Management of Patient Refusing to Eat and Vomiting Liquids
Immediately assess dehydration severity and initiate oral rehydration therapy with small, frequent volumes (1 teaspoon every 1-2 minutes), as over 90% of vomiting patients can be successfully rehydrated orally when fluids are given slowly rather than allowing ad libitum drinking. 1
Immediate Assessment Protocol
Assess dehydration severity by examining the following clinical signs:
- Skin turgor, mucous membranes (dry/moist), mental status, pulse rate, capillary refill time, and urine output 2, 1
- For older adults specifically: Check for at least four of these seven signs indicating moderate-to-severe volume depletion: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes 2
- Measure body weight to establish baseline for monitoring 2, 1
Rehydration Strategy Based on Severity
Mild Dehydration (3-5% fluid deficit)
- Administer 50 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L sodium over 2-4 hours 2, 1, 3
- Use teaspoon, syringe, or medicine dropper to provide small volumes initially 2
Moderate Dehydration (6-9% fluid deficit)
Severe Dehydration (≥10% fluid deficit, shock, altered mental status)
- This is a medical emergency requiring immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 2, 3
- Once consciousness returns, transition to oral rehydration for remaining deficit 2
Critical Management of Vomiting
The key pitfall to avoid is allowing the patient to drink large volumes at once, which perpetuates vomiting. 1, 4
- Give small volumes (1 teaspoon) every 1-2 minutes with gradual increases as tolerated 2, 1
- Wait 10 minutes after vomiting episodes, then resume with slower administration 5
- Most fluid given is actually retained despite apparent vomiting 5
- For intractable vomiting, consider continuous nasogastric ORS infusion 1
- Ondansetron 0.2 mg/kg oral (maximum 4 mg) may be used if persistent vomiting prevents oral intake, as it decreases vomiting rate and improves oral rehydration success 6, 7, 8
Replace Ongoing Losses
During both rehydration and maintenance phases:
- Administer 10 mL/kg ORS for each watery/loose stool 2, 1
- Administer 2 mL/kg ORS for each vomiting episode 2, 1
Route Selection Algorithm
Prioritize oral/enteral routes whenever possible; escalate to IV only when oral fails or severe dehydration present: 2
- Oral rehydration (first-line for mild-moderate dehydration)
- Nasogastric administration (if oral intake inadequate but GI tract functional)
- Subcutaneous administration (alternative for older adults when IV access difficult) 2
- Intravenous (severe dehydration, shock, or failed oral rehydration) 2
Nutritional Management
- Do not withhold food once rehydration begins 2, 1, 3
- For breastfed infants: Continue nursing on demand throughout illness 2, 1, 3
- For bottle-fed infants: Resume full-strength, lactose-free or lactose-reduced formulas immediately upon rehydration 2, 1, 3
- For older children/adults: Resume age-appropriate diet as tolerated 1, 3
Special Considerations for Older Adults
Elderly patients require medical supervision rather than home management due to higher risk of rapid dehydration, electrolyte imbalances, renal decline, and malnutrition. 1, 9
- Older adults are more susceptible due to diminished thirst sensation and age-related changes in water/sodium balance 9
- Polypharmacy and multimorbidity increase dehydration risk 9
- Administer isotonic fluids orally, nasogastrically, subcutaneously, or intravenously based on severity 2
Reassessment
- Reassess hydration status after 2-4 hours of rehydration therapy 2
- If still dehydrated, reestimate fluid deficit and restart rehydration 2
- If rehydrated, transition to maintenance phase 2