Nausea and vomiting

• Nausea is the sensation that you need to vomit, although it does not always lead to vomiting. Vomiting (emesis) is the involuntary, forceful expulsion of the stomach contents stomach through the mouth (and sometimes the nose)

• There may be accompanying abdominal pain, light-headedness, vertigo, tachycardia, excessive sweating and a dry mouth
• NB: Vertigo requires careful assessment to differentiate central from peripheral causes (the NHS website provides useful guidance on this). Vertigo is not typically managed in an OTC setting

• Systemically unwell or showing signs of dehydration (such as severe sore head, stiff neck, lethargy, confusion, decreased alertness, rapid breathing or pulse, non-blanching rash) or clinical shock. Be mindful of neurological symptoms or other features suggestive of central vertigo (see NHS guidance on vertigo for further information) such as signs of asymmetry on the face suggesting a cerebrovascular event, nystagmus, observe the patient's gait and their ability to stand or sit unaided)
• Children, especially those who have vomited three or more times in the past 24 hours or children under 1 year due to dehydration risks (vomiting in the context of gastroenteritis should only last a day or two so medical advice should be sought beyond this)

• Blood (haematemesis); could be severe gastritis, ulceration/a tear, GI bleed, varices

• Immunocompromised

• Weight loss (particularly a substantial amount, unexplained, or linked to a suspected eating disorder)

• Accompanying abdominal pain and tenderness (suspected appendicitis, cholecystitis, cholelithiasis). Also, vomiting immediately after taking fluids is clearly very concerning in the context of dehydration

• Suspected congenital disorder in neonates/infants (Hirschsprung’s disease, pyloric stenosis)

• Suspected/confirmed pregnancy

• Adverse effect of prescribed medication, overdose, suspected poisoning

• Remember that nausea and vomiting could be due to COVID-19 (see separate COVID-19 entry)

• This will depend on the cause. Nausea and vomiting is common in early pregnancy but might resolve in later stages. Nausea and vomiting associated with motion should resolve soon after the motion ceases. Nausea and vomiting associated with mild uncomplicated food poisoning, excessive alcohol consumption or gastroenteritis should resolve in a few days

Depends on the cause:

• If infectious - ways to limit spread, consider the impact on workplace (care home worker etc.) and reporting food poisoning associated with a public eating place

• Provide a safety net on typical time frames and how patients can recognise the clinical features of dehydration, clinical shock or a serious/life-threatening illness (and what to do if these occur)

• Advise the patient to maintain an adequate fluid intake (hydration is key). NHS gives advice about signs and symptoms of dehydration. Check the product licence prior to recommending oral rehydration therapy to ensure it is appropriate for the individual

• As per the diarrhoea heading, consider the consequences of vomiting in the context of taking medicines (i.e. the consequences of a patient not being able to absorb their medicine)

• Children: see NICE information on gastroenteritis (briefly covered under 'diarrhoea' too)

• Depends on the cause:

• Motion-sickness - use motion (travel) sickness products (match journey length with active ingredient)

• Migraine - use anti-emetics licensed for migraine treatment (Buccastem M, Migraleve Pink)

• Other more general indications - OTC options are limited; see Avomine product details

• Children: see NICE guidance on gastroenteritis (also covered briefly under 'diarrhoea')

• Pregnancy - best to involve the patient’s doctor in the management of nausea and vomiting in pregnancy