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Emergency Department Protocol

Acute exacerbation of cyclic vomiting in the adult patient

Target: Patients > 16 yrs of age who have already been diagnosed as cyclic vomiting
Ideally, patients will have utilized an Action Plan at home prior to coming to the ED
- Emesis > 4/hour for MORE than 1 hour
- Anion gap 15-20, ketonuria, hypoglycemia, and/or lactic acidosis support the diagnosis
ED evaluation:
- History
Important to assess glycemic control at home
Cannabis use is very common in this population, and may be evidence of cannabinoid
hyperemesis syndrome rather than true cyclic vomiting syndrome
- Labwork
CBC, CMP, Mag, Lipase, UA, HCG
If prolonged symptoms, consider serum ketones, lactate
- Imaging
Consider to exclude bowel obstruction if risk factors present (prior abdominal surgeries,
prior confirmed
bowel obstruction, bilious emesis)
Plain films (KUB 2 view) with radiology interpretation. Limit use of CT if possible.
- Consults (emergent)
GI ~ for acute hematemesis
EPS ~ for clear acute emotional triggers/crisis, or if no prior psychiatric care within
Hospitalist ~ if failing abortive/supportive protocol below. Consider hospitalist
consult prior to giving
any parenteral opiates.
Addiction medicine ~ consider if significant substance use/abuse issues, but only if
patient expresses an interest in this consultation (which can be counterproductive otherwise)
- Medications Note: there is very little evidence to support any particular medication or regimen
for management of acute exacerbations of cyclic vomiting. What follows is based on
multispecialty literature review and expert opinion.
Common abortive/support home medications:
- Ketorolac 10mg PO
- Diphenhydramine 50mg PO
- Ondansetron 8mg SL
- Sumatriptan 20mg IN/6mg SQ
- Mirtazapine 30mg PO
Abortive/Supportive treatment in the Emergency Department
1. First Line
- D5 NS at 1.5x maintenance
- Magnesium sulfate 1-2 grams IV
- Ondansetron, up to 16mg single dose (with EKG/cardiac monitor, avoid if QTc > 500 msec)
- Sumatriptan 6mg SQ, may repeat in 1-2 hr (if not already used at home)
- Ketorolac 30mg IV (may give with IV PPI if concern for NSAID gastritis)
- Pantoprazole 40mg IV (if prolonged symptoms prior to presentation, or if giving ketorolac)
- GI cocktail if prolonged symptoms prior to presentation
2. Second Line (due to abuse potential)
- Diphenhydramine 50 mg IV Q8H
- Lorazepam 1-2 mg IV Q1-2H
3. Third Line (due to safety concerns)
- Chlorpromazine 25 mg IV, may repeat in 30 minutes (use with caution in the elderly or
medically complex)
- Droperidol (very limited supply, no therapeutic equivalent) 1.25-2.5 mg IV, may give additional
1.25 mg IV (with EKG/cardiac monitor, avoid if QTc > 500 msec)
- Olanzapine 5 mg IM/SL (with EKG/cardiac monitor, avoid if QTc > 500 msec)
4. Fourth line (recommended against in most circumstances)
- Opiate medications, due to lack of evidence of support in the literature, and high abuse
potential. Consider hospitalist consultation for admission prior to administering
parenteral opiates

Investigational use of ketamine, dexamethasone, metoclopramide have been reported, but

there is insufficient evidence or experience to recommend their use at this time.