Nausea and Vomiting – Management

Today we will discuss about nausea and vomiting.

First line Management

When a patient complains of nausea and vomiting you should first give an antacid and an antiemetic drug for symptomatic relief. Give 2-3 tsp of an antacid like Digene and one tablet of Perinorm (Metoclopramide). You may also give a tablet of Ondansetron 4 mg especially if the patient is sensitive to metoclopramide. However, if vomiting is active, the patient can vomit out the medicines, so if vomiting is predominant give injectable drugs. Give injection Perinorm (Metoclopramide) 2cc IM or IV, or injection Emeset (ondansetron) 8 mg IM or IV. In more severe cases of vomiting, the same injections may be given intravenously, that is Inj. Metoclopramide or Inj. Ondansetron IV, followed by IV Fluids to prevent dehydration. Along with this symptomatic treatment give injection of Ranitidine or Omeprazole IV to control acidity, and domperidone 10mg TDS to regulate gastric motility.

When a patient comes complaining of nausea and vomiting, what do we look for in the patient.
1. Indigestion, hyperacidity and Gastritis.

The most common cause of nausea and vomiting is indigestion, hyperacidity and gastritis. So ask history of eating outside food or roadside food, or eating any different food where food poisoning might have occured.

2. Infections

Then is there associated fever. Fever suggest infection, and the common infections which give rise to vomiting are infective hepatitis and rarely meningitis. So you must look at the sclera for icterus and ask whether the urine is dark yellow or reddish. Palpate for tender liver, to rule out infective hepatitis.

3. Meningitis

Also, ask history of headache and test for neck stiffness to rule out meningitis.

4. Intestinal obstruction

Then you must palpate the abdomen look for distension of abdomen, tenderness and ask about abdominal pain. This is to rule out acute abdomen and intestinal obstruction. If vomiting is green, that is bile coloured or feculent, then there must be an intestinal obstruction distally.

5. Pregnancy

Lastly, if the patient is a young female in childbearing age, ask if she is pregnant. Ask the menstrual history carefully.

Which is the best drug to control vomiting?

Inj. Promethazine is the most effective drug. But nowadays it is used less frequently due to higher incidence of extrapyramidal side effects. Injection promethazine 2cc IM or IV will control vomiting very effectively. But it will also cause sedation, so in general practice where the patient has to go back home or go to work, it is less frequently used. But injection perinorm and injection emeset are to be used more commonly. Of course Perinorm also causes extrapyramidal side effects but less frequently.

What are these extrapyramidal side effects?

The patient involuntarily turns up the eyeballs, or makes abnormal facial movement, or there is pulling of the tongue inside, or turning of the neck to one side. This abnormal positions persist for several minutes and the patient cannot correct them. These are all harmless but cause a lot of anxiety to the patient and the relatives, especially because the face remains distorted. You must ensure them that it is harmless and give two tablets of Trihexyphenidyl and one tablet of Diazepam. Intravenous Diazepam will relieve the spasm more quickly. Ondansetron does not have this reaction.

Now lastly, let me tell you some pitfalls.
  • With careful History taking you should differentiate cases of esophageal regurgitation. If the food is vomited immediately after swallowing and every time on swallowing ,then a lower esophageal obstruction is more likely. This patient and also the patient of pyloric stenosis usually do not have nausea. They suddenly vomit.
  • Cases with green vomit with abdominal distension should always be taken seriously, because it suggest intestinal obstruction or peritonitis.
To summarise
  1. When a patient complains of nausea and vomiting give a tablet or injection of either perinorm or ondansetron, Ranitidine or Omeprazole and Domperidone.
  2. Look for Jaundice, fever, headache, abdominal pain and tender hepatomegaly.
  3. Be careful if there is repeated vomiting, green coloured vomiting, colicky abdominal pain, or abdominal distension.
  4. And if it is associated with severe headache, keep in mind meningitis.
  5. When a patient complains of nausea and vomiting give a tablet or injection of either perinorm or ondansetron, Ranitidine or Omeprazole and Domperidone.
  6. Look for Jaundice, fever, headache, abdominal pain and tender hepatomegaly.
  7. Be careful if there is repeated vomiting, green coloured vomiting, colicky abdominal pain, or abdominal distension.
  8. And if it is associated with severe headache, keep in mind meningitis.

Apurva Popat

Apurva Popat

Dr Apurva Popat has been teaching Medical science since he was in his medical school and has helped many students to master medical and spiritual knowledge.

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