Bilious Emesis in a 3-Week-Old
A 3-week-old, 3.2-kg girl is being transported from a critical access hospital to a pediatric surgery center, 90 minutes by air. She has had bilious emesis twice and is now lethargic. HR is 180, RR is 60, BP is 62/38, SpO2 is 94% on room air, capillary refill is 4 seconds, and her anterior fontanel is sunken. Her abdomen is distended and tender. She has a 24-gauge IV in the left hand. The outside nurse reports a glucose of 42 mg/dL. No imaging has been done.
1. What is your immediate stabilization plan before and during transport? Include specific fluid and glucose orders for this patient.
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Stabilization
- Airway/breathing: place on oxygen and monitor; be prepared to intubate if she tires or has apnea.
- Circulation: obtain a second IV or intraosseous line. Give 10 mL/kg isotonic crystalloid (32 mL) over 20 minutes and reassess. Repeat once if perfusion remains poor, up to 20 mL/kg total before reassessing for overload.
- Glucose: give D10W 2 mL/kg (6.4 mL) IV push for glucose 42 mg/dL, then recheck in 15–30 minutes and start a maintenance infusion containing dextrose if needed.
- Decompression: insert an 8–10 Fr nasogastric tube to relieve distension and reduce aspiration risk.
- Temperature: keep warm; neonates lose heat rapidly and hypothermia worsens acidosis.
- Antibiotics and nothing by mouth; notify the receiving surgical team.
Reasoning The infant is in compensated or early decompensated shock with hypoglycemia. Small, repeated boluses and cautious glucose correction are safer than a single large fluid load in a neonate. NG decompression addresses the obstructive component and lowers the risk of vomiting and aspiration during transport.
2. What is your working diagnosis, and why does it change your transport destination and urgency?
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Working diagnosis Malrotation with midgut volvulus until proven otherwise. Bilious emesis in a neonate is a surgical emergency, not simple reflux.
Why it matters
- Volvulus twists the mesentery and can cause bowel ischemia within hours.
- The child needs urgent upper gastrointestinal contrast study and operative detorsion.
- Transport should go to a facility with pediatric surgery and immediate operating room capability, not merely the nearest hospital.
- The receiving center should be notified early so that imaging and surgery can be activated on arrival.
Reasoning The destination decision is driven by time-sensitive surgical need, not by distance alone. If the child becomes unstable, the nearest facility with pediatric surgical capability is preferable to a longer flight to a distant center.
3. En route her HR rises to 200, BP falls to 50/30, and the abdomen becomes rigid. What do you do?
Read the worked answer
Interpretation This suggests worsening shock with possible bowel ischemia or perforation. A rigid abdomen is a surgical abdomen until proven otherwise.
Actions
- Give another 10 mL/kg isotonic fluid bolus (32 mL) while reassessing.
- Ensure the NG tube is functioning and not coiled.
- Prepare for intubation if respiratory status deteriorates; use reduced drug doses because of shock.
- Start a vasoactive infusion if hypotension persists after fluids, using weight-based dosing and a clearly labeled syringe.
- Notify the receiving surgeon and request direct-to-operating-room or direct-to-CT capability.
- Continue glucose checks and temperature control.
Reasoning The infant is moving from compensated shock to decompensated shock. Fluid resuscitation and rapid surgical disposition are the priorities. Vasopressors support perfusion but do not treat the underlying ischemic bowel, so transport must not be delayed for titration.