The Gorelick scale consists of multiple signs, each assigned one point. A group led by Dr. All scales showed poor sensitivities and specificities and were found to be ineffective at predicting the actual degree of dehydration.
Although there is overlap among the three scales and they do not effectively predict true degree of dehydration, they all illustrate clinical signs that can be assessed within a matter of seconds, which can guide clinical decision making.
A review of 26 dehydration studies found the most useful i. After clinically evaluating the severity of dehydration, a practitioner can decide whether IV therapy is necessary. In terms of prehospital management, ORT is typically not found on ambulances. Ideally, a patient should be transported to a hospital for a more thorough evaluation. Administering hypotonic fluid, such as 0. This is because dehydration causes a state of antidiuretic hormone ADH excess due to volume depletion.
Administering hypotonic fluid with an elevated ADH would cause excess amounts of free water to be retained, leading to hyponatremia. Hyponatremia also frequently occurs when parents or other caregivers attempt to rehydrate children with fluids with inadequate amounts of sodium, such as water, juice, soda and Gatorade.
A Cochrane Library database review found no significant clinical differences between ORT and IV therapy for treating dehydration secondary to gastroenteritis in children. ORT did have a higher rate of paralytic ileus; however, the IV group has all the risks related to IV placement and therapy.
Unfortunately, there are few clinical trials that evaluate the efficacy and long-term safety of some of these techniques. Nasogastric rehydration has been adequately studied. It is a safe technique with minimal adverse effects and has been found in four different clinical trials to have efficacy similar to IV therapy. Intraosseous rehydration is also as effective as IV therapy. Depending on the etiology and severity of the dehydration, further studies may be performed in the hospital.
If the dehydration is so severe that the patient has an altered mental status, an appropriate laboratory workup may be conducted. A basic metabolic panel will typically be drawn which analyzes certain electrolyte levels in the blood, such as sodium, potassium and bicarbonate. Disturbances in these electrolytes are associated with dehydration. His mental status is poor, and he has multiple signs on exam indicating the severity of his dehydration. Additionally, his vital signs show mild tachycardia, corresponding with low intravascular volume.
His respiratory rate and blood pressure are appropriate for his age. As for the etiology of his dehydration, he likely suffered from acute viral gastroenteritis. He may have been infected with a virus at daycare and subsequently developed symptoms. She is mildly lethargic and has dry and sticky mucous membranes; however, her capillary refill and skin turgor are normal.
Additionally, she has a normal respiratory pattern. With the exception of a fever, the rest of her vital signs are appropriate for her age. According to the WHO and Gorelick scales the appropriate scales for the age of 4 years , she can be categorized as mildly dehydrated given her mental status and dry mucous membranes. As for the etiology of her mild dehydration, her presentation is suspicious for meningitis.
Transport her promptly to the hospital for further evaluation. Dehydration occurs frequently, and young children are at increased risk.
Recognize key clinical signs such as abnormal capillary refill, abnormal skin turgor and irregular respiratory pattern. Sign in.
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Contact Us. Advisory Board. About Us. Jonathan Ludmir, MD. Copied to clipboard. Case 2 A 4-year-old girl, previously healthy, presents with fever, headache and vomiting for two days. Presentation The presentation of dehydration may vary but can include the symptoms of vomiting, diarrhea, headache, abdominal pain and myalgias.
Management After clinically evaluating the severity of dehydration, a practitioner can decide whether IV therapy is necessary. Hospital Management Depending on the etiology and severity of the dehydration, further studies may be performed in the hospital. Case Reviews 1 According to all scales for the evaluation of dehydration, this baby classifies as severely dehydrated.
Conclusion Dehydration occurs frequently, and young children are at increased risk. References 1. Common causes Other laboratory abnormalities in dehydration include relative polycythemia resulting from hemoconcentration, elevated blood urea nitrogen BUN , and increased urine specific gravity.
The volume eg, amount of fluid , composition, and rate of replacement differ for each. Formulas and estimates used to determine treatment parameters provide a starting place, but treatment requires ongoing monitoring of vital signs, clinical appearance, urine output, weight, and sometimes serum electrolyte levels. Children with severe dehydration eg, evidence of circulatory compromise should receive fluids IV.
Children who are unable or unwilling to drink or who have repetitive vomiting can receive fluid replacement orally through frequently repeated small amounts, through an IV, or through a nasogastric tube see Solutions Solutions Oral fluid therapy is effective, safe, convenient, and inexpensive compared with IV therapy. Patients with signs of hypoperfusion should receive fluid resuscitation with boluses of isotonic fluid eg, 0. The goal is to restore adequate circulating volume to restore blood pressure and perfusion.
The end point of the fluid resuscitation phase is reached when peripheral perfusion and blood pressure are restored and the heart rate is returned to normal in an afebrile child.
Total deficit volume is estimated clinically as described previously. Because 0. Signs include lethargy and seizures. Treatment is cautious hydration with IV saline solution Significant hyponatremia may cause seizures or coma.
Treatment is cautious sodium replacement with IV 0. Replacement should be milliliter for milliliter in time intervals appropriate for the rapidity and extent of the loss. Ongoing electrolyte losses can be estimated by source or cause see Table: Estimated Electrolyte Deficits by Cause Estimated Electrolyte Deficits by Cause Dehydration is significant depletion of body water and, to varying degrees, electrolytes.
Urinary electrolyte losses vary with intake and disease process but can be measured if electrolyte abnormalities fail to respond to replacement therapy. See also the American Academy of Pediatrics' clinical practice guideline for maintenance IV fluids in children.
Fluid and electrolyte needs from basal metabolism must also be accounted for. Maintenance requirements are related to metabolic rate and affected by body temperature. Insensible losses evaporative free water losses from the skin and respiratory tract account for about one third of total maintenance water slightly more in infants and less in adolescents and adults.
Volume rarely must be exactly determined but generally should aim to provide an amount of water that does not require the kidney to significantly concentrate or dilute the urine. More complex calculations eg, those using body surface area are rarely required. Maintenance fluid volumes can be given as a separate simultaneous infusion, so that the infusion rate for replacing deficits and ongoing losses can be set and adjusted independently of the maintenance infusion rate.
The traditional approach to calculating the composition of maintenance fluids was also based on the Holliday-Segar formula. According to that formula, patients require. This calculation indicates that maintenance fluid should consist of 0. Other electrolytes eg, magnesium, calcium are not routinely added.
Normally, serum osmolarity controls moment-to-moment ADH release. Antidiuretic hormone ADH release can also occur in response to vascular volume and not osmolarity nonosmotic ADH release. Recent literature suggests that hospitalized dehydrated children receiving 0. This development is likely due to volume-related ADH release as well as to significant amounts of stimuli-related ADH release eg, from stress, vomiting, dehydration, hypoglycemia.
The ADH causes increased free water retention. Iatrogenic hyponatremia may be a greater problem for more seriously ill children and those who are hospitalized after surgery where stress plays a bigger role. Due to this possibility of iatrogenic hyponatremia, many centers are now using a more isotonic fluid such as 0. The most recent American Academy of Pediatrics' clinical practice guideline recommends all patients 28 days to 18 years of age receive isotonic solutions with appropriate potassium chloride and dextrose as maintenance IV fluids.
This change also has the benefit of allowing use of the same fluid to replace ongoing losses and supply maintenance needs, which simplifies management. Although practice variation still exists in choosing appropriate maintenance IV fluids, all clinicians agree the important point is to closely monitor dehydrated patients receiving IV fluids, which includes monitoring of serum electrolyte levels.
You may need care sooner. Symptoms of dehydration can range from mild to severe. For example: You may feel tired and edgy mild dehydration , or you may feel weak, not alert, and not able to think clearly severe dehydration. You may pass less urine than usual mild dehydration , or you may not be passing urine at all severe dehydration. Severe dehydration means: Your mouth and eyes may be extremely dry. You may pass little or no urine for 12 or more hours.
You may not feel alert or be able to think clearly. You may be too weak or dizzy to stand. You may pass out.
Moderate dehydration means: You may be a lot more thirsty than usual. Your mouth and eyes may be drier than usual. You may pass little or no urine for 8 or more hours. You may feel dizzy when you stand or sit up. Mild dehydration means: You may be more thirsty than usual. You may pass less urine than usual. For example: The baby may be fussy or cranky mild dehydration , or the baby may be very sleepy and hard to wake up severe dehydration.
The baby may have a little less urine than usual mild dehydration , or the baby may not be urinating at all severe dehydration. Severe dehydration means: The baby may be very sleepy and hard to wake up. The baby may have a very dry mouth and very dry eyes no tears. The baby may have no wet diapers in 12 or more hours. Moderate dehydration means: The baby may have no wet diapers in 6 hours. The baby may have a dry mouth and dry eyes fewer tears than usual.
Mild dehydration means: The baby may pass a little less urine than usual. Shock is a life-threatening condition that may occur quickly after a sudden illness or injury.
Babies and young children often have several symptoms of shock. These include: Passing out losing consciousness. Being very sleepy or hard to wake up. Not responding when being touched or talked to.
Breathing much faster than usual. Acting confused. The child may not know where he or she is. Severe dehydration means: The child's mouth and eyes may be extremely dry. The child may pass little or no urine for 12 or more hours. The child may not seem alert or able to think clearly. The child may be too weak or dizzy to stand. The child may pass out.
Moderate dehydration means: The child may be a lot more thirsty than usual. The child's mouth and eyes may be drier than usual. The child may pass little or no urine for 8 or more hours. The child may feel dizzy when he or she stands or sits up. Mild dehydration means: The child may be more thirsty than usual. The child may pass less urine than usual. A baby that is extremely sick : May be limp and floppy like a rag doll. May not respond at all to being held, touched, or talked to.
May be hard to wake up. A baby that is sick but not extremely sick : May be sleepier than usual. May not eat or drink as much as usual.
Shock is a life-threatening condition that may quickly occur after a sudden illness or injury. Adults and older children often have several symptoms of shock. Feeling very dizzy or lightheaded, like you may pass out. Feeling very weak or having trouble standing. Not feeling alert or able to think clearly.
You may be confused, restless, fearful, or unable to respond to questions. Many prescription and nonprescription medicines can cause dehydration. A few examples are: Antihistamines. Blood pressure medicines. Seek Care Today Based on your answers, you may need care soon. Call your doctor today to discuss the symptoms and arrange for care.
If you cannot reach your doctor or you don't have one, seek care today. If it is evening, watch the symptoms and seek care in the morning. If the symptoms get worse, seek care sooner. Call Now Based on your answers, you need emergency care.
Call or other emergency services now. Seek Care Now Based on your answers, you may need care right away. Call your doctor now to discuss the symptoms and arrange for care.
If you cannot reach your doctor or you don't have one, seek care in the next hour. You do not need to call an ambulance unless: You cannot travel safely either by driving yourself or by having someone else drive you.
You are in an area where heavy traffic or other problems may slow you down. Home Treatment In the early stages, you may be able to correct mild to moderate dehydration with home treatment measures. Adults and children age 12 and older If you become mildly to moderately dehydrated while working outside or exercising: Stop your activity and rest.
Get out of direct sunlight and lie down in a cool spot, such as in the shade or an air-conditioned area. Prop up your feet. Take off any extra clothes. Drink a rehydration drink, water, juice, or sports drink to replace fluids and minerals. Drink 2 qt 2 L of cool liquids over the next 2 to 4 hours.
You should drink at least 10 glasses of liquid a day to replace lost fluids. You can make an inexpensive rehydration drink at home. But do not give this homemade drink to children younger than Measure all ingredients precisely. Small variations can make the drink less effective or even harmful. Newborns and babies younger than 1 year of age Don't wait until you see signs of dehydration in your baby.
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