Initial management of the acutely ill, vomiting patient is the same, regardless of cause. The ABCs always take precedence. For patients with circulatory collapse secondary to severe dehydration, aggressive volume repletion must begin immediately upon arrival. Two large-bore intravenous catheters should be placed, and crystalloid should be administered aggressively in order to restore circulation quickly.
For patients with less acute conditions, treatment hinges on making the correct diagnosis. A vomiting patient with diabetic ketoacidosis will not respond to symptomatic therapy with antiemetics: vomiting continues until the underlying illness is treated. It is important, therefore, to recognize the illnesses that are not self-limited and to treat them appropriately. However, not all patients with the chief complaint of vomiting are discharged from the emergency department with a clear diagnosis. These patients should be treated symptomatically, and follow-up should be ensured. For patients with mild-to-moderate dehydration who are actively vomiting, we recommend intravenous rehydration and antiemetic therapy in the form of prochlorperazine [Compazine 10 mg IV or IM q8h or 25 mg rectally q12h] or promethazine (Phenergan 25 mg IM, IV, or rectally q6h). Physicians may prescribe the suppository form of these for the patient to use should vomiting continue at home.
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