CYCLICAL VOMITING

Question 1

Approach to the Critical Patient with Vomiting

Answer 1

A - stridor
B - RR 30, 02 sats 90% on Fi02 30%
C - mottled appearance, cap refill
D - GCS, PERRLA & check POC glucose
E - Exposure, take down dressings

Check for peritonitic abdomen

Monitor
O2 Target to 94%
Vitals
IV Access: 2 large bore IV
Equipment for Airway and ECG - check for prolonged QTc

Correct Vitals:
1-L bolus in adults
10-20 mL/kg in children
THEN
IV Dextrose-containing solution

Antiemetic:

Children: Ondansetron 0.15 mg/kg/dose (max 16 mg for initial dose)

Adults: Ondansetron 4-8 mg IV

Obtain labs for Urea, Cr, Lytes, Mg, Pho, Ca

Question 2

Diagnosis

Answer 2

Diagnosis of exclusion

Question 3

Clinical Features: Pediatrics

Answer 3

Episodes typically begin in the early morning.

A prodrome of pallor, nausea, abdominal pain, and anorexia is often reported.

Episodes can last from 24 h up to several d.

It may occur at regular intervals.

Up to 75% of parents can identify psychological triggers (excitement, stress) or infections.

Question 4

Clinical Features: Adults

Answer 4

Over 90% of patients report a prodrome of nausea, abdominal pain, and headache.

Episodes typically have an early morning onset.
Patients may experience vomiting 8 times/h during the vomiting phase.

Adult cyclical vomiting syndrome is often associated with migraine, menses, or pregnancy.

Question 5

Investigations

Answer 5

Point-of-care glucose
Basic metabolic panel
Extended Lytes
Urea
Creatinine
LFTs
Urinalysis
Lipase
Pregnancy test
ECG - assess for QTc

Question 6

Management: Abortive

Answer 6

Abortive (prodromal phase):

Sumatriptan

Children: age and weight dependent (see dosage details below)
intranasal dose 5 to 20 mg
subcutaneous (SC) dose 2 to 6 mg

Adults: 20 mg intranasal or 6 mg SC

Question 7

Management: Vomiting Phase

Answer 7

Ondansetron
Children: 0.15 mg/kg/dose (max 16 mg for initial dose).
Adults: 4-8 mg IV

Metaclopramide 10 mg slow IV Can administer with diphenhydramine 25-50 mg intravenous as prophylaxis against dystonia.

Haloperidol or droperidol 1.25-5 mg intravenous for intractable nausea/vomiting, acute on chronic abdominal pain, gastroparesis, and cannabis hyperemesis syndrome