Hyperemesis
Cannabinoid, Gravidarum, CVS etc.
Hyperemesis
Cannabinoid, Gravidarum, CVS etc.
Patient with vomiting syndrome and established cause (early pregnancy, history of poorly controlled DM, heavy THC use)
If new diagnosis / first presentation, CT Abdomen/Pelvis done to rule out obstruction or similar pathology (unless pregnant)
Two rounds of medications given in main ED without durable relief
No significant electrolyte abnormalities that would otherwise exclude the patient (see Hypokalemia ) etc
ECG done in main zone without significant QT prolongation (or other abnormality)
CVS with history of very prolonged admissions
Unstable vital signs
Significant Electrolyte abnormalities
Allergies or intolerances to all non-opiate interventions (also exclusion for inpatient admission as well)
QTc > 500 (options for quick turnaround are limited)
Cardiac monitoring
BMP Q12
Medication
Vitamin Repletion
Folic Acid PO or IV 1 mg on admit and then daily
Thiamine 200 mg PO or IV on admit and then daily
Multivitamin Daily
Anti-Emetic medications
Antiemetics - in my subjective order of preference (Droperidol, Olanzapine, Prochlorperazine, Promethazine, Metoclopramide, Ondansetron)
Adjunct to anti-emetics - Sniffing Isopropol Alcohol Swabs can be effective
IV Fluids
For most D5 1/2 NS @ 150 cc/hr
If already hyperglycemic / brittle diabetic can give LR @ 150 cc / hr
General Symptomatic Management
Capsacin Cream to abdominal wall
Hot Showers PRN
Sympathetic Chain Blockade (If Zeccola is around, can do bilateral T6 Paravertebral block, most effective in True Diabetic Gastroparesis)
Medications NOT to give
Please avoid IV opiate medications. These slow down gastric emptying and are contraindicated. Blame your medical director.
Benzodiazepines similar to opiates, high abuse potential
Disposition
Symptoms improved
Tolerating PO
Most recent BMP without significant electrolyte abnormality
Discharge Meds Recommendations:
Gravidarum - Dicyclomine and B6, Ondansetron
Diabetic Gastroparesis - Metoclopramide 10 mg Q8 limit 24 tabs
CVS and Cannabinoid Hyperemesis - Olanzapine Orally Dissolving 5 mg Q8h PRN
Unstable vital signs or worsening clinical condition
Significant lab or imaging abnormalities
Patient unable to take PO medications
Patient unable to ambulate
Learning Links: