Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Vomiting with acute instability
Haematemesis, faeculent vomit, peritonism, severe distension, shock, aspiration, neurological deficit or reduced consciousness may indicate bleeding, obstruction, perforation, sepsis or raised intracranial pressure.
Action: Use ABCDE care, protect the airway, stop unsafe oral intake and medicines, obtain intravenous or subcutaneous access and call urgent medical or surgical help within the agreed ceiling. Treat hypoglycaemia and fluid or electrolyte compromise while providing antiemetic relief that does not delay imaging or definitive treatment.
Synopsis
Identify the dominant nausea mechanism and reversible emergencies, restore a reliable medicine route, choose one mechanism-matched antiemetic with explicit safety checks, and review symptom relief, hydration, nutrition and adverse effects against the person's goals.
First-line history defines nausea versus retching or vomiting, volume and content, relation to food, movement, medicines, bowels, headache and abdominal pain.
Examine hydration, mouth, abdomen, bowel sounds, rectum when indicated, neurology, vestibular signs and current patches, pumps and medicines.
Treat the cause when useful: constipation, obstruction, infection, hypercalcaemia, uraemia, gastric stasis, raised intracranial pressure and medicine toxicity need different interventions.
Key red flags
Colicky pain, distension, constipation or obstipation and faeculent vomiting suggests mechanical bowel obstruction and makes routine prokinetic treatment unsafe in complete obstruction.
Aspiration risk
Drowsiness, bulbar dysfunction, cough failure or active large-volume vomiting threatens airway contamination and requires immediate positioning and support.
Investigation priorities
01
First-line mechanism historyFirst stepFirst line
Link symptoms with meals, bowel function, movement, medicines, headache, pain, treatment and vomiting content and timing.
Management branches
Initial nauseaFormulate mechanism and secure the route
Nausea or vomiting is new, changed or inadequately controlled.
Identify emergency features, assess hydration and aspiration, examine abdomen and neurology and reconcile bowel pattern, medicines and essential oral treatment.
Treat reversible contributors and choose one antiemetic whose receptor and motility action fits the dominant mechanism and organ-function risks.
Key medicines
Metoclopramide for gastric stasisGive 10 mg orally or subcutaneously up to three times daily for a reviewed trial, reducing dose and extending interval in renal impairment according to the BNF and local palliative protocol.
Haloperidol for chemical nauseaStart 500 micrograms to 1.5 mg orally or subcutaneously once daily or as a protocol-defined dose in a frail palliative adult, using the lowest effective total and reducing with hepatic impairment.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE NG31 care of dying adultsIndividual nausea assessment, reversible causes, route and antiemetic selection in the last days.