Nausea and Vomiting

Initial Assessment
  • ABC
  • Check vitals and random blood glucose (RBS)
History
  • Characteristics of Vomit: Content, amount, any relation to food
  • Associated Symptoms:
  • Abdominal pain, fever, last bowel motion, or passing gas
  • Abdominal distention
  • Relevant Medical History:
  • Gastrointestinal: Any GI conditions
  • Renal: Uremia or ESRD
  • Cardiovascular: History of IHD or atrial fibrillation
  • Endocrine: Uncontrolled diabetes
  • Neurological: Head trauma, headache, neck stiffness, photophobia, vertigo, tinnitus, weakness, or numbness
Examination
  • Abdominal Examination:
  • Assess bowel sounds:
    • Normal: Gurgling every 5–10 seconds
    • Attenuated/absent sounds: May indicate paralytic ileus
    • Enhanced/increased sounds: May indicate gastroenteritis
  • Neurological Exam: If indicated
Plan
Hydration
  • Administer IV fluids if dehydrated or not tolerating oral intake
  • Monitor RBS and choose fluids accordingly
Lab Investigations
  • Send VBG, RFT; correct electrolytes as needed
Medications
  • PPI: Losec 20 or 40 mg IV OD
  • Antiemetics:
    • Check ECG for QTc; if normal, administer Zofran 4 or 8 mg IV STAT, then reassess
Further Investigations if Unwell
  • Urgent labs: CBC, VBG, LFT, RFT, HsTrop, Amylase, Lipase, Lactate
  • Imaging: ECG, X-ray KUB
Criteria for Urgent Surgical Consult
  • No stool or gas passage
  • Severe abdominal pain
  • Bilious or fecal vomitus
  • Absent bowel sounds
  • Imaging findings:
    • Air-fluid levels or bowel dilation on AXR
    • Air under the diaphragm
If Suspected, Investigate and Manage Accordingly
  • UTI: Urine R/M and C/S with CRP, PCT; call for assistance for potential empirical antibiotics and imaging if pyelonephritis is suspected (especially with chills and rigors)
  • Cholecystitis: CBC, LFT, arrange abdominal ultrasound; call for assistance to contact surgeon if findings are present
  • Pancreatitis: Keep NPO, send amylase, lipase, arrange abdominal ultrasound, and call for assistance regarding hydration and pain management
  • DKA: Treat accordingly
  • Female in reproductive age: Ask about menstruation and consider pregnancy
  • Elderly or diabetic patients: Send HsTrop and ECG
Differential Diagnosis
  • Most Common: Gastroenteritis, food poisoning, medication/chemotherapy effects, vertigo
  • Can’t Miss: Pregnancy/hyperemesis gravidarum, SBO, ischemia (myocardial and mesenteric), pancreatitis, pyelonephritis, cholecystitis, DKA, increased ICP
  • Other Possible Causes: GERD, IBS, migraine, uremia, bulimia/anorexia, functional (cyclic vomiting, cannabinoid use)
MOC