What should I do if I'm experiencing vomiting, weakness, and vision changes?

Immediate Emergency Assessment Required

If you are experiencing vomiting, weakness, and vision changes together, you need immediate medical evaluation to rule out life-threatening conditions including diabetic ketoacidosis, acute angle-closure glaucoma, orbital trauma with oculocardiac reflex, or neurologic emergencies.

Critical Red Flags Requiring Emergency Department Evaluation

Diabetic Ketoacidosis (DKA) - Most Likely Life-Threatening Cause

• Check blood glucose and ketones immediately if you have diabetes or risk factors, as nausea/vomiting with vision changes (blurred vision from hyperglycemia) may indicate DKA, which is life-threatening and requires urgent IV fluids, insulin, and electrolyte monitoring 1, 2
• Hyperglycemia directly causes blurred vision through osmotic lens swelling when blood glucose is elevated, and this is often accompanied by nausea/vomiting in DKA 2
• If blood glucose is ≥200 mg/dL with classic symptoms (polyuria, polydipsia, weakness), diabetes should be diagnosed immediately 2
• SGLT2 inhibitors significantly increase risk of euglycemic DKA - stop these medications immediately if DKA is suspected 1

Acute Angle-Closure Glaucoma - Ophthalmologic Emergency

• Vision changes with nausea, vomiting, and eye pain suggest acute angle-closure crisis, which causes rapid IOP elevation leading to corneal edema (blurred vision with halos), mid-dilated pupil, eye redness, headache, and vomiting 3
• This is a sight-threatening emergency requiring immediate ophthalmologic intervention 3
• The fellow eye is also at high risk and requires prophylactic treatment 3

Orbital Trauma with Oculocardiac Reflex

• Bradycardia or heart block with dizziness, nausea, vomiting, or loss of consciousness in orbital trauma indicates entrapped muscle causing oculocardiac reflex - this is life-threatening and requires urgent medical and surgical intervention 3
• Check vital signs for bradycardia (heart rate <60 bpm) - if present with nausea/vomiting, consider atropine 0.5-1 mg IV if hemodynamically unstable 4
• Even without recalled trauma history, occult orbital fractures can present with these symptoms 3

Increased Intracranial Pressure

• Headache with vision changes (especially visual field defects), nausea, vomiting, altered mental status, or gait abnormality suggests increased ICP from conditions like hydrocephalus or CNS infection 3
• Pressures ≥250 mm H₂O require urgent intervention with CSF removal 3

Systematic Diagnostic Approach

Step 1: Immediate Vital Signs and Glucose Check

• Measure blood pressure (lying and standing), heart rate, and temperature 4
• Postural pulse change ≥30 bpm or severe postural dizziness with inability to stand indicates volume depletion from vomiting requiring immediate isotonic fluid replacement 3
• Check fingerstick glucose immediately - random glucose ≥200 mg/dL with symptoms confirms diabetes 2
• If diabetic, check blood or urine ketones immediately 1

Step 2: Assess Volume Depletion Status

If vomiting is prominent, check for four or more of these seven signs indicating moderate-to-severe volume depletion: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes 3

• Treatment requires isotonic fluids (oral, nasogastric, subcutaneous, or IV) 3

Step 3: Ophthalmologic Examination

• Check visual acuity, pupil size and reactivity, and intraocular pressure if equipment available 3
• Perform confrontational visual field testing 3
• Mid-dilated, non-reactive pupil with eye redness and corneal edema = acute angle-closure 3
• Blurred vision alone without eye pain in diabetic = likely hyperglycemic lens changes 2

Step 4: Neurologic Assessment

• Assess mental status, cranial nerves, motor strength, coordination, and gait 3
• Headache with papilledema, focal neurologic deficits, or altered consciousness requires urgent neuroimaging 3

Step 5: Medication and Toxin Review

• Review all medications - many cause nausea/vomiting as adverse effects 5, 6
• Consider immune checkpoint inhibitors causing endocrinopathies (headache, visual changes, nausea/vomiting from hypophysitis or DKA) 3

Management Algorithm Based on Most Likely Diagnosis

If Hyperglycemia/DKA Confirmed:

1. Admit to ICU or monitored unit for continuous insulin infusion at 0.1 units/kg/hour IV 1
2. Start aggressive IV fluid resuscitation 1
3. Monitor potassium closely and replace once urine output established 1
4. Hourly vital signs, neurologic checks, and capillary glucose; electrolytes/blood gases every 2-4 hours 1
5. Vision changes will resolve with glycemic control - counsel patient about temporary worsening during treatment 2

If Acute Angle-Closure Suspected:

• Immediate ophthalmology consultation 3
• Lower IOP medically, then perform laser iridotomy 3
• Treat fellow eye prophylactically 3

If Oculocardiac Reflex from Orbital Trauma:

• Immediate CT imaging (not MRI if metallic foreign body possible) 3
• Urgent surgical repair if muscle entrapment confirmed 3
• Atropine for symptomatic bradycardia 4

If Volume Depletion Without Other Emergencies:

• Oral rehydration therapy with isotonic fluids if mild 3
• IV isotonic fluids if moderate-severe or unable to tolerate oral 3
• Antiemetics: serotonin antagonist (ondansetron) or dopamine antagonist (metoclopramide) for symptom control 6

Critical Pitfalls to Avoid

• Never dismiss vision changes in diabetic patients as "just retinopathy" - acute blurred vision from hyperglycemia is reversible and distinct from chronic diabetic retinopathy 2
• Never assume all nausea/vomiting in diabetics is gastroparesis - rule out DKA first 1
• Do not delay treatment for DKA - this is immediately life-threatening 1
• Do not use atropine for Type II or high-grade AV block as it may worsen conduction 4
• Do not perform lumbar puncture before neuroimaging if increased ICP suspected 3
• In women, maintain high suspicion for cardiac ischemia presenting atypically with nausea/vomiting 4

When to Hospitalize vs. Outpatient Management

Hospitalize immediately if:

• DKA confirmed or suspected 1
• Acute angle-closure glaucoma 3
• Orbital trauma with oculocardiac reflex 3
• Severe volume depletion with hemodynamic instability 3
• Increased ICP or neurologic emergency 3
• Inability to tolerate oral fluids with moderate-severe dehydration 3

Outpatient management acceptable if:

• Mild hyperglycemia without ketones in known diabetic 2
• Mild volume depletion with ability to tolerate oral fluids 3
• Viral gastroenteritis without alarm features 6, 7