Treatment of Dry Heaving
For patients experiencing dry heaving (retching without productive vomiting), prioritize rehydration as the cornerstone of treatment, using oral rehydration solution (ORS) for mild-to-moderate cases and intravenous isotonic fluids for severe dehydration, while adding antiemetic agents like ondansetron once adequate hydration is established to facilitate tolerance of oral intake. 1
Immediate Assessment and Hydration Strategy
Assess Hydration Status First
- Evaluate for signs of dehydration: altered mental status, poor perfusion, abnormal pulse, sunken eyes, or extreme thirst 1
- Determine severity: mild-to-moderate dehydration versus severe dehydration with shock 1
First-Line Rehydration Approach
- For mild-to-moderate dehydration: Administer reduced osmolarity oral rehydration solution (ORS) as first-line therapy (strong recommendation) 1
- If oral intake is not tolerated: Consider nasogastric administration of ORS in patients with normal mental status who cannot drink adequately 1
- For severe dehydration, shock, or altered mental status: Immediately initiate isotonic intravenous fluids (lactated Ringer's or normal saline) 1
- In patients with ketonemia, initial IV hydration may be necessary to enable tolerance of oral rehydration 1
Antiemetic Therapy
Timing and Selection
- Antiemetic agents should only be considered once the patient is adequately hydrated—they are not a substitute for fluid and electrolyte therapy 1
- Ondansetron may be given to facilitate tolerance of oral rehydration in children >4 years of age and adolescents with vomiting 1
- Antiemetics help reduce symptom severity and enable patients to tolerate ORS more effectively 1
Critical Pitfall to Avoid
- Never use antiemetics as primary treatment without addressing hydration status first—this approach prioritizes symptom control over the underlying physiological derangement and can mask worsening dehydration 1
Ongoing Management
Maintenance Phase
- Continue ORS to replace ongoing losses until vomiting resolves 1
- Resume age-appropriate usual diet during or immediately after rehydration is completed 1
- Continue breast milk feeding in infants throughout the episode 1
- For severe dehydration requiring IV therapy, continue until pulse, perfusion, and mental status normalize, then transition to ORS for remaining deficit 1
Monitoring Requirements
- Reassess hydration status after 3-4 hours of treatment 1
- Monitor for signs of inadequate response: continued high losses, persistent extreme thirst, failure to improve clinically 1
- Watch for complications of severe dehydration including altered mental status and aspiration risk 1
When to Escalate Care
- Persistent dry heaving despite adequate rehydration and antiemetic therapy warrants investigation for underlying causes 1
- Severe dehydration with shock requires immediate IV access and aggressive fluid resuscitation 1
- Altered mental status, evidence of ileus, or failure of ORS therapy necessitates IV fluid administration 1