In a 4‑year‑old female child weighing 12 kg with leukocytosis (WBC 11,700) who witnessed a relative being burned with turpentine oil and now presents with anorexia and repeated hematemesis, what is the diagnosis and the appropriate treatment including drug dosages?

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Acute Stress Disorder with Hematemesis Secondary to Psychological Trauma

This child is experiencing acute stress disorder with hematemesis (stress-induced gastritis/ulceration) following severe psychological trauma, NOT turpentine poisoning—she witnessed but was not exposed to the chemical. The immediate priorities are fluid resuscitation, gastric protection, and psychological stabilization.

Diagnosis

The clinical picture indicates:

  • Acute stress disorder with severe psychological trauma from witnessing the burning
  • Stress-induced gastritis/acute gastric ulceration causing hematemesis
  • Hypovolemia from vomiting and blood loss
  • Mild leukocytosis (WBC 11,700) consistent with stress response, not infection 1

The leukocytosis at this level (11,700) is non-specific and commonly seen with physiological stress in children. Extreme leukocytosis (>25,000) would be more concerning for infection or malignancy, but this mild elevation is consistent with the acute stress response 1.

Immediate Treatment Algorithm

1. Fluid Resuscitation (First Priority)

Administer 240 mL (20 mL/kg × 12 kg) of Ringer's Lactate or balanced crystalloid solution IV within the first hour 2. This addresses hypovolemia from vomiting and blood loss.

  • Obtain IV access immediately; if unsuccessful, use intraosseous route 2
  • Use balanced crystalloid (Ringer's Lactate preferred over 0.9% NaCl to avoid hyperchloremia and metabolic acidosis) 2
  • Monitor urine output target: 0.5-1 mL/kg/h (6-12 mL/h for this child) 2
  • Adjust fluid rate based on clinical response and hemodynamic parameters 2

2. Gastric Protection and Hematemesis Management

Proton Pump Inhibitor (PPI):

  • Omeprazole 10 mg IV (0.7-1 mg/kg/dose) immediately, then 10 mg IV every 12-24 hours
  • Alternative: Pantoprazole 20 mg IV (1-1.5 mg/kg/dose, max 40 mg) every 12-24 hours

H2 Receptor Antagonist (if PPI unavailable):

  • Ranitidine 1.2 mg IV (0.1 mg/kg/dose) every 8 hours, OR
  • Famotidine 2.4 mg IV (0.2 mg/kg/dose) every 12 hours

Antiemetic:

  • Ondansetron 2.4 mg IV (0.15-0.2 mg/kg/dose, max 4 mg) every 8 hours as needed

3. Monitoring Parameters

  • Serial hemoglobin/hematocrit every 4-6 hours to detect ongoing bleeding 3
  • Vital signs every 1-2 hours initially
  • Urine output hourly
  • Assess for signs of hypovolemic shock (tachycardia, hypotension, delayed capillary refill)
  • Keep NPO (nothing by mouth) initially until hematemesis resolves

4. Psychological Intervention (Concurrent Priority)

Immediate sedation/anxiolysis:

  • Midazolam 0.6-1.2 mg IV (0.05-0.1 mg/kg) for acute severe anxiety, titrated to effect
  • Alternative: Diazepam 2.4 mg IV (0.2 mg/kg) if midazolam unavailable

Pain and distress management:

  • Consider ketamine 6-12 mg IV (0.5-1 mg/kg) for dissociative sedation if severe distress continues, as it provides both analgesia and anxiolysis 2

Early psychiatric consultation for acute stress disorder management and trauma-focused intervention

5. Nutritional Support

Once hematemesis stops (typically 12-24 hours):

  • Begin clear liquids, advance to bland diet as tolerated
  • Continue PPI therapy for 4-6 weeks minimum
  • If unable to tolerate oral intake after 24 hours, consider nasogastric feeding with continuous drip

Key Clinical Pitfalls to Avoid

  1. Do NOT perform gastric lavage - The child did not ingest turpentine; she only witnessed the event. Gastric lavage is contraindicated in hydrocarbon ingestion anyway due to aspiration risk 4

  2. Do NOT assume infection - The WBC of 11,700 is a stress response, not indicative of infection requiring antibiotics 1, 5. Antibiotics are NOT indicated unless clear infectious source identified

  3. Do NOT use 0.9% NaCl - Balanced crystalloids (Ringer's Lactate) are preferred to avoid hyperchloremic acidosis 2

  4. Do NOT overlook psychological trauma - The hematemesis is a somatic manifestation of severe psychological distress; addressing only the GI bleeding without psychiatric intervention will result in incomplete treatment

  5. Monitor for fluid overload - While aggressive initial resuscitation is needed, avoid >10% total body weight fluid overload 6

Expected Clinical Course

  • Hematemesis should resolve within 12-24 hours with appropriate gastric protection and fluid resuscitation
  • Appetite should gradually return over 2-5 days as acute stress symptoms improve
  • Psychological symptoms (nightmares, flashbacks, avoidance) may persist and require ongoing psychiatric care
  • Complete gastric mucosal healing typically takes 4-6 weeks with PPI therapy

Disposition: Admit for observation, serial hemoglobin monitoring, and psychiatric evaluation. Transfer to facility with pediatric gastroenterology and child psychiatry if not available.

References

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