Nausea and vomiting

Thorough history and clinical examination needed
Symptoms have many causes — range from easily treatable to serious and life-threatening
Must identify and treat cause — see Acute assessment of nausea and vomiting

Red Flags — Urgent Medical Consult
Large amount of vomited blood — possible oesophageal tear Abdominal pain Chest pain Severe unresponsive vomiting Moderate to severe dehydration Unknown cause for vomiting Child with vomiting and significant pain Oculogyric crisis

Ask

Medical history — frequent vomiting, migraine, abdominal surgery, other serious illness, eg diabetes, CKD
Treatments already tried and response
How long and how often have been vomiting, amount of vomit, colour and content of vomit
Other symptoms — diarrhoea, pain, fever, headache, photophobia (sensitive to light)
Ability/interest in taking fluids, urine production — check for dehydration
Problems swallowing — do food or liquids get stuck in throat

Check

Calculate age-appropriate REWS

Adult — AVPU, RR, O₂ sats, pulse, BP, Temp
Child (less than 13 years) — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp

Weight, BGL

U/A, pregnancy test — if pregnant — see Common discomforts of pregnancy
If available POC test — WBC, electrolytes, ketones
Head-to-toe exam — attention to abdomen and dehydration

For child — see Assessing dehydration

Abdominal exam

Do first

Medical consult if

Moderate/severe dehydration — to consider IV fluids
Ketones — diabetic ketoacidosis (DKA)
Abnormal electrolytes
If severe unresponsive vomiting

Do

Mild dehydration — oral fluids
Treat with fluids without medicines if uncomplicated
Monitor response to treatment

Medicines — adult

Antiemetics — Table 7.14

Be alert for oculogyric crisis

Medicines — child

Medical consult before giving antiemetic to child

The younger the child — the harder to find cause and higher the risk of severe dehydration

If dehydration — see Fluids for treating dehydration
Gastroenteritis — usually vomiting and diarrhoea. Unlikely if vomiting alone especially with significant pain

Table 7.14 Commonly used antiemetics

Medicine	Cautions	Route	Frequency	Doses
Metoclopramide	Pregnancy: A — safe to use Breastfeed: Safe to use Risk: Oculogyric crisis** Do not use if bowel obstruction	Oral IM Slow IV	Up to 3 times a day (tds)	Adult Less than 60kg — 5mg 60kg or more — 10mg Child 40kg or more* 5mg
Prochlorperazine	Pregnancy: C — safe in early pregnancy Breastfeed: Safe to use Risk: Oculogyric crisis**	IM Slow IV	Up to 3 times a day (tds)	Adult 12.5mg Child N/A
Ondansetron — non-sedating. Use if sedation a problem or others have not worked Preferred for children and young people	Pregnancy: B1 — do not use in first trimester Breastfeed: Safe to use	Oral wafer	Up to 3 times a day (tds)	Adult 8mg Child 6 months to 12 years* 2–4mg (doses)
Promethazine — sedating	Pregnancy: C — safe to use, avoid close to delivery Breastfeed: Appears safe Risk: Oculogyric crisis**	Oral Deep IM	Up to 4 times a day (qid)	Adult Oral 25mg IM 12.5mg Child 2 years and over* Oral 0.5mg/kg/dose up to 25mg IM 0.25mg/kg/dose up to 12.5mg (doses)

* Medical consult before giving to children

**Oculogyric crisis

Metoclopramide, prochlorperazine and promethazine can cause an oculogyric crisis

Symptoms include stiffness, bending back of head, grimace, twisting back, rolling eyes up
Do not use in Parkinson's disease
Can happen at any age — more common in children and young women
Give benzatropine IM/IV — adult 1mg, child 20microgram/kg/dose up to 1mg — doses — single dose
Urgent medical consult