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Nausea & Vomiting

Not a GI complaint until the brain, heart, sugar, and pregnancy are clear.

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobNot a GI complaint until the brain, heart, sugar, and pregnancy are clear.

  1. Glucose, pregnancy, ECG — before the antiemetic is the diagnosis.
  2. Pain before vomiting leans surgical; bilious or feculent vomiting is obstruction until imaged.
  3. Then raised ICP, DKA/adrenal, and cannabinoid hyperemesis as an exclusion.
  4. Ondansetron is a treatment, not a workup.

Vomiting is a final common pathway.

The ED sequence is: glucose, pregnancy, ECG (especially in women and diabetics), surgical abdomen/obstruction, raised ICP, and toxin/metabolic (DKA, adrenal, hyponatremia, cannabinoid hyperemesis). Ondansetron is a treatment, not a diagnosis.

Bowel obstruction / volvulus / perforation Critical

Key: Bilious or feculent vomiting, distension, prior surgery, hernia — CT. Sigmoid/cecal volvulus is time-critical ischemia.

ACS / inferior MI Critical

Key: Isolated vomiting, especially in women, elderly, and diabetics — ECG before the antiemetic is blamed for the “cure.”

Raised ICP / SAH / posterior stroke Critical

Key: Headache, diplopia, ataxia, no abdominal findings — CT/MRI. Projectile vomiting is a clue, not a rule.

DKA / HHS / adrenal crisis / hyponatremia Critical

Key: Glucose and electrolytes in every unexplained case. Steroid-dependent patients get stress-dose steroids.

Pregnancy complications (hyperemesis vs ectopic vs molar) Critical

Key: hCG first; ketones and electrolytes in hyperemesis; ectopic if pain + bleeding.

Acute glaucoma / testicular or ovarian torsion Emergent

Key: The referred-pain mimics — eye and groin exams exist for a reason.

Cannabinoid hyperemesis / cyclic vomiting / gastritis Common

Key: Hot-water bathing is a cannabinoid clue; capsaicin and haloperidol are options. Still exclude the killers once.

Tick what your patient has — the banner updates as you go.

Duration, bilious vs food vs blood, ability to keep down liquids

Pain

before vomiting (surgical) vs after (medical/gastroenteritis)

Headache, visual change, chest pain, pregnancy possibility

Diabetes, adrenal disease, cannabis, chemotherapy, prior abdominal surgery, hernias

Vitals including glucose; orthostatics

Abdomen

distension, hernias, peritoneal signs, succussion splash

Neuro

pupils, papilledema, ataxia, neck stiffness

Eye (glaucoma), groin (torsion), pregnancy

Bedside

  • Glucose, hCG, ECG
  • POCUS: AAA, free fluid, IUP, B-lines

Labs

  • Electrolytes including Na, K, Mg; VBG/ketones if DKA possible; lipase
  • LFTs, CBC, renal panel; cortisol if adrenal crisis is possible

Imaging

  • CT abdomen/pelvis with contrast for obstruction/ischemia when suspected
  • CT/MRI head for raised-ICP features; AXR is insensitive for obstruction
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Gastroenteritis or cannabinoid hyperemesis after successful oral challenge, normal vitals and labs when indicated, reliable follow-up. Driving advice if sedating antiemetics were given.

Admit

  • Obstruction without ischemia, DKA on a protocol, hyperemesis with ketosis not yet reversed, inability to tolerate oral intake in a high-risk host.

Theatre / ICU / cath lab

  • Perforation, ischemic bowel/volvulus, ACS, raised ICP, adrenal crisis, airway from aspiration.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Nausea & Vomiting:
    • Bilious or feculent vomiting, or vomiting with peritonitis
    • Chest pain, dyspnea, or diaphoresis with vomiting
    • Headache, diplopia, or ataxia
    • Glucose high or very low; steroid-dependent patient
    • Positive hCG with pain or bleeding
    • Intractable vomiting with severe electrolyte derangement
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Pain before vomiting leans surgical; vomiting before pain leans medical — not a law, a nudge.
  • ECG and glucose are cheaper than a missed STEMI or DKA.
  • Bilious vomiting in a neonate or young child is surgical until imaging says otherwise.
  • Steroid-dependent + vomiting = stress-dose steroids, do not wait for a cortisol.

Pitfalls

  • Treating with ondansetron and discharging a missed inferior MI or SBO is a classic error.
  • AXR misses a large fraction of obstruction — CT is the test when suspicion is real.
  • Cannabinoid hyperemesis is a diagnosis of exclusion in the first presentations.
  • Ondansetron prolongs QT — look at the ECG in the already-sick.
  • Children with bilious vomiting have malrotation/volvulus until proven otherwise.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Abdominal PainDiarrheaChest PainHeadacheConstipationDKA, HHS & Adrenal Crisis

Selected guidance · source check 2026-09-07. These 3 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — nausea and vomiting
  • 2025 ACC/AHA ACS Guideline (atypical symptoms)
  • ADA DKA/HHS guidance; Tintinalli’s 9th ed.
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