Nausea, vomiting and fever

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Chapter 7 Nausea, vomiting and fever

John Hall, Peter Driscoll

Introduction 117
Primary survey 118
Secondary survey 119
Nausea and vomiting 120
Analysis 120
Plan 122
Communication 122
Fever 122
Analysis 123
Plan 124
Communication 125
Nausea, vomiting and fever 125
Subjective and objective 126
Summary 126

Introduction

Nausea, vomiting and fever are extremely common presenting complaints in community emergency medicine. They are often symptoms of a minor, self-limiting illness but can also be an early, or only, marker of an underlying, potentially life-threatening medical condition. Box 7.1 shows the objectives of this chapter.

Box 7.1 Chapter objectives

image Perform a primary survey to identify and treat any life-threatening problem
image Identify key factors in the history and examination (as part of the secondary survey) which will be needed to identify the severity of the underlying condition as well as its possible cause
image To consider a list of differential diagnoses
image To introduce the concept of ‘little sick/big sick’
image Discuss treatment based on likely diagnoses and whether home or hospital management is appropriate
image Consider the need and practicality of follow-up if not admitted

Primary survey

On first contact with the patient an assessment needs to be made as to whether they are primary survey positive. If so the person requires immediate appropriate treatment and rapid transfer to hospital (see Chapter 2).

The primary survey box from Chapter 3 (Chest pain) is repeated here as a refresher and is also slightly expanded to include further important triggers for these symptoms (Box 7.2).

Box 7.2 Primary survey (adult)

If any observations below are present then treat immediately and transfer to hospital:

image Airway obstruction
image Respiratory rate <10 or >29*
image O2 sats <93%
image Pulse <50 or >120*
image Systolic BP < 90 mmHg
image Glasgow coma score (GCS) <12
image Unexplained neurological signs
image Unexplained rash

Since the signs/symptoms discussed in this chapter span the entire age spectrum some of the parameters will need to be age adjusted. Those parameters in Box 7.2 requiring adjustment are asterisked. Table 7.1 sets out an evidence based paediatric adjusted physiological range for these parameters in children who are OK even though they may be distressed or unhappy.1 As such they differ from the values derived from children who are behaving normally. Child blood pressure is notoriously difficult to take and requires special equipment rarely carried outside hospital. It is unlikely to be abnormal unless other, easier to assess, parameters are affected.

Table 7.1 Paediatric physiological values

Age (years) Pulse rate Respiratory rate
<2 90–180 20–50
2–5 80–160 15–40
6–12 70–140 10–30

If the patient is primary survey positive they will require immediate treatment appropriate to their findings (see Chapter 2). According to local guidelines this may include administering IM/IV/IO antibiotics and fluids if bacterial meningitis or meningococcal septicaemia is suspected.

If immediate transfer to hospital is indicated then the airway should be secured if necessary, respiration assisted as appropriate and IV access/fluids gained in transit unless the journey time/distance or the patient’s condition mandates otherwise.

In many ways finding something requiring urgent transfer to hospital makes management relatively easy – it is often not even necessary to make an accurate diagnosis of the underlying condition. In practice, however, the majority of patients seen with the symptoms dealt with in this chapter will not fall into this category and a more detailed assessment will be needed.2

TIP

Before proceeding further with the discussion of the primary survey negative patient’s take the opportunity to re-read Chapters 2 and 6

Secondary survey

The vast majority of patients who show no primary survey positive signs will have relatively minor, self-limiting illnesses. A small minority, however, can rapidly deteriorate and may die. It is therefore essential to take a precise history and perform an adequate examination of all patients with these symptoms/signs.

The concept of ‘little sick/big sick’ is very useful in deciding whether a patient is sufficiently ill to require active intervention or not. Unfortunately it is mainly a concept based on the practitioner’s experience but there are certain features that are helpful.

image Little sick – unwell

image look and sound alright
image behave normally for age/time of day
image ABC and level of consciousness (LOC) within normal range for age
image no obvious warning signs
image been going on for a while
image possibly some improvement

image Big sick – ill

image look and sound ill
image behave abnormally for age/time of day
image ABC/LOC may be outside normal range
image warning signs may be present
image ‘gut instinct’

The above lists seem obvious but things are often not as simple as they appear.

Nausea and vomiting

Nausea is a non-specific term usually referring to feeling unwell for any reason. Its generality makes it an unhelpful diagnostic symptom. Vomiting is more precise and may or may not be associated with nausea. Table 7.2 lists the subjective and objective information that needs to be elicited from the patient presenting with nausea or vomiting.

Table 7.2 Information that needs to be elicited from the patient presenting with nausea or vomiting

Subjective Objective
The symptom

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