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Nausea and vomiting

Table of Contents
  • Overview
  • Triage
  • Causes
  • Approach
  • Investigations
  • Management
  • References

Overview #

Definitions

Nausea involves the unpleasant sensation of about to vomit and can occur alone or with the presence of vomiting which is the forceful expulsion of gastric contents. Acute nausea and vomiting occurs when symptoms last less than 1 month.  

Key points

  • Nausea and vomiting can be caused by pathology in any organ system.
  • Patients presenting with acute onset of nausea and vomiting should be evaluated for signs of dehydration and electrolyte and acid-base disorders.
  • A thorough history and physical examination should be performed to narrow down the underlying cause. 
  • Targeted therapy should be provided when possible to address the underlying cause.
  • Postoperative nausea and vomiting are common and can delay discharge or lead to readmission if ill managed

Triage #

Triaging nausea and vomiting will depend on the presence of other symptoms and the clinical concern that the referrer has regarding the patient(1). 

  • Call the referrer to inquire if the patient has abnormal vital signs and neurological changes. 
  • If a patient has unstable vital signs or neurological changes they should be seen immediately. 
  • Otherwise it is appropriate to review the patient within 1 hour.

Causes #

This list aims to include the most life threatening and common causes of acute nausea and vomiting but does not encompass every possible cause of nausea and vomiting.

Nausea and vomiting life-threatening causes (1–3)

  • Raised intracranial pressure
    • Haemorrhagic stroke 
    • CNS infection 
  • Myocardial infarction
  • Acute pancreatitis 
  • Bowel obstruction or perforation 
  • Diabetic ketoacidosis
  • Addisonian crisis
  • Drug overdose/withdrawal
  • Poisoning or ingestion of toxins 
  • Allergy and anaphylaxis

Infectious causes of nausea and vomiting (1–3)

Gastrointestinal

  • Gastroenteritis
    • Viral
    • Bacterial
  • Acute cholecystitis
  • Acute cholangitis
  • Acute hepatitis 
  • Liver abscess
  • Acute appendicitis 

HEENT

  • Acute otitis media
  • Acute labyrinthitis 

Cardiopulmonary

  • Pericarditis
  • Pneumonia
  • Empyema

Genitourinary

  • UTI
  • Pelvic inflammatory disease
  • Prostatitis
  • Epididymo-orchitis

Neurological

  • Meningitis
  • Encephalitis
  • Brain abscess

Non-infectious causes of nausea and vomiting

Gastrointestinal

  • GORD
  • PUD
  • Acute gastritis 
  • Gastroparesis
  • Bowel obstruction
  • Acute mesenteric ischemia
  • Acute pancreatitis
  • Biliary colic

HEENT

  • Meniere disease
  • PBBV
  • Vestibular neuritis
  • Acoustic neuroma 
  • Acute angle closure glaucoma 

Cardiopulmonary

  • Myocardial infarction

Genitourinary

  • Pregnancy
  • Renal colic
  • Ovarian torsion
  • Testicular torsion

Neurological

  • Migraine
  • Cluster headaches
  • Brain tumour
  • Intracranial haemorrhage
  • Ischaemic stroke
  • Hydrocephalus 

Psychiatry

  • Bulimia
  • Anorexia nervosa

Endocrinologic and metabolic causes

  • DKA
  • Uraemia
  • Hyper/hypothyroidism
  • Hyper/hypoparathyroidism
  • Adrenal insufficiency/ crisis
  • Alcohol withdrawal 

Iatrogenic

  • Analgesics
    • Opioids
    • NSAIDs
  • Antibiotics
  • Chemotherapy
  • Alcohol and other recreational drugs e.g. marijuana
  • Radiation therapy

Miscellaneous

  • Allergy and anaphylaxis 
  • Postoperative nausea and vomiting

Approach #

Primary survey of unstable patient (1,2)

A: Signs of respiratory distress, inspect mouth and larynx for obstruction from vomit 

B: Assess oxygen saturations and respiratory rate, auscultate for unequal air entry indicative of obstruction

C: Assess for tachycardia, hypotension, reduced capillary refill, overall hydration status

D: Assess patients conscious state using GCS or AVPU

Assessment of a stable patient (1-3)

Ensure a comprehensive history and examination of all organ systems to determine additional  symptoms and the underlying cause 

History

  • Characterise vomiting
  • Volume and frequency 
  • Frequency and timing with meals 
  • Ability to keep food and drink down

The following features are nausea and vomiting red flags 

  • Gastrointestinal
    • Haematemesis or vomiting coffee ground vomitus
    • Feculent vomiting 
    • Melaena
    • Hematochezia
    • Progressive dysphagia 
    • Extreme abdominal pain
  • Neurological
    • Altered mental status 
    • Focal neurological deficits
    • Signs of meningitis 
  • Respiratory/ Cardiovascular
    • Dyspnoea
    • Chest pain

Associated features of note 

  • Gastrointestinal features
    • Vomiting of food eaten several hours earlier
    • Presence and distribution of abdominal pain
    • Past history of abdominal surgery
    • Abdominal distention
    • Early morning vomiting 
  • Neurological features
    • Vertigo and nystagmus 
    • Headache 
    • Past history of motion sickness 
  • Endocrinologic features
    • History of chronic steroid therapy use
    • History of use of insulin for diabetes
  • Infectious disease features
    • Sick contacts that consumed the same food or liquids
  • Medication review
    • Use of opioids 
    • Medications started recently
    • History of use of alcohol and other recreational drugs such as cannabis
    • Currently charted antiemetics 
  • Psychiatric
    • Presence of dental enamel erosion, parotid gland enlargement and calluses on hands

Complications of nausea and vomiting (1)

  • Dehydration
  • Hypochloremic metabolic alkalosis due to loss of stomach acid
  • Oesophagitis
  • Mallory Weiss tear
  • Boerhaave Syndrome and oesophageal rupture 

Investigations #

Select relevant investigations below based on severity and clinical suspicion

Table 2 Initial investigations  (1,2)

InvestigationSignificance
Beta hCG blood testPregnancy
FBERoutine
UECElectrolyte disturbances
Serum glucoseDiabetic ketoacidosis 
LFTs
VBG/ABG*
Urine ketones* Suspicion for diabetic ketoacidosis 

Table 3 Further investigations  (1,2)

InvestigationSignificance 
ECG Associated chest and epigastric pain
Troponin*Associated chest and epigastric pain
Lipase* Ruling out pancreatitis 
CRP*Suspicion of infectious aetiology 
Stool culture*Suspicion of atypical gastroenteritis 
Toxicology screenSuspicion of toxin ingestion
X-ray abdomenSuspicion of bowel obstruction and peritonitis 
X-ray chest Suspicion of hollow viscus perforation 

Management #

Identification of the cause of nausea and vomiting is important to allow:

  • Identification of life threatening causes
  • Guiding treatments to reverse underlying causes 

The management listed below is directed at symptom management.

Table 4 Nonpharmacological Management of Nausea and Vomiting (1,4)

Measure
Sitting upAvoiding large mealsEating light bland foodsDrinking clear or ice cold drinks
Avoiding triggers of nausea and vomiting Medications such as opioidsFatty, spicy or very sweet foods
Continuous monitoring of:Blood pressurePulse oximetryHydration status 
Replacement of electrolyte deficiencies  
* Be conservative with bolus volume in elderly patients and patients with renal or heart failure

Fluid Management of Nausea and Vomiting (1,4)

IndicationRegime
Able to tolerate oral fluidsOral fluid hydration 
Severe dehydration and inability to tolerate oral fluidsSignificant metabolic abnormalities secondary to vomiting Surgical emergenciesIV fluid hydration
Use 0.9% saline or CSL bolus* for hypovolaemia 
Use maintenance 0.9% saline or CSL for ongoing fluid loss 
* Be conservative with bolus volume in elderly patients and patients with renal or heart failure

Table 5 Pharmacological Management of Nausea and Vomiting (4)

Medication Indications Precautions 
Metoclopramide Orally, intramuscularly or intravenously:10mg every 8 hoursGeneral use and particularly useful for nausea and vomiting associated with migraine Risk of:Extrapyramidal adverse effects especially in patients younger than 20
Avoid in Parkinson disease
Do not use for more than 5 days
Avoid if suspicions for gastrointestinal obstruction or perforation 
OndansetronOrally or IV:
4 – 8 mg every 8 – 12 hourly 
General use 
Risk of :Headache ConstipationQT interval prolongation Rare association with dystonic reactions
Rapid IV administration can cause visual disturbance
 
ProchlorperazineIM or slow IV:12.5mg every 8 hours 
OR 
Orally:20mg initial dose. Then if required 10 mg 2 hours later, then 5-10 mg TDS.
General use and particularly useful for nausea and vomiting associated with migraine and vertigoRisk of :SedationQT interval prolongationExtrapyramidal adverse effectsAnticholinergic effects 
Avoid in Parkinson disease
Promethazine hydrochloride
IM:12.5 – 25 mg 4 – 6 hourly ( maximum 100mg in 24 hours)
OR
Orally:25 mg every 4-6 hourly( maximum 100mg in 24 hours)
General use and particularly useful for nausea and vomiting associated with motion sickness Risk of:SedationLowering the seizure thresholdAnticholinergic effects Extrapyramidal adverse effects 
Avoid in Parkinson disease
Droperidol*Limited use
Used for nausea and vomiting refractory to other antiemetics, particularly for anxious or agitated patients
Dexamethasone* Used for nausea and vomiting caused by cerebral oedema 
Domperidone*Used for nausea and vomiting for patients with Parkinson disease
* These medications are added for completion. Seek expert advice regarding these medications. 

References #

1. Approach to the adult with nausea and vomiting – UpToDate [Internet]. [cited 2021 Oct 2]. Available from: https://www-uptodate-com.ezproxy.lib.monash.edu.au/contents/approach-to-the-adult-with-nausea-and-vomiting?search=naseau%20and%20vomiting&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

2. Assessment of nausea and vomiting, adults – Diagnosis Approach | BMJ Best Practice [Internet]. [cited 2021 Oct 2]. Available from: https://bestpractice-bmj-com.ezproxy.lib.monash.edu.au/topics/en-gb/631/diagnosis-approach

3. Metz A, Hebbard G. Nausea and vomiting in adults–a diagnostic approach. Aust Fam Physician. 2007 Sep;36(9):688–92. 

4. Search | Therapeutic Guidelines [Internet]. [cited 2021 Oct 2]. Available from: https://tgldcdp-tg-org-au.ezproxy.lib.monash.edu.au/searchAction?appendedinputbuttons=naseau%20and%20vomiting

  • Contributors

  • Reviewing Consultant/Senior Registrar

Dr Bowen Xia

Dr Sara Mgaieth

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Updated on March 27, 2023
Table of Contents
  • Overview
  • Triage
  • Causes
  • Approach
  • Investigations
  • Management
  • References

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