Emergency Department ProtocolAcute exacerbation of cyclic vomiting in the adult patient

Target: Patients > 16 yrs of age who have already been diagnosed as cyclic vomitingIdeally, patients will have utilized an Action Plan at home prior to coming to the ED

Features: - 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 KP- 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 Department1. 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.