Refractory Vomiting and Recurrent Vomiting Syndromes
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
History
Presenting pattern
Vomiting syndrome characterization
Refractory vomiting
Recurrent discrete episodes with baseline wellness between
Chronic daily vomiting
Regurgitation without nausea
Retching predominant
OPQRST
Onset
First lifetime episode date
Time from trigger to symptoms
Abrupt versus gradual
Provocation and palliation
Cannabis exposure pattern and temporal relationship
Hot shower or hot bath relief
Meals as trigger
Motion as trigger
Stress or sleep deprivation trigger
Relief with antiemetics and which agents
Quality
Nausea predominant versus emesis without nausea
Retching versus effortless regurgitation
Bilious versus non bilious
Feculent odor concern
Region and radiation
Epigastric pain
RUQ pain
Lower abdominal pain
Chest pain after vomiting
Severity
Emesis count per hour
Inability to tolerate oral fluids
Presyncope or syncope
Urine output reduction
Timing
Continuous versus intermittent
Cyclic pattern with stereotyped episodes
Early morning predominance
Postprandial predominance
Episode content and complications
Emesis content
Hematemesis
Coffee ground material
Melena concern
Undigested food hours after eating
Bile
Complication screening
Severe chest pain after forceful vomiting
Neck crepitus
Aspiration event
Severe headache or neurologic symptoms
Associated symptoms
Gastrointestinal
Abdominal pain location pattern
Diarrhea
Constipation
Obstipation
Abdominal distension
Dysphagia
Infectious and inflammatory
Fever
Rigors
Sick contacts
Recent travel food exposure
Neurologic
Headache
Vertigo
Photophobia
Focal neurologic deficits
Endocrine and metabolic
Polyuria
Polydipsia
Weight loss
Heat intolerance
Cardiorespiratory
Dyspnea
Palpitations
Exertional symptoms
Prior evaluation and response
Previous workup and diagnoses
Prior imaging and endoscopy results
Prior admissions and triggers
Prior diagnosis of CVS or CHS or gastroparesis
Response patterns
Failure of ondansetron or metoclopramide
Response to dopamine antagonists
Response to migraine therapies
Response to cannabis cessation
Alarm Features
Immediate life threats
Resuscitation triggers
Shock physiology
Altered mental status
Severe dehydration with anuria
Ongoing hematemesis
Severe chest pain after vomiting
Vital sign danger thresholds
High risk thresholds
Systolic BP below 90 mmHg
HR above 120
RR above 24
SpO2 below 92 percent on room air
Temperature 38.5 C or higher
High risk historical features
Red flags
Age over 60 with new onset vomiting
Immunocompromised state
Pregnancy with inability to tolerate oral intake
Diabetes with hyperglycemia symptoms
Severe headache or neurologic symptoms
Recent abdominal surgery
High risk exam findings
Concerning findings
Peritonitis
Abdominal distension with tympany
Focal neurologic deficits
Nuchal rigidity
Jaundice
GI bleeding stigmata
Escalation and do not miss
Immediate escalation pathways
Suspected esophageal rupture
Suspected bowel obstruction with strangulation
Suspected DKA or HHS
Suspected adrenal crisis
Suspected intracranial process
Medications
Medication reconciliation
Current medications and recent changes
New medication started within 2 weeks
Dose increases
Missed doses of essential medications
High risk emetogenic agents
Medication causes
Opioids
GLP 1 receptor agonists
Antibiotics
NSAIDs
Iron supplements
Digoxin
Chemotherapy agents
Withdrawal and intoxication risks
Substance related
Alcohol withdrawal risk
Opioid withdrawal risk
Cannabis use disorder pattern
Antiemetic safety
QT prolongation and interactions
Ondansetron QT risk
Droperidol QT risk
Haloperidol QT risk
Macrolide QT risk
Fluoroquinolone QT risk
Dopamine antagonist adverse effects
Acute dystonia risk
Akathisia risk
Neuroleptic malignant syndrome risk
Diet
Intake and hydration
Recent oral intake pattern
Time since last tolerated fluid
Time since last tolerated solids
Estimated daily fluid intake
Dehydration indicators
Reduced urine output
Orthostatic symptoms
Trigger exposures
Food and beverage triggers
High fat meals
Large meal bolus
Caffeine and energy drinks
Suspected foodborne exposure
Special populations
Pregnancy and lactation
Prenatal vitamins and iron timing
Weight loss since pregnancy started
Review of Systems
Gastrointestinal
GI symptoms
Abdominal pain
Diarrhea
Constipation
GI bleeding symptoms
Dysphagia
Early satiety
Neurologic
Neuro symptoms
Headache
Vision changes
Vertigo
Weakness
Seizure
Cardiopulmonary
Chest and breathing symptoms
Chest pain
Dyspnea
Palpitations
Genitourinary and pregnancy
GU and pregnancy symptoms
Dysuria
Flank pain
Vaginal bleeding
Pelvic pain
Endocrine and systemic
Systemic symptoms
Fever
Weight loss
Night sweats
Polyuria
Polydipsia
Collateral History and Family History
Collateral sources
Reliability and supports
Family or caregiver report
Medication list source
Prior records availability
Family history
Relevant inherited and familial disorders
Migraine disorders
Mitochondrial disorders
Early cardiovascular disease
Inflammatory bowel disease
Exposure context
Shared exposures
Household gastroenteritis
Shared meals
Outbreak settings
Risk Factors
Dehydration and kidney injury risk
AKI risk factors
Older age
CKD
Diuretic use
ACE inhibitor or ARB use
Obstruction and surgical risk
Mechanical risk factors
Prior abdominal surgery
Hernia history
Malignancy history
Metabolic and endocrine risk
High risk conditions
Diabetes mellitus
Adrenal insufficiency history
Thyroid disease
Infection and immunocompromise
Host factors
Immunosuppressant use
HIV
Transplant history
Toxin and substance exposure
Exposure risks
Cannabis daily use
Heavy alcohol use
Toxin ingestion concern
Pregnancy related risk
Pregnancy complications
Hyperemesis gravidarum history
Multiple gestation
Molar pregnancy risk factors
Differential Diagnosis
Life threatening
Must not miss
Bowel obstruction or volvulus (K56.609)
Distension
Obstipation
High pitched bowel sounds
Esophageal rupture (Boerhaave syndrome) (K22.3)
Severe chest pain after vomiting
Subcutaneous emphysema
Sepsis physiology
Intracranial hemorrhage or mass effect (I62.9)
Headache
Focal deficits
Papilledema
Diabetic ketoacidosis (E10.10) (E11.10)
Kussmaul respirations
Hyperglycemia symptoms
Ketosis
Adrenal crisis (E27.2)
Hypotension
Hyponatremia
Hyperkalemia
Acute coronary syndrome (I21.9)
Epigastric discomfort
Diaphoresis
Risk factors
Sepsis with abdominal source (A41.9)
Fever
Hypotension
Lactate elevation
Common
High probability causes
Acute gastroenteritis (A09)
Sick contacts
Diarrhea
Short duration
Medication induced vomiting (T50.905A)
Temporal relationship to new drug
Dose change
Gastritis or peptic ulcer disease (K29.70) (K27.9)
Epigastric pain
NSAID exposure
Biliary colic or cholecystitis (K80.20) (K81.9)
RUQ pain
Postprandial trigger
Pancreatitis (K85.9)
Epigastric pain radiating to back
Elevated lipase
Pyelonephritis (N10)
Fever
Flank pain
Urinary symptoms
Hyperemesis gravidarum (O21.0)
Pregnancy
Ketonuria
Weight loss
Less common
Important alternatives
Cyclic vomiting syndrome (G43.A0)
Stereotyped episodes
Baseline wellness between episodes
Migraine history
Cannabinoid hyperemesis syndrome
Daily or near daily cannabis use
Hot shower relief
Symptom improvement with cessation
Gastroparesis (K31.84)
Diabetes
Early satiety
Vomiting undigested food
Superior mesenteric artery syndrome (K55.1)
Postprandial pain
Weight loss
Rumination syndrome (F45.8)
Effortless regurgitation
Postprandial
Functional vomiting
Chronic pattern
Normal workup
Key mimics and distinguishing clues
Pattern recognition
CVS versus CHS
Cannabis exposure heavy suggests CHS
Migraine phenotype suggests CVS
Vomiting versus regurgitation
Nausea and retching supports vomiting
Effortless return of food supports regurgitation
Central neurologic causes
Headache and neuro deficits
Morning vomiting with papilledema
Past Medical History
Relevant chronic conditions
Chronic disease context
Diabetes mellitus (E11.9)
Chronic kidney disease (N18.9)
Migraine disorders (G43.909)
GERD (K21.9)
Psychiatric comorbidity
Prior episodes and prior diagnoses
Historical pattern
Prior similar vomiting episodes
Prior diagnosis of CVS or CHS
Prior gastroparesis diagnosis
Surgical and device history
Mechanical risk context
Prior abdominal surgery
Bariatric surgery history
Feeding tube or gastric electrical stimulator
Baseline function
Functional baseline
Usual oral intake
Baseline weight
Baseline bowel habits
Physical Exam
General and vitals interpretation
Overall status
Toxic appearance
Hydration status
Orthostatic vitals when safe
Perfusion indicators
Capillary refill
Skin mottling
Mental status
HEENT and neck
Head and neck findings
Dry mucous membranes
Oropharyngeal lesions
Subcutaneous emphysema
Nuchal rigidity
Cardiopulmonary
Heart and lung findings
Tachycardia and rhythm regularity
Crackles suggesting aspiration
Wheeze
Abdominal
Abdomen focused findings
Distension
Tenderness location
Peritoneal signs
Bowel sound pattern
Hernia exam
Neurologic
Neuro screen
GCS
Focal deficits
Gait when feasible
Fundoscopic exam if concern for raised ICP
Skin and extremities
Systemic clues
Jaundice
Rash
Peripheral edema
Lab Studies
Core labs
Initial panels
CBC
Electrolytes including magnesium and phosphate
Creatinine and urea
Glucose
Liver enzymes and bilirubin
Lipase
Pregnancy and reproductive
Pregnancy testing
Serum or urine beta hCG in patients with pregnancy potential
Rh status when bleeding concern
Acid base and ketosis
Metabolic assessment
Venous blood gas when severe dehydration or DKA concern
Serum ketones or beta hydroxybutyrate when starvation ketosis or DKA concern
Lactate when sepsis or shock concern
Urine studies
UA based guidance
Ketonuria as dehydration marker
Infection markers for pyelonephritis
Specific gravity for hydration
Toxicology and exposure
Selected tests
Serum acetaminophen level when overdose possibility
Salicylate level when mixed ingestion possibility
Urine drug screen when diagnostic uncertainty and safety planning
Interpretation pearls and pitfalls
Common pitfalls
Hypochloremic metabolic alkalosis with prolonged vomiting
Hypokalemia worsening ileus and arrhythmia risk
Normal lipase early in pancreatitis less likely but possible
Starvation ketosis in prolonged poor intake
Imaging
Scoring Systems
Severity tools when specific etiologies suspected
PUQE scoring for nausea and vomiting of pregnancy
Nausea hours per day
Retching episodes per day
Vomiting episodes per day
BISAP for pancreatitis risk
BUN elevation criterion per local lab
Impaired mental status
SIRS
Age over 60
Pleural effusion
CIWA Ar when alcohol withdrawal suspected
Nausea and vomiting item
Tremor and autonomic signs
MRI
Selected indications
Biliary obstruction evaluation when ultrasound equivocal and MRCP available
Intracranial process evaluation when CT nondiagnostic and symptoms persist
Contraindications and cautions
Implanted devices compatibility
Gadolinium risk in advanced CKD
CT
Abdomen pelvis CT indications
Suspected bowel obstruction or perforation
Severe focal abdominal pain with peritonitis
Concern for appendicitis or diverticulitis with atypical exam
Head CT indications
New focal neurologic deficit
Severe headache with vomiting
Immunocompromised with CNS infection concern
Contrast and radiation cautions
Contrast allergy history
AKI risk and hydration strategy local protocol dependent
Ultrasound
RUQ ultrasound
Gallstones and cholecystitis evaluation
Biliary dilation screening
Pelvic ultrasound
Ectopic pregnancy evaluation when pregnant
Ovarian torsion consideration with pelvic pain
POCUS adjuncts
IVC assessment for volume status limitations
Bladder volume assessment for urinary retention contribution
Special Tests
GI focused diagnostics
Endoscopy considerations
Persistent hematemesis or melena
Dysphagia or food impaction concern
Suspected peptic ulcer complications
Gastric emptying evaluation
Outpatient gastric emptying scintigraphy for suspected gastroparesis
Medication and glucose confounders
Syndrome specific clinical criteria
CVS and CHS recognition
CVS stereotyped episodes with baseline wellness
CHS heavy cannabis use with hot bathing behavior
Improvement after cannabis cessation supports CHS
Bedside monitoring tests
Refractory vomiting safety checks
Serial abdominal exams
Strict intake and output
Daily weight when admitted
ECG
When ECG matters
Indications in vomiting presentations
Electrolyte derangements
Chest pain or epigastric pain in high risk patients
Use of QT prolonging antiemetics
High risk patterns
Immediate action findings
Prolonged QTc
Ventricular ectopy
Ischemic changes
Serial ECG logic
Repeat strategy
After potassium and magnesium correction when QTc prolonged
After droperidol or haloperidol when high risk
Assessment
Problem representation
Vomiting syndrome summary
Refractory vomiting with dehydration severity
Recurrent episodic vomiting phenotype
Key suspected syndrome and alternative diagnoses
Severity and risk stratification
Severity markers
Hemodynamic instability
Significant electrolyte abnormalities
AKI presence
Inability to tolerate oral fluids after ED therapy
Working diagnoses
Most likely etiologies with codes when applicable
Acute gastroenteritis (A09)
Cyclic vomiting syndrome (G43.A0)
Hyperemesis gravidarum (O21.0)
Gastroparesis (K31.84)
Pancreatitis (K85.9)
Diagnostic uncertainty
Alternative considerations
Obstruction despite nonclassic symptoms
CNS process with subtle neuro findings
Medication effect despite long term use
Plan
First 5 minutes
Immediate stabilization workflow
Airway protection threshold
Cardiac monitor when severe dehydration or electrolyte derangement
Two large bore IV when shock physiology
Point of care glucose early
Fluid and electrolyte correction
Rehydration strategy
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.