approach to nausea/vomiting

vomiting

Vomiting is sometimes assumed to be of GI origin, and dismissed as gastroenteritis if accompanied by loose stool. But vomiting it is a non-specific symptom that can arise from any body system and requires a thorough approach to diagnose and treat its cause and complications. Use the expanded ABCs to work through all body systems. Notice that gastro and food poisoning are not listed here because they are diagnoses of exclusion.

 

A: ABCDEFGHIJKLM

  • Anaphylaxis

B: CHEST

  • Sick pneumonia, especially elderly, including aspiration pneumonia

C: CARDIOVASCULAR

  • Dysfunctional LV: ACS
  • Outflow: dissection of aorta or carotid/vertebral, with chest/back/neck/facial pain
  • Soft tissue bleed: AAA, with abdo/back pain
  • Lactate: sepsis of any cause
  • Adrenal crisis

D: NEUROLOGIC

  • Encephalitis, meningitis, abscess
  • Unregulated pressure: hydrocephalus, blocked shunt
  • RBC bleed/clot: SAH, EDH, SDH, DSVT, cerebellar stroke
  • Onco tumour

E: ENDO

  • Electrolyte: DKA, hypercalcemia, hyponatremia, hypokalemic from vomiting
  • hOrmones: hyperthyroid, adrenal crisis

F: CREATININE, PELVIS, TESTICLE

  • CREATININE: Renal artery/vein thrombosis, Impacted stone; uremia from any cause
  • PELVIS: Pregnant, Ectopic, Vascular torsion, Infection
  • TESTICLE: Torsion, Incarcerated hernia

G: ABDOMINAL

  • Ammonia: hepatitis
  • Biliary diseas
  • Dyspepsia, PUD
  • Organomegaly: splenic
  • Mesenteric ischemia
  • Islet pancreatitis
  • No motion: obstruction
  • Appy, diverticulitis
  • Loose stool colitis: infectious, inflammatory

H

I: INTOX

  • Ingest: etoh/withdrawal, opioid withdrawal, marijuana cyclic vomiting
  • N
  • T
  • OTC: NSAID gastritis
  • X

J

  • peripheral vertigo
  • acute glaucoma
  • otitis

 

Putting this together you should take a broad approach to vomiting

  • A: assess risk of aspiration or airway compromise from anaphylaxis
  • B: assess oxygenation, consider pneumonia in elderly or those at risk for aspiration
  • C: ECG, fluid replacement, ultrasound cardiac/IVC/abdomen; consider ACS, vascular catastrophes, sepsis and adrenal crisis
  • D: thorough neuro exam (including HINTS), consider need for CT r/o mass bleed, LP r/o infection, or MR r/o posterior circulation stroke
  • E: check bedside glucose, measure and correct electrolytes, consider hormones
  • F: examine pelvis/testicles, r/o pregnancy, meausure renal function, consider ultrasound
  • G: examine abdomen, measure liver enzymes
  • H
  • I: assess exposures
  • J: examine eyes, ear, consider peripheral vertigo

vomiting

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