What are the red flags for nausea that require immediate medical attention?

Red Flags for Nausea Requiring Immediate Medical Attention

Nausea accompanied by any of the following signs or symptoms requires immediate medical attention as they may indicate life-threatening conditions.

Neurological Red Flags

• Severe headache, especially if sudden onset or "worst headache of life"
• Altered mental status or confusion
• Visual disturbances
• Neck stiffness
• Focal neurological deficits
• Seizures

Cardiovascular Red Flags

• Chest pain or pressure
• Shortness of breath
• Irregular heartbeat
• Dizziness with positional changes

Gastrointestinal Red Flags

• Severe, persistent abdominal pain
• Blood in vomit (hematemesis)
• Coffee-ground appearance of vomit (indicating digested blood)
• Signs of bowel obstruction 1:
  • Severe abdominal distention
  • Inability to pass gas or stool
  • Progressive abdominal pain
  • Projectile vomiting

Metabolic/Systemic Red Flags

• Fever above 101.5°F (38.6°C)
• Severe dehydration signs:
  • Extreme thirst
  • Dry mouth and skin
  • Little or no urination
  • Sunken eyes
  • Rapid heartbeat
  • Low blood pressure
• Hypercalcemia symptoms 1
• Unintentional weight loss

Cancer-Related Red Flags

• Nausea that persists for more than one week despite treatment 1
• Nausea with unexplained weight loss
• Nausea that worsens with specific positions or activities
• Nausea in patients with known malignancy that suddenly worsens 1

Medication-Related Red Flags

• Nausea after starting new medications, particularly those with known serious side effects
• Nausea in patients on opioids who develop signs of respiratory depression 1

Special Populations

• Pregnancy: Severe hyperemesis gravidarum with inability to keep any fluids down
• Post-surgical patients: New onset nausea with fever or severe pain
• Patients with recent head trauma: Any nausea or vomiting

Assessment Algorithm

1. Initial evaluation: Assess vital signs, hydration status, and mental status

2. Focused history: Determine:

   • Onset and duration of nausea
   • Associated symptoms (pain, fever, neurological symptoms)
   • Medication use (especially new medications)
   • Recent food intake or potential exposures
   • History of similar episodes

3. Physical examination: Focus on:

   • Abdominal examination for tenderness, distention, or masses
   • Neurological assessment for focal deficits
   • Signs of dehydration
   • Evidence of jaundice or other systemic disease

4. Immediate action needed if:

   • Hemodynamic instability (tachycardia, hypotension)
   • Signs of delirium or altered mental status 1
   • Severe pain unresponsive to initial management
   • Persistent vomiting despite antiemetic therapy 1
   • Evidence of GI bleeding or bowel obstruction

Management Considerations

For patients with red flags, immediate management should include:

• Intravenous fluid resuscitation for dehydration

• Appropriate antiemetics based on suspected etiology 1:

  • Dopamine antagonists (haloperidol, metoclopramide) for most causes
  • Serotonin antagonists (ondansetron) for persistent nausea
  • Corticosteroids for suspected increased intracranial pressure

• Diagnostic studies as indicated:

  • Laboratory studies (electrolytes, renal function, liver function)
  • Imaging (CT scan for suspected neurological causes or abdominal pathology)
  • Endoscopy for suspected GI bleeding

Remember that nausea can be the presenting symptom of many life-threatening conditions including myocardial infarction, stroke, meningitis, bowel obstruction, and toxic ingestions. Prompt recognition of red flags and appropriate intervention can be lifesaving.