Signs and Symptoms
History
- Symptom duration, frequency, severity:
- Acute, recurrent, chronic, cyclic
- Characteristics of vomiting: Timing, description, content of vomitus
- Associated symptoms: Pain, fever, diarrhea, neurologic
- Past surgical or GI history
- Medication and drugs use
- Last menstrual period
- Complete past medical history
Physical Exam
- Vital signs:
- Fever: Appendicitis, gastroenteritis, cholecystitis, hepatitis, bowel perforation
- Tachycardia: Dehydration
- Head, ears, eyes, nose, throat:
- Abnormal anterior chamber: Glaucoma
- Dry mucous membranes: Dehydration
- Nystagmus: Labyrinthitis, stroke, tumor, intracranial hemorrhage
- Papilledema: Elevated ICP
- Abdomen:
- Blood in stool or emesis: Peptic ulcer, Mallory-Weiss tear
- Decreased bowel sounds: Ileus
- Distention, high-pitched bowel sounds, scars or hernias: Intestinal obstruction
- Tenderness: Appendicitis, cholecystitis, pancreatitis, perforated viscus, ovarian torsion
- Testicular pain: Testicular torsion
- Neurologic:
- Abnormal mental status, cerebellar test abnormalities, cranial nerve abnormalities: CNS pathology
Essential Workup
The workup is aimed at determining the underlying etiology of vomiting and excluding dangerous sequelae
Diagnostic Tests & Interpretation
Lab
- CBC:
- Elevated WBC: Infectious process (e.g., appendicitis, gastroenteritis), stress response
- Elevated hematocrit: Dehydration
- Decreased hematocrit: GI bleed from ulcer
- Electrolytes/renal function:
- Prolonged vomiting may cause hypochloremic hypokalemic metabolic alkalosis
- BUN/creatinine ratio >20 may indicate dehydration
- Renal insult may occur from dehydration
- Liver/pancreatic function tests:
- Lipase elevation: Pancreatitis
- AST/ALT elevation: Hepatitis
- Alkaline phosphatase elevation: Cholecystitic etiology (biliary stone, pancreatic mass)
- Urine analysis:
- WBC, nitrites, leukocyte esterase, bacteria: UTI/pyelonephritis
- Ketones: Dehydration, DKA, alcohol abuse
- Pregnancy test in women of childbearing age
- Toxicology screen/drug levels:
- For suspected drug toxicity or overdose
Imaging
- Abdominal series (kidney, ureter, bladder/upright):
- CT abdomen/pelvis:
- Suspected appendicitis, obstruction, nephrolithiasis
- CT/MRI head:
- Suspected intracranial etiology
- US:
- Suspected biliary disease, gonadal torsion, nephrolithiasis
Diagnostic Procedures/Surgery
- ECG:
- Suspected acute coronary syndrome
- Endoscopy:
- Peptic ulcer disease leading to significant GI bleed
Prehospital
- Aimed at stabilizing patient until arrival in the ED where the workup of underlying cause of vomiting can proceed
- Placement of IV, oxygen, cardiac monitor
- Begin administration of isotonic fluids in suspected dehydration
- Fingerstick glucose in mental status change or known diabetic
- Specific protocols may permit antiemetics for motion sickness or other etiologies of vomiting
Initial Stabilization/Therapy
- Address ABCs
- Urgent fluid resuscitation if vomiting has led to hypovolemic shock
- Urgent antiemetic therapy for patient comfort and reduce aspiration risk
- Urgent analgesic therapy if indicated
ED Treatment/Procedures
- 3 principles of ED treatment:
- Correct fluid, electrolyte, and nutritional deficiencies as a result of vomiting
- Identify and treat underlying cause
- Suppress or eliminate symptoms
- Antibiotics if indicated: UTI, appendicitis, bacterial gastroenteritis (rare)
- Medications:
- Serotonin antagonists often first-line treatment:
- Ondansetron, dolasetron, granisetron
- Useful in chemotherapy-induced nausea
- Ondansetron available as an oral dissolving tablet for patients who cannot tolerate pills
- Can cause QT prolongation
- Dopamine D2 antagonists also useful in most types of nausea:
- Prochlorperazine, promethazine, metoclopramide
- Side effects (e.g., akathisia, dystonia) more common than in serotonin antagonists
- Note black box warnings on use of promethazine (tissue injury with IV administration)
- Anticholinergic and antihistamine agents useful in labyrinthitis, positional vertigo, and motion sickness:
- Benzodiazepines and glucocorticoids have mild antiemetic properties and can be used as adjuncts
- Consultation with other specialties (e.g., surgery, gynecology, gastroenterology) depending on underlying etiology
Medication
- Diphenhydramine: 25-50 mg IM/IV/PO
- Dolasetron: 12.5 mg IV
- Doxylamine/pyridoxine: 10 mg/10 mg up to t.i.d PO
- Droperidol: 0.625-1.25 mg IM/IV
- Granisetron: 1 mg IV or 2 mg PO
- Hydroxyzine: 25-100 mg IM
- Meclizine: 25-50 mg PO
- Metoclopramide: 10 mg IM/IV/PO
- Ondansetron: 4-8 mg IM/IV/PO
- Prochlorperazine: 5-10 mg IM/IV/PO or 25 mg PR
- Promethazine: 12.5-25 mg PO/PR/deep IM
- Scopolamine: 1.5 mg patch applied behind the ear 4 hr prior to travel
Geriatric Considerations |
- Dopamine-antagonizing antiemetics have potential cardiac side effects:
- The doses of these medications should be reduced in the elderly
- Serotonin antagonists are safer in this population:
- Still consider using lower doses and obtaining an ECG to detect QT prolongation prior to administration
|
Pediatric Considerations |
- Vomiting in children can result from a host of other diagnoses, e.g., structural/anatomical disorders, infections, and metabolic disorders:
- Workup and treatment may therefore be different in children
|
Pregnancy Prophylaxis |
- Vomiting occurs in >25% of pregnancies
- Hyperemesis gravidarum requires ketosis and weight loss
- Dopamine D2 antagonists (e.g., promethazine, chlorpromazine, metoclopramide) or serotonin antagonists (e.g., ondansetron, granisetron) most commonly used; doxylamine-pyridoxine also can be useful
|
First Line
- Serotonin antagonists
- Dopamine D2 antagonists
Second Line
- Anticholinergics
- Antihistamines
- Benzodiazepines
- Glucocorticoids
Disposition
Admission Criteria
- Depends on underlying pathology
- Significant underlying disease or symptoms necessitating close observation or surgical procedure
- Uncontrolled emesis resulting in inability to tolerate food or liquids by mouth
- Severe dehydration requiring continued IV fluids
- Significant electrolyte disturbances
- Unknown etiology of vomiting with inadequate outpatient follow-up
Discharge Criteria
- Significant underlying pathology is excluded
- Patient is sufficiently hydrated
- Patient can tolerate PO
- Close follow-up is arranged (preferably within 24-36 hr)
Follow-up Recommendations
- All patients who are unable to tolerate fluids at home should return to the ED
- Patients in whom the etiology of vomiting is unknown or who had electrolyte disturbances should follow-up
- GuttmanJ. Nausea and vomiting. In: WallsRM, HockbergerRS, Gausche-HillM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed.Philadelphia, PA: Mosby Elsevier; 2018.
- LongstrethGF. Approach to the adult with nausea and vomiting . UpToDate. www.uptodate.com. 2016.
- MalageladaJR, MalageladaC. Nausea and vomiting. In: FeldmanM, FriedmanLS, Brand tLJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Diseases. 10th ed.Philadelphia, PA: Saunders Elsevier; 2016.
- SimonettoDA, OxentenkoAS, HermanML, et al. Cannabinoid hyperemesis: A case series of 98 patients . Mayo Clin Proc. 2012;87:114-119.
See Also (Topic, Algorithm, Electronic Media Element)
Vomiting, Pediatric