What treatment is recommended for an elderly patient experiencing dry heaving, cough, and recent vomiting, with a history of sinusitis and mild dehydration?

Treatment of Dry Heaving and Vomiting in an Elderly Patient with Recent Sinusitis

For this elderly patient with persistent dry heaving and vomiting following sinusitis, the immediate priority is addressing dehydration with oral rehydration and treating the nausea with ondansetron, while simultaneously treating the underlying postinfectious cough and upper airway cough syndrome (UACS) with a first-generation antihistamine/decongestant combination.

Immediate Management: Dehydration and Nausea

Rehydration Strategy

• Elderly patients are highly susceptible to dehydration due to diminished thirst sensation, age-related changes in water/sodium balance, and the stress of intercurrent infections 1
• Administer small amounts of fluids frequently throughout the day rather than large volumes at once, targeting at least 1.7 liters per 24 hours 1
• If oral intake remains inadequate despite encouragement, consider subcutaneous fluids (hypodermoclysis) or IV fluids for more severe dehydration 1

Antiemetic Treatment

• Prescribe ondansetron (4-8 mg orally) for nausea and vomiting control 2
• Ondansetron is safe in elderly patients with no dosage adjustment needed unless severe hepatic impairment is present (maximum 8 mg daily if Child-Pugh score ≥10) 2
• Monitor for constipation as a side effect, which could worsen symptoms 2

Treating the Underlying Cause: Postinfectious Cough and UACS

First-Line Therapy

• Start a first-generation antihistamine/decongestant combination (such as brompheniramine with sustained-release pseudoephedrine) as the primary treatment for UACS-induced symptoms 3, 4
• Begin with once-daily bedtime dosing for a few days, then advance to twice-daily to minimize sedation in this elderly patient 4
• Add intranasal corticosteroids to decrease nasal inflammation and promote drainage 4

Critical Monitoring in Elderly Patients

• Watch carefully for anticholinergic side effects: urinary retention, increased intraocular pressure, sedation, confusion, insomnia, jitteriness, tachycardia, and worsening hypertension 4
• Avoid topical nasal decongestant sprays beyond 3-5 days to prevent rebound congestion (rhinitis medicamentosa) 5, 4
• Review all current medications for potential drug interactions 4

Additional Therapeutic Options if First-Line Fails

Second-Line Treatments

• Consider inhaled ipratropium bromide as an alternative with fewer systemic side effects if the patient cannot tolerate antihistamines/decongestants 3, 4
• Add inhaled corticosteroids if cough persists despite initial therapy and significantly affects quality of life 3, 4
• Central-acting antitussives (codeine or dextromethorphan) may be used when other measures fail 3, 4

For Severe Symptoms

• Short-term prednisone (30-40 mg daily) can be considered for severe paroxysms of cough after ruling out other causes 3, 4

When to Reassess for Bacterial Sinusitis

Red Flags Requiring Reevaluation

• Symptoms worsening or failing to improve within 7-10 days of treatment 5, 4
• Development of high fever, severe facial pain, or purulent discharge for ≥3 consecutive days 5
• Symptoms persisting beyond 10 days with worsening (double worsening pattern) 6

If Bacterial Sinusitis is Suspected

• Amoxicillin is first-line antibiotic therapy for acute bacterial rhinosinusitis in adults 6
• However, antibiotics are not indicated for viral upper respiratory infections and contribute to resistance 5
• The absence of fever argues strongly against bacterial infection 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics without clear evidence of bacterial infection (symptoms >10 days with worsening, or double worsening pattern) 5, 6
• Do not use newer-generation nonsedating antihistamines for postinfectious cough—they are ineffective 3
• Do not allow topical decongestant use beyond 3-5 days due to rebound congestion risk 5, 4
• Do not overlook dehydration monitoring in elderly patients, as they require continuous awareness and assistance with fluid intake 1

Pathophysiology Context

This presentation represents postinfectious cough (3-8 weeks duration) with UACS following viral rhinosinusitis 3, 4. Multiple factors contribute: postviral airway inflammation, bronchial hyperresponsiveness, mucus hypersecretion, and impaired mucociliary clearance 3. The vomiting likely results from post-tussive vomiting (gagging on mucus) and postnasal drainage, which are characteristic symptoms in sinusitis patients 3.