Diarrhoea and/or vomiting

Any person, 4 weeks to 15 years, presenting with liquid stool and/or vomiting.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Severe dehydration and/or shock: dehydration 10% and over Reduced conscious state Tachycardia Increased respiratory rate or acidotic breathing Hypotension Pale or mottled Cold extremities Weak peripheral pulse Deeply sunken eyes and/or fontanelle Dry mucous membranes Decreased skin turgor CRT 3 seconds and over	Escalate immediately as per local CERS protocol Attach cardiorespiratory monitor Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section Give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL If shock is unresolved following initial bolus, switch to sepsis (suspected) protocol Keep nil by mouth until review
Moderate dehydration: 5–9% dehydration Lethargic or irritable Normal-mild tachycardia Increased respiratory rate Dry mucous membranes Sunken eyes and/or fontanelle CRT 3 seconds and over Decreased skin turgor	Start trial of oral fluids using oral rehydration solution (ORS), see specific treatment section, or frequent breastfeeds where appropriate Aim for 10 mL/kg/hr of ORS. Give slowly in incremental doses If refusing feeds or having profuse losses, check for contraindications of rapid nasogastric rehydration: no bowel sounds reduced level of consciousness persistent abdominal pain significant comorbidities age under 6 months If contraindications present, escalate as per local CERS protocol. Rapid nasogastric rehydration Insert nasogastric tube and confirm placement Start rapid nasogastric rehydration (NGR) with ORS via an enteral pump at 10 mL/kg/hr for 4 hours If not tolerating enteral rehydration (persistent vomiting) and/or worsening clinical state, escalate immediately as per local CERS protocol and treat as severe dehydration
Mild dehydration: less than 5% dehydration No clinical signs of dehydration	Start trial of oral fluids using oral rehydration solution (ORS), see specific treatment section, or frequent breastfeeds where appropriate Aim for 10 mL/kg/hr of ORS (give slowly in incremental doses)

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
Nausea and/or vomiting	If actively vomiting and/or unable to tolerate fluids, and over 6 months, give ondansetron: 8–15 kg: 2 mg orally, once only 15–30 kg: 4 mg orally, once only Over 30 kg: 8 mg orally, once only

Glucose

Assessment

Intervention

BGL

Measure BGL. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated If BGL over 10 mmol/L: check blood ketones escalate as per local CERS protocol

Focused assessment

Complete a dehydration focused assessment.

Consider an abdominal focused assessment.

Precautions and notes

• Most cases of diarrhoea and vomiting are self-limiting and only require encouragement of fluid intake and hydration monitoring.
• Nasogastric rehydration is a safe and effective way of rehydrating patients with moderate dehydration, and is preferred over the intravenous route.
• Rapid improvement following rehydration therapy is common. Any patient receiving rehydration therapy is expected to gradually improve. If there are clinical concerns despite improvement, escalate as per local CERS protocol.
• Ondansetron can be given for symptomatic relief. However, cessation of vomiting does not exclude a serious cause.
• Medications to stop diarrhoea are not recommended.
• Bilious, dark green vomiting is due to a gastrointestinal obstruction until proven otherwise and requires an urgent surgical referral.
• If vomiting without diarrhoea, consider causes other than gastroenteritis, e.g. intracranial causes, non-accidental injury (NAI).
• Patients should cease fortified formulas during acute illness.

Interventions and diagnostics

Specific treatment

• Weigh patient before starting rehydration.
• Bare weight, if possible, otherwise minimal clothing.

Oral replacement therapy (ORT)

• Breastfeeding: encourage frequent small feeds.
• Encourage parents to explore alternative methods of rehydration, such as ice blocks, the use of oral syringes or teaspoons. Examples of suitable oral rehydration solutions (ORS) include Gastrolyte®, Hydralyte® and Pedialyte®.
• If other fluids are refused, give a mixture of apple juice and water in a 1:1 ratio.
• Encourage the reintroduction of an age-appropriate diet once vomiting has settled.

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Analgesia

If pain score 1–6 (mild–moderate): give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

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Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

• Urinalysis:
  • Patient who can void in the toilet: mid-stream urine
  • Patient who is not toilet trained: clean catch or catheter urine
  • If only vomiting or positive for nitrites and/or leucocytes, send for MC&S. Keep the sample refrigerated if transport delayed.
  • Refer to urine sampling appendix for further detail
• Stool culture for:
  • returned traveller with persistent diarrhoea
  • unwell with bloody diarrhoea
  • immunocompromised with fever or diarrhoea
  • diarrhoea lasting over 7 days
• Signs of shock: VBG with lactate
• Requiring IV hydration: FBC, UEC, glucose

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au