Management of a 19-Year-Old with Vomiting and Cough
For this 19-year-old with acute vomiting and cough, prioritize oral rehydration therapy as the cornerstone of management, use ondansetron only if vomiting prevents adequate oral fluid intake, and treat the cough symptomatically with simple measures first while monitoring for signs of severe illness. 1, 2
Immediate Assessment Priorities
Assess hydration status first by checking for sunken eyes, decreased skin turgor, dry mucous membranes, decreased urine output, tachycardia, and hypotension. 1 These signs indicate severe dehydration requiring immediate intervention.
Check for red flags suggesting serious illness:
- Severe breathlessness or respiratory distress 3
- Bilious vomiting or blood in vomit 1
- Severe abdominal pain 1
- Altered mental status or increasing lethargy 1
- Fever with severe systemic symptoms 3
Hydration Management
Begin oral rehydration solution (ORS) immediately with small, frequent volumes—start with 5 mL every minute using a spoon or syringe, gradually increasing as tolerated. 1 This takes precedence over antiemetic therapy, as fluid and electrolyte replacement is the cornerstone of management. 1
Replace ongoing losses by giving 10 mL/kg of ORS for each episode of vomiting. 1 If severe dehydration is present or the patient cannot tolerate oral fluids despite antiemetics, intravenous rehydration is required. 1
Antiemetic Therapy
Use ondansetron 8 mg orally only if persistent vomiting prevents oral rehydration—its purpose is to facilitate tolerance of oral fluids and reduce immediate need for hospitalization. 1, 4 The FDA-approved dosing for postoperative nausea is 16 mg as a single dose one hour before anticipated symptoms, though 8 mg is commonly used for acute gastroenteritis. 4
Alternative antiemetics if ondansetron is unavailable or contraindicated:
- Metoclopramide 10 mg orally has the strongest evidence for non-chemotherapy-related nausea and improves gastric emptying 2, 3
- Prochlorperazine 10 mg orally is an effective dopamine antagonist 2, 3
Important caveat: Ondansetron may increase stool volume/diarrhea as a side effect, but this does not outweigh its benefit in controlling vomiting. 1 Monitor for QTc prolongation, especially if the patient has cardiac risk factors. 5
Cough Management
Encourage the patient to avoid lying flat, as this makes coughing ineffective. 3 Use simple measures first:
- Honey (one teaspoon as needed) for patients over 1 year of age 3
- Sitting upright and leaning forward with arms bracing improves ventilatory capacity 3
- Controlled breathing techniques including pursed-lip breathing 3
For distressing cough, consider short-term use of codeine linctus 15-30 mg or codeine phosphate tablets 15-30 mg every 4-6 hours to suppress coughing. 3 This is particularly appropriate if cough is preventing sleep or causing significant distress.
Nutritional Management
Resume normal diet immediately upon adequate rehydration—do not delay feeding. 1 Offer age-appropriate foods such as starches, cereals, yogurt, fruits, and vegetables, while avoiding foods high in simple sugars and fats. 1
Diagnostic Considerations for This Age Group
Obtain a cannabis use history, as Cannabis Hyperemesis Syndrome is common in this age group and presents with cyclic vomiting. 5 If heavy cannabis use is present, this diagnosis should be strongly considered. 5
Check for COVID-19, as gastrointestinal symptoms (nausea/vomiting 2-4%, diarrhea 6-23%) can occur with respiratory symptoms. 3 However, most acute cough with vomiting in this age group is viral upper respiratory infection or acute bronchitis. 6
Laboratory Testing
If symptoms persist beyond 24-48 hours or the patient appears systemically ill, obtain:
- Complete blood count, serum electrolytes, glucose 5
- Liver function tests if vomiting is prolonged 5
- Urine drug screen if Cannabis Hyperemesis Syndrome is suspected 5
Prolonged vomiting causes hypokalemia, hypochloremia, and metabolic alkalosis—correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia. 5
Follow-Up Instructions
Instruct the patient to return immediately if they become increasingly lethargic or difficult to arouse, develop decreased urine output, intractable or bilious vomiting, blood in vomit or stool, severe abdominal pain, or worsening symptoms despite treatment. 1
Critical Pitfalls to Avoid
- Never withhold oral rehydration in favor of antiemetics alone—hydration is the priority 1
- Do not use antiemetics if mechanical bowel obstruction is suspected, as this can mask progressive ileus 5
- Avoid repeated imaging or endoscopy unless new symptoms develop 5
- Do not prescribe antibiotics for acute cough unless bacterial pneumonia is confirmed, as most cases are viral 6
- Monitor for extrapyramidal symptoms with dopamine antagonists (metoclopramide, prochlorperazine), particularly in young males 5