How to manage projectile vomiting in long-term care patients?

Management of Projectile Vomiting in Long-Term Care

Initiate treatment with ondansetron as first-line therapy, as 5-HT3 antagonists are most commonly used in long-term care settings where traditional dopamine antagonists (domperidone and metoclopramide) are no longer recommended for chronic use. 1

Immediate Assessment and Stabilization

Identify Red Flag Causes Requiring Urgent Intervention

• Check for bowel obstruction immediately – bilious vomiting, abdominal distension, or absent bowel sounds mandate surgical consultation and nasogastric decompression 1
• Assess for fecal impaction, which commonly causes vomiting in long-term care residents and may require manual evacuation under anesthesia if severe 1
• Rule out medication toxicity by checking blood levels of digoxin, phenytoin, carbamazepine, and tricyclic antidepressants 1
• Evaluate for metabolic causes including hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 1

Address Dehydration and Electrolyte Abnormalities

• Monitor for hypokalemia, hypochloremia, and metabolic alkalosis from prolonged vomiting 2
• Ensure adequate fluid intake of at least 1.5 L/day when tolerated 2
• Correct hypomagnesemia and hypokalemia as these perpetuate vomiting 2

Pharmacologic Management Algorithm

First-Line Antiemetic Therapy

Start with ondansetron (5-HT3 antagonist) as the primary agent since cyclizine can cause psychological dependence and metoclopramide/domperidone are no longer recommended for long-term use in this population 1

• Ondansetron 4-8 mg orally or sublingually every 8 hours 1
• Critical pitfall: Monitor for QTc prolongation, especially when combined with other QT-prolonging medications common in long-term care 2
• Note: Ondansetron can worsen constipation, which itself causes vomiting – address bowel regimen concurrently 1

Second-Line Options for Persistent Symptoms

If ondansetron alone is insufficient after 48 hours, add:

• Haloperidol 0.5-2 mg orally or subcutaneously every 6-8 hours (dopamine antagonist with strong evidence) 1
• Olanzapine 2.5-5 mg orally at bedtime (antipsychotic with antiemetic properties) 1
• Prochlorperazine 5-10 mg orally or rectally every 6-8 hours 1

Refractory Vomiting Management

For symptoms persisting beyond 1 week despite the above:

• Add corticosteroids (dexamethasone 4-8 mg daily) if gastric outlet obstruction or inflammation suspected 1
• Consider anticholinergic agents (hyoscine butylbromide intramuscularly, glycopyrrolate) if bowel hypermotility present 1
• Trial continuous subcutaneous infusion of antiemetics for around-the-clock coverage 1

Treatment of Underlying Causes

Gastritis or Gastroesophageal Reflux

• Proton pump inhibitor or H2 receptor antagonist 1
• Continue even if vomiting improves, as acid suppression prevents recurrence 1

Opioid-Induced Nausea

• Consider opioid rotation to alternative agent 1
• Do NOT discontinue necessary pain medications – manage the side effect instead 1

Constipation (Present in 50% of Long-Term Care Residents)

• Prophylactic stimulant laxative (senna 15-30 mg daily) for all residents on opioids 1
• Bisacodyl 10-15 mg 2-3 times daily if constipation develops 1
• Glycerol suppositories or phosphate enemas for impaction 1
• Avoid adding fiber if fluid intake inadequate 1

Bacterial Overgrowth (in Residents with Dysmotility)

• Rifaximin as first-choice antibiotic if available on formulary 1
• Alternative: rotating courses of amoxicillin-clavulanate, metronidazole, or ciprofloxacin every 2-6 weeks 1

Alternative Routes of Administration

Oral administration is often not feasible during active vomiting – use alternative routes:

• Sublingual ondansetron tablets for better absorption than standard tablets 1
• Rectal suppositories: promethazine, prochlorperazine 1
• Subcutaneous infusions: haloperidol, metoclopramide 1
• Transdermal patches: scopolamine for anticholinergic effect 1

Critical Pitfalls to Avoid

Never Use Prokinetic Agents in Mechanical Obstruction

Do NOT give metoclopramide if bowel obstruction suspected – this masks progressive ileus and worsens gastric distension 1, 2

Monitor for Extrapyramidal Side Effects

• Haloperidol and metoclopramide carry risk of dystonia and akathisia 2
• Higher risk in elderly residents with dementia 2
• Have diphenhydramine 25-50 mg available for acute dystonic reactions 2

Avoid Repeated Diagnostic Testing

• One-time upper endoscopy or imaging is sufficient to exclude obstruction 2
• Do not repeat endoscopy unless new symptoms develop 2

When Conservative Management Fails

Consider Venting Gastrostomy

If nasogastric drainage provides symptom relief, endoscopic placement of venting gastrostomy (≥20 French gauge) may reduce vomiting by decompressing the stomach 1

• Caution: Associated with complications including leakage and infection 1
• Reserve for residents with life expectancy of months who have failed all pharmacologic options 1

Palliative Sedation as Last Resort

If all intensified efforts fail and vomiting remains intractable, palliative sedation may be considered for comfort 1

Nutritional Considerations

• Small, frequent meals rather than large meals 2
• Thiamin supplementation to prevent Wernicke's encephalopathy in persistent vomiting 2
• Avoid aggressive enteral or parenteral nutrition in residents with limited life expectancy (weeks to days), as this increases suffering without improving quality of life or survival 1