Nausea and Vomiting Evaluation and Management

Critical Initial Assessment

The American College of Cardiology recommends obtaining an ECG immediately to exclude acute coronary syndrome in adults presenting with nausea, vomiting, and shortness of breath, as this symptom triad may represent a potentially atypical presentation of myocardial ischemia, particularly in women 1, 2
Cardiac ischemia should be ruled out by obtaining an ECG within minutes of presentation, as nausea and vomiting frequently accompany acute coronary syndrome 1, 2
The Society for Critical Care Medicine suggests beginning rapid IV fluid resuscitation immediately if hypotension, tachycardia, or signs of volume depletion are present, with a strength of evidence rated as high 3

The Infectious Diseases Society of America recommends CT scan as the imaging modality of choice for determining the presence of intra-abdominal infection or obstruction in patients not requiring immediate laparotomy, with a strength of evidence rated as moderate 3

The American Gastroenterological Association recommends initiating dopamine receptor antagonists as first-line treatment once cardiac causes are excluded, with metoclopramide 10-20 mg IV/IM having the strongest evidence for non-chemotherapy-related nausea and vomiting, and a strength of evidence rated as high 1, 4
The American Society of Clinical Oncology suggests adding dexamethasone 2-8 mg IV/PO to the antiemetic regimen as second-line therapy, with a strength of evidence rated as moderate 1, 4

The Infectious Diseases Society of America recommends initiating antimicrobial therapy immediately if intra-abdominal infection is suspected or diagnosed, with antibiotics administered as soon as possible in patients with septic shock, and a strength of evidence rated as high 3

The National Comprehensive Cancer Network recommends metoclopramide 10-20 mg every 6 hours for suspected gastroparesis or gastric outlet obstruction, providing both antiemetic and prokinetic effects, with a strength of evidence rated as moderate 6, 4

The American College of Emergency Physicians advises never assuming benign gastroenteritis without obtaining an ECG in patients with nausea, vomiting, and SOB, as this combination warrants cardiac evaluation, with a strength of evidence rated as high 1, 2
The Society for Critical Care Medicine suggests avoiding delay in surgical consultation if peritoneal signs, severe abdominal pain, or imaging suggests obstruction or perforation, with a strength of evidence rated as high 3, 2