Nausea is the unpleasant, disabling, and painless urge to vomit. It can exist independently or be accompanied by vomiting. The potential causes for nausea and vomiting are extensive; nausea and vomiting are not considered diseases in and of themselves but rather symptoms of other conditions. In caring for individuals with nausea and/or vomiting, paramedics and EMRs/FRs should work towards two goals: identification of the underlying cause to determine appropriate treatment and the management of symptoms to improve patient comfort.
An attempt at identifying acute etiologies for nausea and vomiting must be made.
Provide therapies to alleviate symptoms.
Facilitate appropriate conveyance.
A complete physical and neurological assessment should be completed for all patients. Acute etiologies may include but are not limited to:
Vertigo: One of the most common causes of out-of-hospital nausea/vomiting, this is the perceived sensation of motion often described as spinning or whirling. Sweating, pallor, nausea, vomiting, and balance disturbances often accompany vertigo. Vertigo is caused by many different factors including:
Impaired visual input, inner ear function, or peripheral sensory input
Migraines: These headaches can last from minutes to days and are characterized by intense throbbing pain, photosensitivity, nausea and vomiting, and sweating. Patients may be prescribed metoclopramide as it treats both the pain and nausea associated with suspected migraines.
Opioid-induced: Due to the low incidence of opioid-induced nausea, the lack of efficacy of prophylactic therapy, and the possibility of additional side effects, opioids should not be accompanied by an antiemetic agent. Antiemetic therapy is only indicated if the patient develops nausea or vomiting after opioid use.
Alcohol withdrawal: Patients experiencing alcohol withdrawal are at higher risk of developing electrolyte abnormalities which can affect the QT interval. Dimenhydrinate is the antiemetic of choice in these cases as it does not cause QT interval elongation.
Upper gastrointestinal bleeding: Blood in the stomach is often a cause of extreme nausea. Metoclopramide can be useful in these cases as it improves gastric emptying in addition to treating nausea.
Pregnancy: Nausea can be a common issue during pregnancy, especially in the first trimester and in the morning. Dimenhydrinate is considered to be the first-line medication for nausea and vomiting that is safe and effective during pregnancy. Women should be reassured as to dimenhydrinate’s safety and low risk of toxicity for the fetus.
First Responder (FR) Interventions
Keep the patient at rest in a position of comfort
Maintain patient in position of comfort consistent with the need to protect the patient’s airway