Pain Management

Pain management is one of the most important components of patient care in the Emergency Department. Evidence suggests that patients in pain are commonly under-treated, under-recognised and treatment is often delayed. The process for recognition and management of pain should be a priority for Emergency Departments. Pain control should start in the pre-hospital phase for those brought in by ambulance or at Triage for those who self-present. Response to analgesia should be monitored during the patient’s stay in the Emergency Department and consideration given to analgesia requirements post discharge.

Paint control is one of the top clinical priorities for SJRHEM

Visit the – SJRHEM Pain Control Resource Page

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Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea



To assess and address dehydration and initiate treatment to prevent further clinical decline in children >6m with vomiting +/- diarrhea triaged CTAS 3,4,5

The hydration guidelines will be implemented in Triage level 3, 4 and 5 children who are greater than 6 months old presenting with a history of vomiting and/ or diarrhea with no abdominal pain other than expected cramping.



  • >6m-10y
  • children with nausea
  • vomiting or diarrhea
  • mild dehydration
  • CTAS 3,4,5.


  • <6m, >10y
  • severe dehydration
  • CTAS 1,2
  • symptoms >7 days
  • focal abdominal pain
  • PMHx
    • inborn errors of metabolism
    • diabetes
    • immuno deficiency
    • major organ system disorder
  • signs of symptoms of bowel obstruction
    • distention
    • bilious emesis
    • absent bowel sound


Children presenting with moderate or severe dehydration must be triaged at Level 1 or 2 and seen by a physician prior to initiating treatment.

Severe Dehydration (>9%) is defined as marked volume loss with classic signs of dehydration, with signs and symptoms of shock, (increased heart rate, decreased BP, decreased perfusion, lethargy, dry mucous membranes, etc)

Moderate Dehydration (5-8%) is defined as a child presenting with dry mucous membranes, tachycardia, plus or minus decreased skin tugor and decreased urine frequency.

Mild Dehydration (3-5%) is defined as stable VIS, c/o increased thirst, concentrated urine, and history of decreased fluid intake or increased fluid loss or both.

*use of Gorelick score to determine degree of dehydration.


Goerlick Score:

One point for each of:

  • Capillary refill >2 seconds
  • Absence of tears
  • Dry mucous membranes
  • Ill general appearance
Score Percent dehydrated Degree of dehydration
< 1 <5% Mild
2 5-10% Moderate
>3 >10% Severe


  • Medicine cup or oral syringe
  • Oral rehydration solution (ORS) ie: Pedialyte


  • Instruct and encourage parents/caregivers to administer hydration therapy with ORS using the medicine cup or oral syringe and record intake/output
  • Oral hydration should begin in the waiting room before the child’s condition deteriorates and further GI losses occur. Juice may be substituted for ORS, mix 1/3 juice with 2/3 water.

Mild dehydration

  • Parenterial Fluids rarely required
  • Administer 1ml po fluid per kg child’s weight every 5min
  • Goal 50-100 ml po fluid per kg within 2-4 hr of presentation

Severe dehydration

  • CTAS 1 or 2
  • May require NS or LR 20ml/kg IV bolus (push) up to 60 ml/kg initially.


Re-Assessment and monitoring of child’s compliance, improvement or deterioration, according to the following:

  • Triage level 3 = q 30 minutes
  • Triage level 4 = q 1 hour
  • Triage level 5 = q 2 hour


  • Vital signs
  • Intake output
  • Solution type taken
  • Response to therapy
  • Ongoing losses


Ondansetron is the antiemetic of choice in the treatment of dehydration associated with pediatric gastroenteritis. There is no role for multiple doses, or the alternative use of dimenhydrinate. Suggested dosing as follows:

*[routine use in the absence of dehydration]

Ondansetron Dosing
Weight (kg) Dose (mg)
8-15 2
15-30 4
>30 8

*0.2mg/kg if <8kg

Criteria for admission/ Pediatric consultation

  • Progressive/ Intractable symptoms.
  • Hypo/hyper natremia, on going metabolic acidosis
  • Significant social concerns
  • Diagnostic uncertainty or comorbid illness
  • Severe dehydration/ resuscitation

Discharge Criteria

  • Gorelick score <1
  • Likely to maintain hydration at home


  1. Armon,K.,T.,MacFaul,R.,Eccleston,P.,&Wemcke,U.(2001). March An Evidence and Consensus Based Guideline For Acute Diarrhea Management.
  2. Burkhart,D.(1999)December .Management of Acute Gastroenteritis in Children. American Family Physician. Vol.60(9) .
  3. CAEP, COT retrieved Dec 2009-12-14.
  4. Hugger,J.,Gene,H.,&Rentschler,D.(1998). December. Oral Rehydration Therapy for children with Acute Diarrhea. Vol.23(12) .
  5. Jarvis,C.(1996). Physical Examination and Health Assessment. 2nd edition.
  6. Trekk, Friedman S, & Trekk Network. Bottom Line: Gastroenteritis (2016)
  7. Watt,J.,(1999). April. Acute Gastroenteritis in children. Australian Family Physician. Vol.28(4)

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