How should I manage severe vomiting after binge alcohol consumption?

Management of Severe Vomiting After Binge Alcohol Consumption

Administer isotonic IV fluids (normal saline or lactated Ringer's) immediately to correct dehydration and electrolyte abnormalities, followed by metoclopramide 10 mg IV every 6-8 hours on a scheduled basis (not PRN), with thiamine 100-500 mg IV given before any glucose-containing fluids to prevent Wernicke encephalopathy. 1

Immediate Stabilization and Assessment

Your first priority is fluid resuscitation and electrolyte correction:

• Start isotonic IV fluids immediately (normal saline or lactated Ringer's) to address the dehydration that occurs in one-third of post-alcohol emergency visits 1
• Check and correct electrolyte abnormalities, particularly hypokalemia, hypomagnesemia, hypochloremia, and metabolic alkalosis, which are common after excessive vomiting 1
• Assess vital signs, mucous membrane moisture, and mental status to gauge dehydration severity 1
• Screen for alcohol withdrawal syndrome, which can develop 6-24 hours after the last drink and presents with tremor, sweating, tachycardia, and autonomic instability 1, 2

Antiemetic Therapy Algorithm

First-line antiemetic management:

• Metoclopramide 10 mg IV or IM is the first-line antiemetic for vomiting in heavy drinkers 1
• Administer on a scheduled basis every 6-8 hours, not as-needed, which is more effective in preventing recurrent vomiting 1, 3
• Add dexamethasone 8-10 mg IV to metoclopramide for superior control compared to monotherapy 1

Critical pitfall to avoid: Do not use oral rehydration solutions or oral antiemetics during active vomiting—they are ineffective and designed for diarrhea-related losses, not vomiting 1

Mandatory Thiamine Administration

Give thiamine 100-500 mg IV immediately before any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy 1, 2. This is non-negotiable in all alcohol-related presentations. Continue thiamine 100-300 mg/day for 2-3 months following resolution 2

Gastric Protection

• Add acid suppression with a proton pump inhibitor or H2 receptor antagonist if gastritis or gastroesophageal reflux is suspected, as patients may confuse heartburn with nausea 1
• This is particularly important given the high prevalence of alcohol-related gastritis 1

Concurrent Alcohol Withdrawal Management

If withdrawal symptoms are present (tremor, sweating, tachycardia, anxiety):

• Benzodiazepines are the gold standard for treating alcohol withdrawal syndrome 1, 2
• Use short-acting benzodiazepines (lorazepam or oxazepam) rather than long-acting agents in heavy drinkers due to potential hepatic dysfunction 1, 2
• Start lorazepam 6-12 mg/day if withdrawal is suspected 2

Monitoring for Complications

Watch for extrapyramidal symptoms from metoclopramide (dystonia, akathisia), and treat with diphenhydramine 50 mg IV if they occur 1

Evaluate for life-threatening complications requiring urgent intervention:

• Hematemesis or signs of gastrointestinal bleeding 1
• Severe abdominal pain suggesting pancreatitis 1
• Altered mental status beyond expected intoxication 2

When to Escalate Care

• Consider nasogastric tube placement for gastric decompression if vomiting is severe or persistent despite antiemetics 1
• Admit to hospital if vomiting persists beyond 24 hours despite treatment, if there are signs of severe dehydration, or if withdrawal symptoms develop 1, 2
• Provide alcohol cessation counseling and refer for addiction treatment before discharge 1

Duration of Treatment

• If vomiting persists for >2-3 weeks, increase thiamine supplementation to prevent neurological complications 4
• Maintain adequate hydration throughout the recovery period 4