Nausea and vomiting are common symptoms encountered in the emergency department (ED) and can result from a wide range of conditions. As a junior doctor in emergency medicine, understanding the potential causes, assessment, and management strategies for these symptoms is crucial for effective patient care.
Understanding Nausea and Vomiting
Nausea: A subjective sensation of unease and discomfort in the stomach with an urge to vomit.
Vomiting: The forceful expulsion of stomach contents through the mouth.
These symptoms can be acute or chronic and may be associated with other gastrointestinal or systemic symptoms.
Common Causes of Nausea and Vomiting
Gastrointestinal Causes
Gastroenteritis: Inflammation of the stomach and intestines, often due to viral or bacterial infections.
Obstruction: Intestinal obstruction can cause nausea and vomiting due to impaired passage of contents.
Peptic Ulcer Disease: Ulcers can cause pain, nausea, and vomiting.
Cholecystitis: Inflammation of the gallbladder often presents with nausea, vomiting, and right upper quadrant pain.
Central Nervous System Causes
Migraine: Often accompanied by nausea and vomiting.
Increased Intracranial Pressure: Conditions such as tumors or hemorrhage can lead to nausea and vomiting.
Vestibular Disorders: Such as vertigo or labyrinthitis.
Metabolic and Endocrine Causes
Diabetic Ketoacidosis (DKA): Can present with nausea, vomiting, abdominal pain, and altered mental status.
Adrenal Insufficiency: May cause nausea and vomiting along with fatigue and hypotension.
Other Causes
Pregnancy: Nausea and vomiting are common in early pregnancy (morning sickness).
Medications: Side effects from drugs such as chemotherapy agents or opioids.
Psychogenic Factors: Anxiety or stress-related disorders can manifest with these symptoms.
Initial Assessment and Management
History Taking
A thorough history is essential to guide further evaluation:
Onset, duration, and frequency of symptoms
Associated symptoms such as abdominal pain, headache, or dizziness
Recent travel or dietary changes
Medication history
Past medical history including diabetes or neurological conditions
Physical Examination
The physical examination should focus on identifying signs that may indicate specific causes:
Abdominal examination: Assess for tenderness, distension, or masses.
Neurological examination: Evaluate for signs of increased intracranial pressure or focal deficits.
Hydration status: Check for signs of dehydration such as dry mucous membranes or decreased skin turgor.
Diagnostic Workup
Depending on clinical suspicion from history and examination, the following tests may be considered:
Laboratory Tests: Electrolytes, blood glucose levels, liver function tests, amylase/lipase if pancreatitis is suspected.
Imaging: Abdominal X-ray or CT scan if obstruction is suspected; CT scan of the head if neurological causes are suspected.
Urine Pregnancy Test: In women of childbearing age to rule out pregnancy-related causes.
Management Strategies
Management of nausea and vomiting in the ED focuses on addressing both symptom relief and underlying causes:
Symptomatic Treatment:
Antiemetics such as ondansetron or metoclopramide for symptom relief.
Rehydration with oral fluids or intravenous fluids if dehydration is present.
Specific Interventions:
Antibiotics for bacterial gastroenteritis if indicated.
Surgical consultation for suspected obstruction or cholecystitis.
Monitoring and Follow-up:
Continuous monitoring for any deterioration in clinical status.
Referral to specialists for chronic or recurrent cases requiring further evaluation.
Challenges and Considerations
Nausea and vomiting can be challenging due to their broad differential diagnosis. It is important to identify red flags that suggest serious underlying conditions requiring urgent intervention. These include severe abdominal pain, neurological deficits, persistent vomiting leading to dehydration, or evidence of gastrointestinal bleeding.
By taking a systematic approach to the assessment and management of nausea and vomiting, you can effectively address these common symptoms in the emergency setting while ensuring appropriate follow-up care.
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