From the Guidelines
The approach to vomiting should begin with a thorough assessment of the patient's history, physical examination, and potential causes, followed by targeted management, with the goal of preventing nausea and vomiting being much easier than treating it, as stated in the study by 1. The management of vomiting involves several key steps, including:
- Evaluating for red flags such as hematemesis, severe abdominal pain, altered mental status, or signs of dehydration that may require urgent intervention
- Correcting fluid and electrolyte imbalances with IV fluids like normal saline or lactated Ringer's solution
- Administering antiemetics based on the suspected mechanism, with first-line options including ondansetron 4-8mg IV/PO every 8 hours, metoclopramide 10mg IV/PO every 6 hours, or prochlorperazine 5-10mg IV/PO every 6 hours, as recommended by 1
- Considering the use of multiple concurrent agents, perhaps in alternating schedules or by alternating routes, as suggested by 1
- Ensuring adequate hydration or fluid repletion, and assessing and correcting any possible electrolyte abnormalities, as emphasized by 1
- Reassessing the patient before the next cycle of chemotherapy, with attention to various possible non-chemotherapy-related reasons for breakthrough emesis, as recommended by 1 Some key points to consider in the management of vomiting include:
- The importance of preventing nausea and vomiting, rather than just treating it, as stated by 1
- The use of routine, around-the-clock administration of antiemetics, rather than PRN dosing, as recommended by 1
- The potential need for multiple concurrent agents, with differing mechanisms of action, as suggested by 1
- The importance of addressing the underlying cause of the vomiting, whether it's discontinuing offending medications, treating infections, or managing metabolic disorders, as emphasized by 1
- The use of antiemetics, such as 5-HT3 receptor antagonists, corticosteroids, and aprepitant, as recommended by 1 Overall, the approach to vomiting should be tailored to the individual patient's needs, with the goal of preventing nausea and vomiting, and addressing the underlying cause of the symptoms, as stated by 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Approach to Vomiting Algorithm
The approach to vomiting can be complex, given the numerous possible underlying causes and the vast array of diagnostic and therapeutic options.
- A practical 5-step approach to the clinical evaluation and treatment of nausea and vomiting includes:
- Defining what the patient means by nausea and vomiting
- Determining whether symptoms are acute or chronic 2
- Considering medication or toxin adverse effects
- Using the patient's presentation, severity of symptoms, and physical examination findings to formulate a differential diagnosis and to guide evaluation
- Directing treatment on the basis of knowledge of neurotransmitters and receptors involved in the emetic pathways 2
- The evaluation of nausea and vomiting should include a careful history of related factors, such as associated symptoms, timing of onset and duration of symptoms, exacerbating or relieving factors, alarm symptoms, medication and substance use, relationship with recent food ingestion, and comorbidities 3
- Nonpharmacologic management options include fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods 3
- Antiemetic drugs can effectively reduce symptoms of acute nausea and vomiting, but chronic symptoms are often more challenging to treat 3
- In children, oral rehydration therapy (ORT) is effective and successful in the majority of patients with acute gastroenteritis, and anti-emetic medications such as ondansetron may be used to facilitate ORT 4
- Electrolyte and fluid imbalances should be assessed and managed promptly to prevent severe complications 5
- In cases of chronic vomiting, referral for specialist assessment may be necessary to rule out underlying conditions such as food allergy or gastro-oesophageal reflux 6