Emergency Department Treatment:

Acute intractable nausea, vomiting, and abdominal pain

Target: (1) Patients with a pattern of intractable nausea vomiting and abdominal pain that according to your gestalt as a
emergency clinician does not have a clear etiology eg. appendicitis or SBO. (2) Patients with a known diagnosis and
decompensated pain (gastroparesis, post surgical pain w/o obstruction). In the ED a definitive diagnosis is not available in many
cases. Some patients may simply be in withdrawal from opioids, other may have a bona fide cyclic vomiting syndrome, you will
likely never know! The following describes the kitchen sink. You should tailor your cocktail to the individual patient and scenario.
Features:
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Emesis > 4/hour for MORE than 1 hour
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Anion gap 15-20, ketonuria, hypoglycemia, and/or lactic acidosis support the diagnosis
ED evaluation:
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History
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Important to assess glycemic control at home
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Cannabis and opioid use is very common in this population and likely contributory
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Labwork
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CBC, CMP, Mag, Lipase, UA, HCG
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If prolonged symptoms, consider serum ketones, lactate
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Imaging
If concern is high and risk factors present (prior abdominal surgeries, prior confirmed bowel obstruction, bilious
emesis) Of course, consider imaging, however, given risk of iatrogenic harm after recurrent visits be judicious in
your use of computed tomography.
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Medications Note: there is very little evidence to support any particular medication or regimen for management of acute
exacerbations of cyclic vomiting or fulminant abdominal pain with vomiting. What follows is based on multispecialty
literature review and expert opinion.

Abortive home medications:

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NSAIDs eg. ibuprofen 400
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Diphenhydramine 50mg PO
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Ondansetron 8mg SL
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Sumatriptan 20mg IN/6mg SQ
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Mirtazapine 30mg PO
Abortive/Supportive treatment in the Emergency Department
1. First Line for a moderate presentations
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D5 NS at 1.5x maintenance
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Magnesium sulfate 1-2 grams IV
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Ondansetron, up to 16mg single dose (with EKG/cardiac monitor, avoid if QTc > 500 msec)
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Sumatriptan 6mg SQ, may repeat in 1-2 hr (if not already used at home)
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Ketorolac 30mg IV ( often given with IV PPI or H2)
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PPI or H2B e.g. Famotidine 20mg IV or Pantoprazole 40mg IV
2. Second Line for severe presentations: Neuroleptic sedation. These patients are often difficult to examine due to emotional
upset, acute distress, and intolerable symptoms. (with EKG/cardiac monitor, avoid if QTc > 500 msec)
Options: (chose one: listed in order of expected sedating potency)
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Chlorpromazine 12.5- 25 mg IV or 25-50mg IM may repeat in 30 minutes. (careful with orthostatic hypotension: it is not
uncommon)
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Droperidol (for the lucky few) 1.25-2.5 mg IV (alternative Haldoperidol 2.5-5mg IV/IM)
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Olanzapine 5 mg IM/SL or 2.5 -5mg IV
3. Ketamine! A burst of ketamine (10-20mgIV bolus bolus +/- infusion of 20-30mg over 1hr) during an ED stay will facilitate
discharge and symptom resolution. Most patients experience a mood elevation and pain relief that lasts several days to weeks.
BUT, if the ketamine is given in isolation, it may just be another narcotic ED experience enabling self-harming behavior patterns.
We should not be nave to the reality of iatrogenic keta-monsters. Ideally ketamine is used as a bridge to reducing opioid use,
starting on buprenorphine if in need of addiction treatment, engaging in a home action plan, or otherwise connecting with an
outpatient care plan to move toward recovery.

Highland Emergency DepartmentAlameda Health System: Herring 2016