Vomiting (emesis) is a common yet complex symptom that can indicate anything from benign gastroenteritis to life-threatening emergencies such as bowel obstruction, increased intracranial pressure, or diabetic ketoacidosis.
Your uploaded chart organizes vomiting into:
- Red flags
- Immediate bedside tests
- Abdominal causes
- Head and neurological causes
- Metabolic, infectious, and toxic causes
- Pregnancy-related causes
- High-yield pearls and documentation tips
This article translates the chart into a clear, academically structured guide.
Red Flags in Vomiting
These symptoms strongly suggest a dangerous underlying cause:
Red Flags
- Bloody or coffee-ground emesis
- Bilious vomiting
- Inability to tolerate oral intake
- Severe dehydration
- Headache
- Abdominal pain
- Vertigo
- Toxic ingestion
- Altered mental status
- Risk of aspiration
Red flags warrant urgent evaluation and often imaging or labs.
#1 Step: Immediate Fingerstick Glucose + Urine Pregnancy Test
The chart emphasizes:
“#1 Immediate fingerstick/UPreg”
Why?
- Hypoglycemia → mimic AMS, seizures, vomiting
- Pregnancy → hyperemesis gravidarum or ectopic pregnancy
Testing glucose and pregnancy status avoids critical misses.
Major Causes of Vomiting (Chart Breakdown)
The chart divides causes into Abdominal, Head, and Other categories.
A. Abdominal Causes
1. Small Bowel Obstruction (SBO)
History/Exam:
- Surgical history
- Decreased bowel movements or gas
- Abdominal distention
Workup:
CT abdomen (KUB rarely helpful)Treatment:
- NG tube
- Surgery consult
2. Other Abdominal Emergencies
Includes:
- Gastroenteritis
- Appendicitis
- Gallbladder disease
- Pancreatitis
- Peptic ulcer disease
- Perforated viscus
Workup:
- Clinical evaluation
- CT abdomen if needed
Treatment:
Based on specific diagnosis(Chart reference: See Abdominal Pain, p. 20)
B. Head-Related Causes
1. Increased Intracranial Pressure (ICP)
History/Exam:
- Headache
- Hypertension
- Focal neurological deficits
- Vision changes
Workup:
- CT head
- Lumbar puncture if safe
Treatment:
Neurosurgery consult2. Meningitis
History/Exam:
- Fever
- Neck stiffness
- Photophobia
Workup:
CT → then lumbar puncture, if indicatedTreatment:
- IV antibiotics
- Steroids
- Isolation
3. Vertigo (Vestibular causes)
History/Exam:
Spinning sensationWorkup:
Follow vertigo pathway (see Dizziness chart)Treatment:
Based on the cause (BPPV, vestibular neuritis, etc.)C. Other Causes (Metabolic, Cardiac, Endocrine, Infectious)
1. Abnormal Electrolytes
Vomiting can cause or result from electrolyte abnormalities.
Workup:
- BMP
- LFTs
Treatment:
Correct the specific abnormality2. ACS / MI
Vomiting can be a presenting symptom of myocardial infarction.
History:
- Chest pain
- SOB
Workup:
- EKG
- Troponins
Treatment:
Follow ACS protocol (see Chest Pain chart)3. Acute Gastroenteritis
History:
- Diarrhea
- No focal tenderness
- Sick contacts
Workup:
ClinicalTreatment:
- IV fluids
- Antiemetics
- Consider antibiotics if traveler’s diarrhea
4. DKA (Diabetic Ketoacidosis)
History:
- Vomiting
- AMS
- Known diabetes
Workup:
- Fingerstick glucose
- Urine dip
- Serum ketones
- Anion gap
- pH
Treatment:
- IV fluids
- Insulin
- Potassium
- ICU if severe
5. Alcohol (EtOH) or Toxin Ingestion
History:
- Alcohol use
- Poisoning risk
Workup:
Ketones (if alcoholic ketoacidosis → AKA)Treatment:
- D5 normal saline
- IV fluids
(Chart references: See Intoxication, p. 12)
6. Hyperemesis Gravidarum
History:
- Pregnancy
- Severe nausea/vomiting
- Weight loss
Workup:
- Urine pregnancy
- Ketones
Treatment:
- Antiemetics
- IV fluids
- Dextrose solutions
7. Post-Tussive Vomiting
Cause:
Intense coughing spellsWorkup:
Consider pertussis testingTreatment:
Treat underlying coughPearls & Pitfalls
- Rebound tenderness or rigid abdomen = surgical emergency
- Avoid metoclopramide if SBO suspected (use ondansetron instead)
- Inability to tolerate PO = cannot go home
- Diarrhea is reassuring, provided it’s not just soft stool
- Always obtain UPreg in females of childbearing age
- Consider dehydration and electrolyte abnormalities early
- If patient vomits blood or bile → urgent evaluation
Documentation Essentials
General
- Duration and frequency
- Bilious or non-bilious
- Bloody vs. non-bloody
- Tolerance of PO
- Travel history
- No new medications
- Mucous membranes moist vs. dry
HEENT
- No signs of head trauma
- Normal neurological exam
Abdominal Exam
- Soft, non-distended
- No tenderness
- No peritoneal signs
Reassessment
- Ability to tolerate PO
- Resolution of nausea
- Stability for discharge
High-Yield Clinical Summary Table
| Category | Condition | Key Clues | Workup | Treatment |
|---|---|---|---|---|
| Abdominal | SBO | No flatus, distention | CT | NG tube + surgery |
| Pancreatitis, PUD, gallbladder | Pain + vomiting | CT/US | Based on diagnosis | |
| Head | ICP ↑ | HA + neuro deficits | CT/LP | Neurosurgery |
| Meningitis | Fever, photophobia | CT/LP | ABx + steroids | |
| Other | DKA | AMS, DM | FS, ketones | IVFs, insulin |
| Gastroenteritis | Diarrhea | Clinical | Fluids, antiemetics | |
| ACS/MI | Chest pain | ECG + troponins | ACS protocol | |
| EtOH/Tox | Alcohol use | Ketones | D5 NS, IVFs | |
| Special | Pregnancy | Hyperemesis | UPreg | D5, antiemetics |
FAQs About Vomiting
1. When is vomiting an emergency?
When accompanied by dehydration, blood, severe abdominal pain, altered mental status, or inability to tolerate oral intake.
2. Why test glucose immediately?
Hypoglycemia can mimic serious neurological problems.
3. When should a CT scan be done?
If obstruction, abdominal emergency, ICP, or meningitis is suspected.
4. How do you know vomiting is due to DKA?
Check for high glucose, ketones, anion gap, and acidosis.
5. When should a patient with vomiting be admitted?
If dehydrated, hypoglycemic, pregnant with hyperemesis, in DKA, or unable to tolerate PO.
