Nausea & Vomiting

On Call: Nausea & Vomiting

Table of Contents

  1. Basics
  2. Evaluation
  3. Treatment

Basics

Common Causes of Nausea

  • Medications – Especially Opioids & Anesthesia Postoperatively
  • Gastrointestinal Pathology:
    • Small Bowel Obstruction
    • Ileus
    • Gastroparesis
    • Symptomatic Cholelithiasis/Cholecystitis
    • Gastroenteritis
    • Pancreatitis
    • Appendicitis
    • Mesenteric Ischemia
    • Gastroesophageal Reflux Disease (GERD)
    • GI Bleed
    • Liver Failure
  • Neurologic Pathology:
    • Vertigo
    • Migraine
    • Migraine
    • Intracranial Hemorrhage
  • Pregnancy
  • Bulimia
  • Cyclic Vomiting Syndrome

Principal Neurotransmitter Mediators

  • Muscarinic (M1)
  • Dopamine (D2)
  • Histamine (H1)
  • Serotonin (5-HT-3)
  • Neurokinin-1 (NK-1)

Effects of Vomiting

  • Risk for Aspiration
  • Dehydration
  • Metabolic Derangements – Hypokalemic Hypochloremic Metabolic Alkalosis

Evaluation

Subjective

  • Abdominal Pain
  • Associated Factors
  • Last Bowel Movement & Passage of Flatus
  • Frequency of Vomiting
  • Hematemesis
  • Heartburn

History

  • Recent Medication Taken
  • History of Bowel Obstruction
  • Surgical History

Physical Exam

  • Vital Signs
  • Abdominal Tenderness
  • Abdominal Distention

Further Work Up to Consider Depending on Findings

  • Labs (CBC, CMP, etc.)
  • Abdominal X-Ray (AXR)
  • Abdominal CT
  • Upper Endoscopy

Treatment

General Treatment Approach

  • First Determine the Cause
  • Avoid Any Causative Agents – Opioids, etc.
  • Antiemetic Medication
  • Consider Nasogastric Tube Placement for Ileus or Obstruction

Antiemetic Pharmacology – Classes

  • Serotonin (5-HT3) Antagonists – Ondansetron (Zofran)
  • Dopamine Antagonists
    • Phenothiazines: Prochlorperazine (Compazine) or Promethazine (Phenergan)
    • Butyrophenones: Haloperidol (Haldol) or Droperidol (Inapsine)
    • Metoclopramide (Reglan)
  • Anticholinergic Agents – Scopolamine Patch
  • Antihistamines – Diphenhydramine (Benadryl) or Dimenhydrinate (Dramamine)
  • Other Agents:
    • NK-1 Receptor Antagonist – Aprepitant
    • Cannabinoids
    • Glucocorticoids – Dexamethasone or Methylprednisolone
  • *See Antiemetics

Small Bowel Obstruction & Ileus Management