›Isotonic crystalloid bolus 10 to 20 mL per kg for hypovolemia
›Reassess perfusion after each bolus
›Avoid large free water in hyponatremia
›Electrolyte repletion
›Potassium replacement target above 3.5 mmol/L when safe
›Magnesium replacement target above 0.8 mmol/L when QTc risk
›Phosphate replacement when severe hypophosphatemia
Antiemetic escalation ladder
›Stepwise pharmacotherapy
›Ondansetron IV 4 mg once
›Repeat ondansetron IV 4 mg after 15 to 30 minutes if partial response
›Metoclopramide IV 10 mg once
›Prochlorperazine IV 10 mg once
›Haloperidol IV 2.5 mg once local protocol dependent
›Droperidol IV 1.25 mg once local protocol dependent
›Adjuncts
›Diphenhydramine IV 25 mg for dystonia prophylaxis with dopamine antagonists
›Acetaminophen for pain when appropriate
›Avoid opioid escalation when possible
Syndrome specific management
›Cannabinoid hyperemesis syndrome
›Topical capsaicin 0.025 to 0.1 percent to abdomen or arms
›Haloperidol low dose strategy local protocol dependent
›Cannabis cessation counseling and referral pathway
›Cyclic vomiting syndrome
›Treat as migraine phenotype when present
›IV fluids and antiemetics as above
›Consider triptan therapy when typical migraine features and no contraindications
›Gastroparesis flare
›Metoclopramide strategy with dystonia risk counseling
›Avoid anticholinergics and opioids when possible
›Diabetes glucose optimization pathway
›Hyperemesis gravidarum
›Thiamine IV 100 mg before dextrose containing fluids when prolonged poor intake
›Doxylamine pyridoxine pathway local protocol dependent
›Obstetric consultation criteria
Targeted etiologic pathways
›Suspected obstruction
›NPO
›NG tube decompression when significant distension and persistent vomiting
›Early surgical consultation
›Suspected GI bleeding
›Large bore IV access
›Type and screen
›Proton pump inhibitor IV local protocol dependent
›Suspected DKA
›DKA protocol local protocol dependent
›Potassium threshold logic before insulin
Monitoring and reassessment loop
›Reassessment structure
›Symptom response check at 15 to 30 minutes after each antiemetic step
›Repeat vitals after fluids
›Repeat electrolytes after significant replacement
›Urine output monitoring goal at least 0.5 mL per kg per hour
17Disposition/dispo24
ICU and high acuity criteria
›ICU level indicators
›Persistent hypotension after fluids
›Severe electrolyte derangement with arrhythmia risk
›DKA or HHS requiring insulin infusion
›Sepsis requiring vasopressors
Inpatient admission criteria
›Admission indicators
›Intractable vomiting despite ED escalation
›AKI or rising creatinine
›Inability to tolerate oral fluids after observation period
›Significant metabolic alkalosis or acidosis
›Complication suspicion requiring serial exams
Observation pathway criteria
›Observation appropriate when
›Hemodynamically stable after initial therapy
›Electrolytes correctable within hours
›Need for serial antiemetic dosing and PO challenge
Discharge criteria
›Safe discharge requirements
›Tolerating oral fluids
›Stable vitals
›No red flags and reassuring workup
›Reliable follow up and return precautions understood
Follow up timing
›Outpatient pathways
›Primary care within 48 to 72 hours when recurrent symptoms
›Gastroenterology referral for suspected CVS or gastroparesis
›Obstetrics follow up when pregnant
18Discharge Instructions/di30
Copy discharge instructions
›Summary
›You were seen for vomiting
›Your tests today did not show an emergency cause
›Medications
›Take prescribed anti nausea medication as directed
›Avoid taking more than prescribed
›Avoid alcohol while using sedating medicines
›Hydration and diet
›Start with small sips of clear fluids
›Advance to bland foods as tolerated
›Avoid large fatty meals until improved
›Activity
›Avoid driving if you feel dizzy or if your medication causes drowsiness
›Rest today and resume normal activity as tolerated
›Follow up
›Follow up with your doctor in 1 to 3 days
›If symptoms are recurring ask about evaluation for cyclic vomiting or other causes
›Return to emergency care now for
›Chest pain
›Trouble breathing
›Fainting or confusion
›Vomit that looks like blood or coffee grounds
›Black stools
›Severe worsening belly pain
›Unable to keep fluids down for 8 hours
›Fever 38.5 C or higher
›New severe headache or weakness
›Special note for cannabis users
›If you use cannabis daily stopping cannabis is the best treatment for recurrent vomiting related to cannabis
›Return if symptoms worsen despite stopping
19References/r6
Guidelines and core sources
›Key references for recurrent and refractory vomiting
›American College of Gastroenterology guideline on gastroparesis 2022
›ANMS and CVSA guideline on cyclic vomiting syndrome in adults 2019
›American College of Obstetricians and Gynecologists guidance on nausea and vomiting of pregnancy 2018
›Rome IV criteria for functional GI disorders 2016
›American Diabetes Association standards of care for DKA and hyperglycemic crises 2024
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.