Nausea and Vomiting

📚Definitions 

• Nausea: Unpleasant sensation of impending vomiting.
• Vomiting: Forceful expulsion of gastric contents.

🗺️ Overview

This guideline addresses the diagnosis and management of acute nausea and vomiting in adult outpatients, including mild cases associated with pregnancy. It does not cover chronic vomiting or hyperemesis gravidarum, which require in-person evaluation.

🔑 Key Points

• Patients with chronic nausea/vomiting require in-person evaluation.
• Bloody or coffee-ground emesis warrants urgent referral for GI bleeding assessment.

• GLP-1 agonist side effects (nausea/vomiting) should be managed by prescribing clinician.

   

🚨 Important History

• Duration and severity of symptoms

   

• Associated symptoms:
  • Fever
  • Hematemesis
  • Weight loss
  • Headache

  • Vertigo

     

• Recent travel, food exposures

   

• Medication history (including GLP-1 agonists, opioids, supplements)

   

• Pregnancy status

   

• Comorbid conditions (migraine, diabetes, immunocompromise)

📹 Video Examination 

• Vital signs: Heart rate, BP, temperature

   

• Hydration assessment:
  • Skin turgor
  • Mucous membranes
  • Capillary refill

  • Orthostatic changes

     

• Abdominal exam (patient-assisted):
  • Localized tenderness

  • Peritoneal signs

     

• Neurologic assessment:

•  
  • Mental status
  • Nystagmus

  • Focal deficits

     

🎯 Differential Diagnosis 

Acute Viral Gastroenteritis

Diagnosis:

• Acute-onset nausea/vomiting ± diarrhea
• Low-grade fever

• Self-limited course (24-48 hours) Treatment:

   

1. Fluid rehydration:

1. Small, frequent sips of clear liquids

2. Oral rehydration solutions preferred

    

1.  
   1.  Diet:

      1. Advance slowly as tolerated (BRAT diet)

          

• Antiemetics (for severe cases):

1.  
   1. Ondansetron 4-8 mg every 8 hours PRN (max 3 doses)
   2. Contraindicated in cardiac arrhythmias

Vestibular Neuritis

Diagnosis:

• Acute vertigo with nausea/vomiting
• Nystagmus
• Gait instability
• ± Hearing changes Management:
• Refer for in-person evaluation to rule out CVA
• Symptomatic care if mild:
  • Meclizine 25-50 mg every 24 hours
  • Diphenhydramine 25-50 mg every 4-6 hours

Motion Sickness

Management:

1. Non-pharmacologic:
   1. Sit in front of vehicle
   2. Focus on horizon
   3. Avoid reading/mobile devices
2. Medications:
   1. Dimenhydrinate 50 mg 30-60 min pre-travel
   2. Scopolamine patch (1.5 mg behind ear q72h)
   3. Meclizine 25-50 mg 1 hour pre-travel

Migraine-Associated Nausea

Management:

• Ondansetron ODT 4-8 mg every 6-8 hours PRN
• Refer if:
  • No established migraine diagnosis
  • Persistent symptoms despite treatment
  • Neurologic changes 

Nausea/Vomiting of Pregnancy Management:

• Non-pharmacologic:

1.  
   1. Small, frequent meals
   2. Ginger (250 mg QID)

   3. Avoid triggers (odors, heat)

       

2. Medications:
   1. First-line:
      1. Pyridoxine 10-25 mg every 6-8 hours

      2. Doxylamine/pyridoxine (Diclegis)

          

   2. Second-line:

      1. Ondansetron 4-8 mg every 8 hours

          

   3. Refer if:
      1. No improvement in 24-48 hours
      2. Signs of dehydration
      3. Weight loss >5%

📩 Referral Indicators 

• Urgent:
  • Signs of severe dehydration
  • Peritoneal signs
  • Hematemesis
  • Neurologic symptoms (headache, confusion)
  • Persistent symptoms (>48 hours in adults)
  • High-risk patients (elderly, immunocompromised)

 🔮 Follow Up 

• Reassess hydration status if symptoms persist
• Refer for in-person evaluation if:
  • No improvement with treatment
  • Red flags present

  • Need for diagnostic testing

     

📘 Coding

ICD-10 Codes

• R11.0: Nausea
• R11.2: Nausea with vomiting
• R11.10: Vomiting unspecified
• O21.9: Vomiting of pregnancy

If you have any questions or would like more information, please reach out to the Delegating Physician.