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)
| Investigation | Significance |
| Beta hCG blood test | Pregnancy |
| FBE | Routine |
| UEC | Electrolyte disturbances |
| Serum glucose | Diabetic ketoacidosis |
| LFTs | |
| VBG/ABG* | |
| Urine ketones* | Suspicion for diabetic ketoacidosis |
Table 3 Further investigations (1,2)
| Investigation | Significance |
| 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 screen | Suspicion of toxin ingestion |
| X-ray abdomen | Suspicion 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)
| Indication | Regime |
| Able to tolerate oral fluids | Oral fluid hydration |
| Severe dehydration and inability to tolerate oral fluidsSignificant metabolic abnormalities secondary to vomiting Surgical emergencies | IV 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 hours | General 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 vertigo | Risk 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
