
Oliguria (low urine output).
3.2.3 Children may be at an increased risk when assessing dehydration if:
▲▲ Under one year of age, particularly if under 6 months old;
▲▲ Low birth weight;
▲▲ Past more than 5 diarrhoeal stools in past 24hrs;
▲▲ More than 2 episodes of vomiting in past 24 hours;
▲▲ Children who have not been tolerant of supplementary fluids;
▲▲ Infants who have stopped feeding during the illness ;
▲▲ Children with malnutrition.
3.3Admission
3.3.1 Consider conveying to hospital if:
▲▲ The person is vomiting and unable to retain oral fluids, particularly in infants
who have stopped feeding;
▲▲ They have features of severe dehydration. Be alert for the signs of septic
shock which are detailed in Clinical Guideline CG21 - Sepsis, Including
Meningitis.
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3.3.2 Other factors influencing admission (clinical judgement should be used) include:
▲▲ Recent foreign travel;
▲▲ Older age (people 60 years of age or older are more at risk of complications);
▲▲ Home circumstances and level of support;
▲▲ Fever;
▲▲ Bloody diarrhoea;
▲▲ Abdominal pain and tenderness;
▲▲ Faecal incontinence;
▲▲ Diarrhoea lasting more than 10 days;
▲▲ Increased risk of poor outcome, for example: Coexisting medical conditions:
Immunodeficiency, inflammatory bowel disease, valvular heart disease,
diabetes mellitus, renal impairment, rheumatoid disease, systemic lupus
erythematosus;
▲▲ Drugs: Immunosuppressants or systemic steroids, proton pump inhibitors,
H2-receptor antagonists, simple antacids, angiotensin-converting enzyme
inhibitors, diuretics.
3.3.3 The Diarrhoea and Vomiting Hospital Liaison Guidelines detailed in Appendix 1
must be applied when a patient is conveyed.
3.4Rehydration
3.4.1 In most otherwise healthy adults, encouraging fluid intake (especially if
supplemented with fruit juice and soups) will be sufficient.
3.4.2 In adults who are at increased risk of a poor outcome (for example people who
are 60 years of age or older, frail, or with comorbidities with which dehydration
may be a concern, consider supplementing fluid intake with oral rehydration salt
solution.
3.4.3 Consumption of solid food should be guided by appetite. Advise the person to
eat small, light meals and avoid fatty, spicy, or heavy food.
3.4.4 In children with suspected gastroenteritis without indication of clinical
dehydration, encourage continuation of breastfeeding and other milk feeds.
Encourage fluid intake, but discourage the use of fruit juices and any carbonated
drinks.
3.5Medication
3.5.1 Anti-diarrhoeal drugs are not usually necessary for the management of
gastroenteritis. Anti-motility drugs may be useful for symptomatic control in
adults with mild-to-moderate diarrhoea, for example if quicker resolution of
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diarrhoea would enable the person to continue essential activities. They should
be avoided if there is blood and/or mucus in the stools, or high fever. Antibiotics
are not recommended for adults with acute diarrhoea of unknown pathology.
Anti-emetics are not usually necessary for the primary care management of
gastroenteritis.
4.
Incident Closure
4.1
Patients must be admitted if indicated under Section 3.3, with the Diarrhoea
and Vomiting Hospital Liaison Guidelines applied to ensure a seamless hospital
handover. Patients who remain on-scene must be supplied with a copy of the
PCR, a patient information leaflet and advised to seek further medical advice if:
▲▲ Their condition does not improve within 48 hours;
▲▲ Symptoms exacerbate or their condition worsens;
▲▲ Warning signs or symptoms develop (such as severe vomiting or dehydration,
persistent fever, abdominal distension, or frank blood in stools).
5.Documentation
5.1 In line with Trust Policy, a Patient Clinical Record must be completed and
annotated appropriately. Any deviation from this guideline must be recorded,
with any potential or actual adverse event reported through the incident
reporting system.
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Appendix 1 - Diarrhoea and Vomiting Hospital Liaison Guidelines
Patient presents with sudden onset of diarrhoea and/or vomiting?
YES
Does the patient present with any of the following:
▲▲Unexpected onset of diarrhoea and/or vomiting? E.g. cannot be explained by
other presenting conditions. Examples may include, but are not limited to - recent
prescription of medication which may cause D&V, patient vomiting but appears under
the influence of alcohol, overdose, recent bowel surgery, heart attack?
▲▲Recent contact with someone with diarrhoea and/or vomiting within the previous
48 hours?
▲▲Resides, works or visits an institution with a known infectious outbreak?
▲▲Taken antibiotics within the previous 14 days?
▲▲Alternative method of feeding present e.g. PEG, naso-gastric tube?
YES
NO
Does the patient’s condition
require them to be transported
to an Emergency Department
Resuscitation Room?*
YES
Transport
patient directly to
ED resuscitation
room.*
State ‘patient
likely to require
isolation’ during
the hospital prealert.
Enter department
immediately upon
arrival at hospital.
Is the patient vomiting or actively
experiencing diarrhoea following
arrival of ambulance clinician?
NO
YES
Transport patient to
normal destination.
Transport patient to
normal destination.
Place a hospital prealert specifically to
state ‘patient likely to
require isolation’.
No specific pre-alert
regarding infectious
status required.
On arrival attendant
to remain with
patient, whilst driver
discusses case with
senior nurse on duty
before patient enters
department.
If patient’s clinical
condition permits
attendant to remain
with patient on arrival,
whilst driver discusses
case with senior nurse
on duty before patient
enters department.
NO
Transport
patient to normal
destination.
On arrival,
convey patient
into department.
Discuss any
issues regarding
diarrhoea and/
or vomiting
with nurse
during routine
handover.
*May also include transport to catheter laboratory for primary angioplasty, to other condition specific bypasses.
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