What is a good in-hospital treatment for an elderly patient with a sore throat following hyperemesis (excessive vomiting)?

In-Hospital Treatment for Post-Hyperemesis Sore Throat in Elderly Patients

The priority is aggressive rehydration with intravenous fluids, correction of electrolyte abnormalities including thiamine supplementation to prevent Wernicke's encephalopathy, and scheduled (not PRN) antiemetic therapy with ondansetron, combined with systemic analgesics for throat pain. 1

Immediate Management Priorities

Fluid and Electrolyte Restoration

• Administer intravenous hydration aggressively, as biochemical abnormalities from hyperemesis typically resolve with adequate fluid replacement 1
• Correct all electrolyte abnormalities identified on laboratory assessment, as these are common sequelae of prolonged vomiting 1
• Give thiamine supplementation immediately to prevent Wernicke's encephalopathy, which is a critical risk in patients with hyperemesis 1

Antiemetic Therapy

• Use ondansetron as the preferred antiemetic given its favorable safety profile and effectiveness; administer on a scheduled basis rather than PRN to prevent recurrent vomiting 1
• Consider adding dexamethasone (12 mg IV daily) if nausea/vomiting persists despite ondansetron 1
• Avoid oral routes initially due to ongoing vomiting risk; use intravenous or rectal administration 1
• If breakthrough nausea occurs, add agents from different drug classes such as metoclopramide (10-20 mg IV every 4-6 hours) or lorazepam (0.5-2 mg IV every 4-6 hours) 1

Pain Management for Sore Throat

• Provide systemic analgesics immediately: ibuprofen 400-600 mg every 6-8 hours or acetaminophen 500-1000 mg every 6 hours for throat pain control 2, 3, 4
• In elderly patients, favor acetaminophen over NSAIDs due to cardiovascular risk, nephrotoxicity, and gastrointestinal toxicity concerns 5, 2
• Consider adding proton pump inhibitors or H2 blockers to manage dyspepsia and reflux-related symptoms that may worsen throat discomfort 1

Assessment for Complications

Rule Out Serious Pathology

• Evaluate urgently for peritonsillar abscess, retropharyngeal abscess, or epiglottitis if the patient has severe throat pain, neck swelling, difficulty swallowing, drooling, or respiratory distress 5, 6
• The sore throat in this context is likely chemical irritation from gastric acid exposure during vomiting episodes, but serious complications must be excluded 7, 6

Determine Need for Antibiotics

• Do NOT prescribe antibiotics empirically without confirming bacterial infection 5, 7, 2
• Use Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) only after ruling out complications 5, 7, 2, 4
• With 0-2 Centor criteria, neither testing nor antibiotics are indicated 7, 2, 4
• If ≥3 Centor criteria present, perform rapid antigen testing or throat culture before considering antibiotics 5, 2, 4

Critical Pitfalls to Avoid

• Never use PRN dosing for antiemetics—scheduled administration is essential to prevent breakthrough vomiting 1
• Do not overlook thiamine supplementation, as Wernicke's encephalopathy is a preventable but devastating complication 1
• Avoid NSAIDs in elderly patients with renal impairment or cardiovascular disease; use acetaminophen instead 5, 2
• Do not dismiss persistent liver chemistry abnormalities after symptom resolution—this warrants investigation for alternative etiologies 1
• Exercise caution with olanzapine in elderly patients due to increased mortality risk in dementia-related psychosis and metabolic complications 1

Monitoring and Follow-Up

• Reassess electrolytes and liver function tests after initial hydration to ensure normalization 1
• Monitor for resolution of vomiting within 24-48 hours; persistent symptoms require investigation for alternative diagnoses 1
• Ensure adequate nutrition once vomiting controlled, starting with small frequent meals 1