What is the immediate management for a pediatric patient traumatized by an 80-pound dog and presenting with vomiting?

Immediate Management of Pediatric Trauma with Vomiting

This child requires immediate trauma evaluation using the ABCDE approach with concurrent assessment for intra-abdominal injury, as blunt abdominal trauma from an 80-pound dog can cause solid organ injury or intestinal perforation, and vomiting may indicate either the trauma response itself or evolving abdominal pathology. 1, 2

Primary Survey and Stabilization

Airway and Breathing Assessment:

• Assess airway patency while maintaining cervical spine precautions (even though mechanism suggests isolated abdominal trauma, maintain vigilance) 1, 2
• Look for chest and abdominal movement, listen for breath sounds, and feel for expired air 1
• Ensure adequate oxygenation and ventilation 2

Circulation and Hemorrhage Control:

• Check brachial pulse for presence, rate, and volume 1
• Assess for signs of shock (tachycardia, delayed capillary refill, altered mental status) 1, 2
• Establish IV access if the child shows signs of hemodynamic instability 2

Critical Red Flags to Identify Immediately:

• Bilious (green) vomiting indicates intestinal obstruction and requires emergency surgical consultation 3, 4
• Blood in vomitus (hematemesis) suggests upper GI injury 1, 3
• Abdominal distension or tenderness indicates possible solid organ injury or perforation 3, 2
• Altered mental status or lethargy suggests head injury or shock 3, 4

Vomiting Management Strategy

For Non-Bilious Vomiting Without Red Flags:

• Administer small volumes (5 mL) of oral rehydration solution (ORS) every 1-2 minutes using a spoon or syringe 1, 3
• Gradually increase volume as tolerated 1, 3
• Do NOT allow the child to drink large volumes ad libitum, as this will worsen vomiting 1

For Persistent Vomiting Impeding Oral Intake:

• Consider ondansetron 0.2 mg/kg orally (maximum 4 mg) to facilitate oral rehydration 3, 4
• This is particularly useful if vomiting prevents adequate fluid intake 4, 5

For Bilious Vomiting or Severe Abdominal Findings:

• Stop all oral intake immediately 4
• Place nasogastric tube for gastric decompression 4
• Obtain immediate surgical consultation 3, 4
• Establish IV access and begin fluid resuscitation 2

Abdominal Trauma Assessment

Physical Examination Priorities:

• Inspect for abdominal wall bruising, distension, or visible trauma 1, 2
• Palpate all four quadrants for tenderness, guarding, or rigidity 5
• Examine genitalia and hernial orifices 5
• Monitor for evolving peritoneal signs over time 4, 5

Imaging Considerations:

• Plain abdominal radiography if obstruction suspected (look for dilated bowel loops, air-fluid levels) 4, 6
• Use pediatric-specific imaging protocols to minimize radiation exposure 2
• Abdominal ultrasound or CT may be needed if solid organ injury suspected, but clinical assessment guides this 2

Pain Management

Analgesic Approach:

• Provide pain control early in the evaluation 2
• Acetaminophen 15 mg/kg orally or IV every 6 hours is first-line for mild-moderate pain 1
• Avoid NSAIDs initially due to potential for GI bleeding in trauma and possible need for surgery 1
• For severe pain, small repeated doses of opioids are preferred over large boluses to avoid respiratory depression 1
• Titrate carefully in children with vomiting, as they may have altered absorption 1

Observation and Disposition

Admission Criteria:

• Persistent vomiting despite antiemetics 3, 4
• Any bilious vomiting 3, 4
• Signs of dehydration not responding to oral rehydration 3
• Abdominal tenderness or distension 3, 2
• Hemodynamic instability 2
• Concern for evolving intra-abdominal injury 1, 2

Transfer to Pediatric Trauma Center:

• Younger children and those with severe injuries have improved outcomes at specialized pediatric facilities 1, 2
• Stabilize before transfer if immediate transport not feasible 2
• Use pediatric critical care transport teams when available 2

Common Pitfalls to Avoid

• Do not assume vomiting is "just gastroenteritis" after trauma—always consider intra-abdominal injury 4, 7
• Do not give large volumes of fluid rapidly to a vomiting child—this perpetuates the cycle 1
• Do not delay surgical consultation for bilious vomiting 3, 4
• Do not overlook non-accidental trauma—an 80-pound dog sitting on a child should prompt consideration of supervision adequacy 1, 2
• Regular reassessment is essential, as abdominal injuries can evolve over hours 4, 5

Monitor for signs of deterioration: decreased urine output, increasing lethargy, worsening abdominal pain, or persistent vomiting beyond 4-6 hours warrant escalation of care 3, 4