Vomiting, Adult, Emergency Medicine

Basics

Description

3 phases:
- Nausea: Unpleasant sensation prior to vomiting
- Retching: Rhythmic contractions of diaphragm, abdominal muscles, intercostals that bring gastric contents up the esophagus
- Vomiting: Forceful retrograde expulsion of gastric contents through the mouth
Vomiting center in medulla coordinates vomiting through vagus, phrenic, spinal nerves
Irritated by impulses from the GI tract, pharynx, vestibular system, heart, genitalia, or via stimulation of chemoreceptor trigger zone (CTZ) in the area postrema of the brain by medications, toxins, or hormones in circulation
CTZ response mediated by dopamine D2, serotonin (5-HT3), cholinergic, and histamine receptors:
- Medications providing symptomatic treatment of vomiting antagonize these receptors

Etiology

GI:
- Appendicitis
- Boerhaave syndrome
- Bowel obstruction or ischemia
- Cholecystitis, biliary colic
- Gastric outlet obstruction, gastroparesis
- Gastritis
- Gastroenteritis (e.g., infectious)
- GI bleeding
- Hepatitis
- Inflammatory bowel disease
- Pancreatitis
- Peptic ulcer disease, dyspepsia
- Perforated viscus
- Peritonitis
Neurologic:
- Elevated intracranial pressure (ICP)
- Intracranial blood
- Labyrinthitis, vertigo
- Meningitis
- Migraine
- Stroke
- Tumor
Endocrine:
- Adrenal insufficiency
- Diabetic ketoacidosis (DKA)
- Hypoparathyroid, hyperparathyroid
- Hypothyroid, hyperthyroid
- Uremia
Pregnancy:
- Hyperemesis gravidarum
- Nausea/vomiting of pregnancy
Drug toxicity:
- Acetaminophen
- Aspirin
- Digoxin
- Theophylline
Therapeutic medication use:
- Antibiotics
- Aspirin
- Chemotherapy
- Ibuprofen
Drugs of abuse:
- Narcotics/narcotic withdrawal
- Alcohols
Genitourinary:
- Gonadal torsion
- Nephrolithiasis
- UTI/pyelonephritis
Miscellaneous:
- Carbon monoxide or organophosphate poisoning
- Electrolyte disorders
- Glaucoma
- Motion sickness
- Myocardial infarction/ischemia (MI)
- Pain
- Post-procedural (after anesthesia)
- Self-induced (eating disorders)
- Sepsis/shock

Diagnosis

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
- Pain: Appendicitis, cholecystitis, pancreatitis, perforated viscus, ovarian torsion
- Testicular pain: Torsion
Neurologic:
- Abnormal mental status, cerebellar test abnormalities, cranial nerve abnormalities: CNS pathology

Essential Workup

The workup is aimed at determining the underlying cause of vomiting and excluding dangerous sequelae

Diagnosis Tests & Interpretation

Lab

CBC:
- Elevated WBC: Infectious process (e.g., appendicitis, gastroenteritis)
- Elevated hematocrit: Dehydration
- Decreased hematocrit: GI bleed from ulcer
Electrolytes/renal function:
- Prolonged vomiting may cause hypochloremia, hypokalemia.
- BUN/creatinine ratio >20 may indicate dehydration.
- Renal insult may occur from dehydration
Liver/pancreatic function tests:
- Amylase/lipase elevation: Pancreatitis
- AST/ALT elevation: Hepatitis
- Alkaline phosphatase elevation: Cholecystic etiology
Urine analysis:
- WBC, nitrites, leukocyte esterase, bacteria: UTI
- Ketones: Dehydration, DKA
- Pregnancy test in women of childbearing age
Toxicology screen/drug levels:
- For suspected drug toxicity or overdose

Imaging

Abdominal series (kidney, ureter, bladder/upright):
- Suspected bowel obstruction or perforated viscus
CT abdomen/pelvis:
- Suspected appendicitis, obstruction, nephrolithiasis
CT/MRI head:
- Suspected intracranial etiology
US:
- Suspected biliary disease, gonadal torsion, nephrolithiasis

Diagnostic Procedures/Surgery

EKG:
- Suspected MI
Endoscopy:
- Peptic ulcer disease leading to significant GI bleed

Treatment

Pre-Hospital

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
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
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
Medications:
- Serotonin antagonists often 1st 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, droperidol
  - Side effects (e.g., akathisia, dystonia) more common than in serotonin antagonists
  - Note black box warnings on use of droperidol (potential QT prolongation and/or torsades de pointes) and promethazine (tissue injury with IV administration)
- Anticholinergic and antihistamine agents useful in labyrinthitis, positional vertigo, and motion sickness:
  - Meclizine, diphenhydramine, scopolamine
- 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
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
Scopalamine: 1.5 mg patch applied behind the ear 4 hr prior to travel

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 EKG to detect QT prolongation prior to administration

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

Vomiting occurs in >25% of pregnancies
Dopamine D2 antagonists (e.g., promethazine, chlorpromazine, metoclopramide) or serotonin antagonists (e.g., ondansetron, granisetron) most commonly used

First Line

Serotonin antagonists
Dopamine D2 antagonists

Second Line

Anticholinergics
Antihistamines
Benzodiazepines
Glucocorticoids

Follow-Up

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
Emesis is controlled
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

Pearls and Pitfalls

Vomiting is a symptom and not a diagnosis:
- It is important to be familiar with the broad differential diagnoses and exclude dangerous etiologies
Many antiemetics have notable side effects, ranging from dystonia to cardiac arrhythmias.
- Know contraindications and treatment of adverse reactions before using these agents
Oral dissolving tablets and suppositories useful to avoid IV and for home care

Additional Reading

Longstreth GF. Approach to the adult with nausea and vomiting. Up to Date on-line text. www.uptodate.com. March 2012.
Malagelada JR, Malagelada C. Nausea and vomiting. In: Feldman M, et al., eds. Sleisenger and Fordtrans Gastrointestinal and Liver Diseases. 9th ed. Philadelphia, PA: Saunders Elsevier; 2010.
Zun LS, Singh A. Nausea and vomiting. In: Marx JA, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2010.

Codes

ICD9

643.00 Mild hyperemesis gravidarum, unspecified as to episode of care or not applicable
787.01 Nausea with vomiting
787.03 Vomiting alone
787.02 Nausea alone
643.10 Hyperemesis gravidarum with metabolic disturbance, unspecified as to episode of care or not applicable
787.0 Nausea and vomiting

ICD10

O21.0 Mild hyperemesis gravidarum
R11.10 Vomiting, unspecified
R11.2 Nausea with vomiting, unspecified
R11.0 Nausea
O21.1 Hyperemesis gravidarum with metabolic disturbance
R11.11 Vomiting without nausea

SNOMED

422400008 Vomiting (disorder)
16932000 Nausea and vomiting (disorder)
14094001 Excessive vomiting in pregnancy (disorder)
422587007 nausea (finding)
129598007 Severe hyperemesis gravidarum

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