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symptom.nausea_vomiting.ed.v1PRODUCTION
symptom.nausea_vomiting.ed.v1

Acute nausea & vomiting (ED triage — undifferentiated adult)

symptomacuteundifferentiatedadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Onset (acute vs subacute vs chronic; episodic vs persistent), character (bilious vs feculent vs bloody vs projectile), timing (postprandial vs morning vs cyclic) — anchors DDx (Quigley 2013 PMID 29407306)

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Set
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pattern characterized

Patient inputs (42)

Age shifts priors: SBO / mesenteric ischemia / atypical ACS rise with age; pregnancy + cyclic vomiting + cannabinoid hyperemesis in younger adults (Quigley 2013 PMID 29407306)

Female + childbearing age → pregnancy mandatory; female + atypical chest symptoms → atypical ACS prior raised; PONV female-predominant

ALL women of childbearing age (10-55) — pregnancy test mandatory; hyperemesis vs molar/heterotopic/ectopic; route ob; first-trimester pyridoxine + doxylamine + ondansetron risk (Cleft palate risk debated)

Hypotension + vomiting → volume depletion / sepsis / adrenal crisis / hemorrhage / anaphylaxis / mesenteric ischemia / massive PE

Tachycardia + vomiting → dehydration / sepsis / ACS / anxiety / thyroid storm / hypoglycemia; relative bradycardia → typhoid, ICP

Tachypnea + vomiting → DKA (Kussmaul) / sepsis / aspiration; bradypnea → opioid / ICP

Hypoxia + vomiting → aspiration pneumonia / Mallory-Weiss bleed / cardiogenic / Boerhaave

Fever + vomiting → infectious DDx; hypothermia + vomiting → severe sepsis / adrenal crisis / hypothyroid

Prior abdominal surgery → adhesive SBO #1 cause; chronic constipation + distension → fecal impaction / colonic obstruction

DM2 + missed insulin + vomiting → DKA/HHS; metformin + lactic acidosis (rare)

Chronic steroid use abruptly stopped OR known Addison → adrenal crisis with vomiting + hypotension + hyperK + hypoNa

Chemo within 5 days → CINV (acute or delayed); platinum-based & anthracycline highly emetogenic; aprepitant + ondansetron + dexamethasone

Opioid use → opioid-induced nausea; constipation + obstruction; consider naloxone if respiratory depression

Known migraineur → migraine-with-emesis recurrence; IV metoclopramide / prochlorperazine / sumatriptan

CAD / diabetic / elderly / female → atypical ACS prior raised; ECG + troponin if vomiting + chest/diaphoresis/dyspnea

Vomiting + abdominal pain mandatory triage; localization narrows DDx (RUQ/cholecystitis; RLQ/appendicitis; epigastric/pancreatitis; periumbilical → migratory RLQ → appendicitis; diffuse → gastroenteritis/SBO/ischemia)

Vomiting + diarrhea → gastroenteritis (route symptom.diarrhea.ed.v1 if diarrhea-predominant); vomiting WITHOUT diarrhea + distension → obstruction

Fever + vomiting → infection (gastroenteritis, cholangitis, pyelonephritis, meningitis); afebrile → metabolic / mechanical / drug-induced / pregnancy / migraine

Vomiting + headache + photophobia/phonophobia → migraine; + papilledema/focal → raised ICP/ICH/SAH; + neck stiffness + fever → meningitis

Vomiting + chest pain/dyspnea/diaphoresis → atypical ACS workup (diabetic/elderly/female); ECG + troponin always when paired

Vomiting + vertigo → peripheral (BPPV, vestibular neuritis, Ménière) vs central (posterior stroke, cerebellar) → HINTS exam + posterior MRI if concerning (route symptom.vertigo.v1)

Acute <24-48 h vs subacute days vs chronic >1 week; episodic stereotypical → cyclic vomiting (Quigley 2013)

Bilious vomit → distal obstruction; bloody/coffee ground → UGIB → route gi.ugib.core.v1; feculent → distal SBO/colonic; non-bilious → proximal/gastric; projectile → ICP

Postprandial → gastric outlet obstruction / gastroparesis / pregnancy / functional; morning → pregnancy / uremia / ICP / alcohol; nocturnal/cyclic → CVS/CHS

Leukocytosis + left shift → infection (appendicitis, cholangitis, cholecystitis, gastroenteritis, peritonitis); anemia → bleeding (UGIB), chronic disease

Glucose (DKA/HHS/hypoglycemia stroke mimic), Na/K (vomiting alkalosis hypokalemia; adrenal crisis hyperK/hypoNa), BUN/Cr (volume depletion / AKI), anion gap (DKA, salicylate, toxic alcohols)

AST/ALT/bili/ALP (hepatitis, cholangitis, cholecystitis, choledocholithiasis); lipase >3× ULN → acute pancreatitis (Tenner ACG 2013 PMID 23589549)

MANDATORY for ALL women of childbearing age (10-55) — guides ob route + imaging choice + drug selection

UA — ketones (DKA / starvation / pregnancy), nitrites/leukocyte esterase (UTI/pyelonephritis), specific gravity (volume status), glucose (DKA/HHS)

ECG — atypical ACS phenotype; hyperK/hypoK changes; long QT pre-ondansetron; LVH

CT abdomen/pelvis with IV contrast — gold-standard for SBO transition point, appendicitis, pancreatitis severity, mesenteric ischemia, perforation, abscess (PMID 24698526)

US RUQ — gallstones, gallbladder thickening, sonographic Murphy → acute cholecystitis; first-line in pregnancy / radiation-avoidance

Transvaginal US in pregnant patient with abdominal pain + bleeding → ectopic vs viable; correlate with beta-hCG

NCCT head if vomiting + headache + neuro deficit / papilledema / projectile / new-onset — rule out ICH/SAH/mass/raised ICP

Recent outbreak / sick contacts / travel → Norwalk/rotavirus/Salmonella/Shigella/STEC/parasitic; cross-link symptom.diarrhea.ed.v1

Chronic daily cannabis + cyclic vomiting + hot-water bathing relief → cannabinoid hyperemesis (Habboushe PMID 25965476); supportive + cessation

Cirrhosis + vomiting + hematemesis → variceal bleed → route gi.variceal_bleed.v1; SBP / hepatic encephalopathy overlay

Lactate ≥4 → severe sepsis OR mesenteric ischemia; supports SSC bundle activation

Atypical ACS workup if vomiting + chest/diaphoresis/dyspnea + diabetic/elderly/female

Quantitative beta-hCG if pregnant — ectopic vs molar vs viable; trend with TVUS

CXR — free air (perforation), aspiration, pneumonia, pneumomediastinum (Boerhaave)

Acute abdominal series (upright + supine + CXR) — dilated loops, air-fluid levels, free air; first-line for SBO suspicion (low sensitivity for early SBO)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateningsurgical_abdomen_peritonitis
    Vomiting + peritoneal signs (rebound, guarding, rigidity) OR free air on imaging — surgical abdomen / perforation; STAT surgery consult + broad antibiotics + CT + OR
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsmall_bowel_obstruction_strangulation
    Vomiting + distension + obstipation + prior surgery + CT with transition point ± closed-loop / strangulation signs — SBO; NG decompression + fluids + antibiotics + surgery consult (strangulation = STAT OR)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdka_severe
    Vomiting + glucose >250 + anion gap + ketosis + pH <7.3 OR HCO3 <15 — DKA; insulin infusion + K replacement + IV fluids (route endo.dka.core.v1)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghhs_severe
    Vomiting + glucose >600 + osmolality >320 + AMS WITHOUT acidosis — HHS; insulin + fluids (route endo.hhs.core.v1); higher mortality than DKA in elderly
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningadrenal_crisis
    Vomiting + hypotension + hyperK + hypoNa + chronic steroid use OR known Addison — adrenal crisis; hydrocortisone 100 mg IV STAT + fluids (route endo.adrenal-crisis.core.v1)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningatypical_acs_with_vomiting
    Vomiting + chest pain/diaphoresis/dyspnea + diabetic/elderly/female — atypical ACS; ECG + troponin + HEART score → cardio.nstemi.core.v1 / cardio.stemi.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningraised_icp_with_vomiting
    Vomiting (often projectile/morning) + headache + papilledema + focal neuro deficit — raised ICP / ICH / SAH / mass; STAT NCCT + neurosurgery + osmotic therapy if herniation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmesenteric_ischemia
    Vomiting + pain out of proportion to exam + lactate ≥4 + elderly vasculopath + AFib — acute mesenteric ischemia; STAT CT angiography + vascular surgery (mortality 70% if delayed)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_appendicitis
    Vomiting + RLQ pain + anorexia + fever + leukocytosis (Alvarado ≥7) — appendicitis; appendectomy or selective non-operative (IDSA antibiotic-only protocol in selected); CT or US (peds/pregnancy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_pancreatitis_severe
    Vomiting + epigastric pain radiating to back + lipase >3× ULN + Ranson/BISAP/APACHE-II severity criteria — acute pancreatitis; aggressive IV fluids (LR), pain control, NPO; severe → ICU (Tenner ACG 2013 PMID 23589549)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_cholecystitis_or_cholangitis
    Vomiting + RUQ pain + Murphy sign + fever + leukocytosis + US gallbladder thickening — acute cholecystitis; antibiotics + cholecystectomy within 72 h (Charcot triad → cholangitis → emergent ERCP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehyperemesis_gravidarum
    Pregnancy + persistent vomiting + ketosis + >5% weight loss + electrolyte derangement — hyperemesis; IV fluids + thiamine 100 mg + pyridoxine + doxylamine + ondansetron (RCOG NVP PMID 25584725; SOM Canada PMID 28209253)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemigraine_with_vomiting
    Vomiting + unilateral throbbing headache + photophobia + phonophobia + aura — migraine; IV metoclopramide + diphenhydramine ± dihydroergotamine ± sumatriptan (route neuro.migraine.core.v1)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecannabinoid_hyperemesis_syndrome
    Chronic daily cannabis use + cyclic vomiting + compulsive hot-water bathing for relief — CHS; capsaicin topical + haloperidol second-line + cessation; ondansetron often ineffective (Habboushe 2018 PMID 25965476)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ed playbook — drug actions (12)

  1. 1. IV NS or LR (volume resuscitation)
    1-2 L bolus then 100-150 mL/h titrate to vitals + UOP ≥0.5 mL/kg/h • IV • continuous
    trigger: Hypotension OR tachycardia OR poor PO tolerance OR ketosis OR dry mucosa
    SSC 2026 / clinical — crystalloid first-line; LR for hyperchloremic acidosis avoidance; correct K (typically low in vomiting alkalosis)
  2. 2. ondansetron IV (or PO ODT)
    4 mg IV q4-6h (or 4-8 mg PO ODT) • IV/PO • q4-6h
    trigger: Persistent vomiting in adult (non-obstruction)
    First-line antiemetic; check QTc + electrolytes; pregnancy safety category B (cleft palate signal debated; second-line in pregnancy per RCOG PMID 25584725)
  3. 3. metoclopramide IV
    10 mg IV q6-8h • IV • q6-8h
    trigger: Vomiting with gastroparesis suspicion (DM2) OR migraine
    Prokinetic + antiemetic; AVOID in suspected obstruction OR Parkinson disease; tardive dyskinesia risk; pair with diphenhydramine to prevent EPS
  4. 4. prochlorperazine IV/IM
    5-10 mg IV q4-6h OR 25 mg PR q12h • IV/PR • q4-6h
    trigger: Migraine with vomiting OR refractory CINV
    D2 antagonist; effective in migraine + CINV; risk of EPS / akathisia / sedation; pair with diphenhydramine
  5. 5. pyridoxine + doxylamine (pregnancy)
    Pyridoxine 10-25 mg PO q6-8h + doxylamine 12.5 mg PO at bedtime (and additional 12.5 mg morning/afternoon PRN) • PO • q6-8h
    trigger: NVP (nausea/vomiting of pregnancy) — first-trimester first-line
    RCOG NVP PMID 25584725 / SOM Canada 2016 PMID 28209253 — first-line; pregnancy category A; over-the-counter combo Diclegis
  6. 6. hydrocortisone IV (adrenal crisis)
    100 mg IV bolus then 50 mg IV q6h × 24 h then taper • IV • q6h
    trigger: Suspected adrenal crisis (vomiting + hypotension + steroid history + hyperK + hypoNa)
    Empiric stress-dose steroid; do NOT wait for cortisol level if clinically suspected; route to endo.adrenal-crisis.core.v1
  7. 7. regular insulin IV + dextrose (DKA/HHS)
    Regular insulin 0.1 U/kg IV bolus then 0.1 U/kg/h infusion (or 0.14 U/kg/h without bolus); add D5/D10 when glucose <250 • IV • continuous
    trigger: DKA OR HHS with glucose >250 + ketosis/hyperosm
    ADA 2026 — hold insulin until K ≥3.3; correct K + fluids first; route to endo.dka.core.v1 OR endo.hhs.core.v1
  8. 8. KCl IV (vomiting alkalosis hypokalemia)
    10 mEq IV q1h via central or peripheral (max 40 mEq/L peripheral) titrate to K 4.0-4.5 • IV • q1-4h
    trigger: Vomiting hypokalemic alkalosis OR DKA/HHS hypokalemia + before/with insulin
    Vomiting causes Cl/H+ loss → contraction alkalosis + secondary hypokalemia; replete aggressively; ECG monitor
  9. 9. IV PPI (UGIB / Boerhaave)
    Pantoprazole 80 mg IV bolus then 8 mg/h infusion × 72 h • IV • continuous
    trigger: UGIB / Boerhaave / Mallory-Weiss with active bleeding
    PPI reduces rebleed after EGD; route to gi.ugib.core.v1 OR variceal-bleed engine
  10. 10. sumatriptan SC or IV metoclopramide (migraine)
    Sumatriptan 6 mg SC OR metoclopramide 10 mg IV ± dihydroergotamine 1 mg IV (avoid in CAD/HTN/pregnancy) • SC/IV • once
    trigger: Migraine with vomiting (after antiemetic)
    AHS guidelines — IV metoclopramide first-line ED migraine; sumatriptan if no triptan in last 24 h; route to neuro.migraine.core.v1
  11. 11. aprepitant + ondansetron + dexamethasone (CINV)
    Aprepitant 125 mg PO day 1 then 80 mg PO days 2-3 + ondansetron 8 mg PO/IV + dexamethasone 12 mg PO/IV day 1 then 8 mg days 2-4 • PO/IV • daily
    trigger: Highly emetogenic chemotherapy (cisplatin, anthracycline)
    ASCO antiemetic guideline — triple-agent prophylaxis for HEC; olanzapine 5-10 mg PO daily quad for refractory
  12. 12. capsaicin topical + cessation (CHS)
    Capsaicin 0.025-0.075% cream applied to abdomen q4-6h; cannabis cessation counseling • topical • q4-6h PRN
    trigger: Cannabinoid hyperemesis syndrome (chronic daily cannabis + cyclic vomiting + hot-water bathing relief)
    Habboushe 2018 PMID 25965476 — capsaicin TRPV1 agonist replicates hot-shower effect; haloperidol 5 mg IV as second-line; ondansetron often ineffective; only definitive cure is cessation

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Acute nausea + vomiting without alarm features — usually viral gastroenteritis OR functional dyspepsia (Quigley ACG 2013 PMID 29407306); Vomiting + crampy abdominal pain + distension + obstipation — small bowel obstruction → route gi.small-bowel-obstruction.core.v1; Vomiting + RLQ pain + anorexia + fever + leukocytosis — appendicitis → route gi.acute-appendicitis.core.v1.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute nausea & vomiting (ED triage — undifferentiated adult)** (symptom.nausea_vomiting.ed.v1).
Phenotype framing: Acute self-limited (~60-70%): viral gastroenteritis (Norwalk, rotavirus), food poisoning, food intolerance. Surgical abdomen: SBO, appendicitis, pancreatitis, cholecystitis, mesenteric ischemia, perforation. Metabolic: DKA, HHS, adrenal crisis, uremia, hyperCa. Neuro: migraine, raised ICP, ICH, SAH, vertigo (central/peripheral). Pregnancy: morning sickness, hyperemesis, molar, ectopic. Cardiac: atypical ACS (diabetic/elderly/female). Drug-induced: chemo, opioids, antibiotics. Functional: cyclic vomiting, cannabinoid hyperemesis, functional dyspepsia, gastroparesis. Vestibular. Toxic ingestion (acetaminophen, salicylate, ethanol, methanol)
Scope: Onset (acute vs subacute vs chronic; episodic vs persistent), character (bilious vs feculent vs bloody vs projectile), timing (postprandial vs morning vs cyclic) — anchors DDx (Quigley 2013 PMID 29407306)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Pattern-anchored triage (isolated vs surgical abdomen vs metabolic vs neuro vs pregnancy vs cardiac atypical vs drug-induced vs functional); rule out surgical abdomen (SBO, appendicitis, pancreatitis, cholecystitis, mesenteric ischemia, perforation), DKA/HHS, adrenal crisis, raised ICP/ICH, atypical ACS, ectopic pregnancy, UGIB; activate downstream engine (Quigley ACG 2013 PMID 29407306; Tenner ACG 2013 PMID 23589549; RCOG NVP 2016 PMID 25584725; SOM Canada 2016 PMID 28209253; Habboushe 2018 PMID 25965476; PMID 24698526 CT workup)
1. IV NS or LR (volume resuscitation) 1-2 L bolus then 100-150 mL/h titrate to vitals + UOP ≥0.5 mL/kg/h IV continuous — Hypotension OR tachycardia OR poor PO tolerance OR ketosis OR dry mucosa (SSC 2026 / clinical — crystalloid first-line; LR for hyperchloremic acidosis avoidance; correct K (typically low in vomiting alkalosis))
2. ondansetron IV (or PO ODT) 4 mg IV q4-6h (or 4-8 mg PO ODT) IV/PO q4-6h — Persistent vomiting in adult (non-obstruction) (First-line antiemetic; check QTc + electrolytes; pregnancy safety category B (cleft palate signal debated; second-line in pregnancy per RCOG PMID 25584725))
3. metoclopramide IV 10 mg IV q6-8h IV q6-8h — Vomiting with gastroparesis suspicion (DM2) OR migraine (Prokinetic + antiemetic; AVOID in suspected obstruction OR Parkinson disease; tardive dyskinesia risk; pair with diphenhydramine to prevent EPS)
4. prochlorperazine IV/IM 5-10 mg IV q4-6h OR 25 mg PR q12h IV/PR q4-6h — Migraine with vomiting OR refractory CINV (D2 antagonist; effective in migraine + CINV; risk of EPS / akathisia / sedation; pair with diphenhydramine)
5. pyridoxine + doxylamine (pregnancy) Pyridoxine 10-25 mg PO q6-8h + doxylamine 12.5 mg PO at bedtime (and additional 12.5 mg morning/afternoon PRN) PO q6-8h — NVP (nausea/vomiting of pregnancy) — first-trimester first-line (RCOG NVP PMID 25584725 / SOM Canada 2016 PMID 28209253 — first-line; pregnancy category A; over-the-counter combo Diclegis)
6. hydrocortisone IV (adrenal crisis) 100 mg IV bolus then 50 mg IV q6h × 24 h then taper IV q6h — Suspected adrenal crisis (vomiting + hypotension + steroid history + hyperK + hypoNa) (Empiric stress-dose steroid; do NOT wait for cortisol level if clinically suspected; route to endo.adrenal-crisis.core.v1)
7. regular insulin IV + dextrose (DKA/HHS) Regular insulin 0.1 U/kg IV bolus then 0.1 U/kg/h infusion (or 0.14 U/kg/h without bolus); add D5/D10 when glucose <250 IV continuous — DKA OR HHS with glucose >250 + ketosis/hyperosm (ADA 2026 — hold insulin until K ≥3.3; correct K + fluids first; route to endo.dka.core.v1 OR endo.hhs.core.v1)
8. KCl IV (vomiting alkalosis hypokalemia) 10 mEq IV q1h via central or peripheral (max 40 mEq/L peripheral) titrate to K 4.0-4.5 IV q1-4h — Vomiting hypokalemic alkalosis OR DKA/HHS hypokalemia + before/with insulin (Vomiting causes Cl/H+ loss → contraction alkalosis + secondary hypokalemia; replete aggressively; ECG monitor)
9. IV PPI (UGIB / Boerhaave) Pantoprazole 80 mg IV bolus then 8 mg/h infusion × 72 h IV continuous — UGIB / Boerhaave / Mallory-Weiss with active bleeding (PPI reduces rebleed after EGD; route to gi.ugib.core.v1 OR variceal-bleed engine)
10. sumatriptan SC or IV metoclopramide (migraine) Sumatriptan 6 mg SC OR metoclopramide 10 mg IV ± dihydroergotamine 1 mg IV (avoid in CAD/HTN/pregnancy) SC/IV once — Migraine with vomiting (after antiemetic) (AHS guidelines — IV metoclopramide first-line ED migraine; sumatriptan if no triptan in last 24 h; route to neuro.migraine.core.v1)
11. aprepitant + ondansetron + dexamethasone (CINV) Aprepitant 125 mg PO day 1 then 80 mg PO days 2-3 + ondansetron 8 mg PO/IV + dexamethasone 12 mg PO/IV day 1 then 8 mg days 2-4 PO/IV daily — Highly emetogenic chemotherapy (cisplatin, anthracycline) (ASCO antiemetic guideline — triple-agent prophylaxis for HEC; olanzapine 5-10 mg PO daily quad for refractory)
12. capsaicin topical + cessation (CHS) Capsaicin 0.025-0.075% cream applied to abdomen q4-6h; cannabis cessation counseling topical q4-6h PRN — Cannabinoid hyperemesis syndrome (chronic daily cannabis + cyclic vomiting + hot-water bathing relief) (Habboushe 2018 PMID 25965476 — capsaicin TRPV1 agonist replicates hot-shower effect; haloperidol 5 mg IV as second-line; ondansetron often ineffective; only definitive cure is cessation)

Non-pharmacologic actions:
- Two IV access points; NG tube for SBO (decompression) or massive vomiting
- NPO if surgical abdomen, severe pancreatitis, anticipating procedure
- Foley if shock / severe pancreatitis / I/O tracking
- Aspiration precautions; HOB elevated; rapid sequence intubation if airway concern
- Surgical consult: appendicitis, complicated cholecystitis, perforation, strangulated SBO, mesenteric ischemia
- OB consult: pregnancy + abdominal pain, hyperemesis with electrolyte derangement, ectopic
- Endocrinology consult: DKA/HHS, adrenal crisis
- Telemetry if atypical ACS, electrolyte derangement, ondansetron with QTc concerns

Monitoring

Setting (ed) monitoring:
- Vitals q1h × 4 then q4h once stable
- I/O hourly until stable; UOP target ≥0.5 mL/kg/h
- BMP q4-6h while vomiting (K, Na, HCO3, BUN, Cr)
- Glucose q1h in DKA until <250 then q2h
- Anion gap + ketones (DKA closure: AG normalized + HCO3 ≥18 + glucose <200)
- Lipase trend q12-24h in pancreatitis
- Repeat ECG with K shifts; QTc pre/post-ondansetron
- Serial abdominal exam q2-4h in surgical phenotype
- Fetal monitoring if pregnant + GA ≥20 weeks
- CXR if aspiration concern develops
- Daily weight if hyperemesis / persistent

Follow-up plan: Outpatient GI for cyclic vomiting / functional / gastroparesis / IBS overlay; OB for hyperemesis; endocrine for adrenal insufficiency / chronic DM; cardiology for atypical ACS post-cath; neurology for migraine prevention; addiction support for CHS / opioids; chemotherapy team for CINV optimization
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Vitals q1-4h, I/O, K/Na/BUN/Cr q4-6h while vomiting; glucose q1h in DKA; lipase trend in pancreatitis; ECG monitoring if ondansetron + electrolyte derangement (QTc); fetal monitoring if pregnant; serial abdominal exam in surgical phenotype

Disposition

Current setting: ed — Pattern-anchored triage (isolated vs surgical abdomen vs metabolic vs neuro vs pregnancy vs cardiac atypical vs drug-induced vs functional); rule out surgical abdomen (SBO, appendicitis, pancreatitis, cholecystitis, mesenteric ischemia, perforation), DKA/HHS, adrenal crisis, raised ICP/ICH, atypical ACS, ectopic pregnancy, UGIB; activate downstream engine (Quigley ACG 2013 PMID 29407306; Tenner ACG 2013 PMID 23589549; RCOG NVP 2016 PMID 25584725; SOM Canada 2016 PMID 28209253; Habboushe 2018 PMID 25965476; PMID 24698526 CT workup)

Disposition criteria:
- Discharge: viral gastroenteritis tolerating PO + stable vitals + adequate PO hydration + reliable follow-up; first-trimester NVP managed at home with pyridoxine + doxylamine; resolved migraine; mild functional dyspepsia
- Observation: persistent vomiting with mild dehydration; cyclic vomiting episode resolving; CHS during cannabis cessation
- Ward: SBO non-operative trial + NG; mild-moderate pancreatitis; cholecystitis pre-op; hyperemesis gravidarum with electrolyte derangement; DKA closure + downgrade; adrenal crisis stabilized
- Telemetry / step-down: atypical ACS, severe DKA after closure, severe HHS, intractable migraine on IV meds
- ICU: shock (septic, hemorrhagic, adrenal, ACS), severe pancreatitis with organ failure, mesenteric ischemia post-op, severe HHS with AMS, severe DKA with cerebral edema (peds)
- OR: appendicitis, complicated cholecystitis, perforation, strangulated/closed-loop SBO, ectopic rupture, mesenteric ischemia

Escalation triggers (move to higher acuity):
- Hypotension (SBP <90) + vomiting → resuscitation + sepsis bundle + consider adrenal crisis (hydrocortisone empirically) + mesenteric ischemia + UGIB
- Peritoneal signs (rebound, guarding, rigidity) → STAT surgery consult + CT + broad antibiotics
- Vomiting + projectile/papilledema/focal neuro → STAT NCCT + neurosurgery
- Vomiting + hyperglycemia + acidosis → DKA protocol → endo.dka.core.v1
- Vomiting + severe hyperglycemia + AMS WITHOUT acidosis → HHS → endo.hhs.core.v1
- Vomiting + hypotension + hyperK + hypoNa + steroid history → adrenal crisis → hydrocortisone 100 mg IV empiric → endo.adrenal-crisis.core.v1
- Vomiting + chest symptoms + diabetic/elderly/female → ECG + troponin + HEART → cardio.nstemi.core.v1 / cardio.stemi.core.v1
- Vomiting + RLQ pain + leukocytosis → CT or US → gi.acute-appendicitis.core.v1
- Vomiting + epigastric pain + lipase >3× ULN → fluids + pain control + severity score → gi.acute-pancreatitis.core.v1
- Vomiting + RUQ pain + Murphy + US thickening → gi.acute-cholecystitis.core.v1
- Vomiting + distension + obstipation + prior surgery → NG decompression + CT + surgery consult → gi.small-bowel-obstruction.core.v1
- Vomiting + pregnancy + dehydration + ketosis + >5% weight loss → admit IV fluids + thiamine + pyridoxine/doxylamine + ondansetron → ob route
- Hematemesis / coffee-ground emesis → UGIB → PPI + EGD → gi.ugib.core.v1
- Vomiting + hypotension + abdominal pain + lactate ≥4 in elderly vasculopath → mesenteric ischemia → STAT CT angiography + vascular surgery

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Vomiting + peritoneal signs (rebound, guarding, rigidity) OR free air on imaging — surgical abdomen / perforation; STAT surgery consult + broad antibiotics + CT + OR
- [LIFE_THREATENING] Vomiting + distension + obstipation + prior surgery + CT with transition point ± closed-loop / strangulation signs — SBO; NG decompression + fluids + antibiotics + surgery consult (strangulation = STAT OR)
- [LIFE_THREATENING] Vomiting + glucose >250 + anion gap + ketosis + pH <7.3 OR HCO3 <15 — DKA; insulin infusion + K replacement + IV fluids (route endo.dka.core.v1)

Citations

- 2013 Quigley ACG nausea/vomiting + 2013 Tenner ACG acute pancreatitis + 2016 RCOG NVP guideline + 2016 SOM Canada NVP + 2018 Habboushe cannabinoid hyperemesis + 2018 Tokyo cholecystitis + 2024 IDSA appendicitis antibiotic-only (CODA) + 2026 ADA DKA/HHS + AHS migraine + ASCO CINV [PMID:26411330](https://pubmed.ncbi.nlm.nih.gov/26411330/)
- Cited evidence (PMID 36755492) [PMID:36755492](https://pubmed.ncbi.nlm.nih.gov/36755492/)

Last reconciled with current guidelines: 2026-05-30.
References
  • 2013 Quigley ACG nausea/vomiting + 2013 Tenner ACG acute pancreatitis + 2016 RCOG NVP guideline + 2016 SOM Canada NVP + 2018 Habboushe cannabinoid hyperemesis + 2018 Tokyo cholecystitis + 2024 IDSA appendicitis antibiotic-only (CODA) + 2026 ADA DKA/HHS + AHS migraine + ASCO CINV — PMID:26411330
  • Cited evidence (PMID 36755492) — PMID:36755492