What is the management approach for a patient presenting with vomiting, diarrhea, fever, and chills?

From the Guidelines

The management of a patient with vomiting, diarrhea, fever, and chills should focus on rehydration, symptom control, and identifying the underlying cause, with antimotility and antiemetic agents considered only after adequate hydration is achieved, as per the 2017 Infectious Diseases Society of America guidelines 1. The initial approach to managing these symptoms includes oral rehydration with clear fluids containing electrolytes, such as Pedialyte or Gatorade, or homemade solutions (1 teaspoon salt, 8 teaspoons sugar in 1 liter of water) 1. Patients should consume small amounts frequently, starting with 1-2 tablespoons every 15 minutes and gradually increasing as tolerated. For nausea and vomiting, ondansetron 4-8 mg every 8 hours can be used, as it may be given to facilitate tolerance of oral rehydration in children >4 years of age and in adolescents with acute gastroenteritis associated with vomiting 1, while fever can be managed with acetaminophen 650 mg every 6 hours or ibuprofen 400 mg every 6 hours. Severe dehydration with signs like decreased urination, dry mucous membranes, dizziness, or confusion requires immediate medical attention for IV fluid administration. Most viral gastroenteritis cases resolve within 2-3 days with supportive care. Patients should seek medical attention if symptoms persist beyond 3 days, if there's blood in stool or vomit, severe abdominal pain, signs of dehydration, or high fever (>102°F/39°C). Antibiotics are generally not recommended unless bacterial infection is confirmed, as they can worsen certain conditions like C. difficile colitis and don't help viral infections, which are the most common cause of these symptoms 1. Some key points to consider in the management include:

• The use of antimotility drugs like loperamide should be avoided in children <18 years of age with acute diarrhea and in cases where toxic megacolon may result from inflammatory diarrhea or diarrhea with fever 1.
• The choice of antimicrobial agent, if needed, may change due to evolving resistance patterns, with fluoroquinolone resistance in US and Canadian patients without international travel remaining low but significantly higher in many commonly visited countries 1.
• Treatment of STEC O157 infections and likely non-O157 STEC infections that produce Shiga toxin 2 with fluoroquinolones, β-lactams, TMP-SMX, and metronidazole should be avoided due to evidence of harm 1.

From the Research

Management Approach

The management approach for a patient presenting with vomiting, diarrhea, fever, and chills involves several key components:

• Assessment of dehydration status and red flag signs, such as bilious or bloody vomiting, altered sensorium, and severe dehydration 2
• Treatment of dehydration, which is crucial in managing acute gastroenteritis 3, 4, 5
• Use of oral rehydration therapy (ORT) with hypoosmolar fluids as the standard first-line treatment 3, 4, 5
• Administration of anti-emetic medications, such as ondansetron, to reduce the intensity of nausea and vomiting 6, 2, 5
• Consideration of other effective procedures, including probiotics, racecadotril, and diosmectite as antidiarrheals 5

Dehydration Assessment and Treatment

Dehydration assessment is critical in determining the severity of acute gastroenteritis and deciding on hospital admission 4, 5

• Oral rehydration solution (ORS) is the mainstay of treatment for acute watery diarrhea, and its effectiveness can be assessed through an ORS tolerance test 3
• The volume of ORS a child with diarrhea and moderate dehydration needs to tolerate to be successfully managed at home can be determined through observation in a Children's Emergency Department (CED) 3

Anti-Emetic Medications

Anti-emetic medications, such as ondansetron, can facilitate oral rehydration therapy (ORT) and minimize the risk of dehydration and hospitalization 6

• Ondansetron has been shown to be efficacious and superior to other anti-emetic medications in the treatment of gastroenteritis-related vomiting 6
• The use of anti-emetic medications should be considered in situations where vomiting hinders ORT, but a larger randomized, placebo-controlled trial is necessary before routine recommendation 6

Other Considerations

Other considerations in the management of acute gastroenteritis include:

• The use of probiotics, such as Lactobacillus GG and Saccharomyces boulardii, as antidiarrheals 5
• The administration of racecadotril and diosmectite as antidiarrheals 5
• The consideration of antibiotherapy only in exceptional situations 5