Antiemetic therapy for nausea and vomiting in the emergency department

Antiemetic agents are among the most frequently prescribed medications in the emergency department (ED). Nevertheless, there are no widely accepted evidence-based guidelines to optimize the use of these medications for nausea or vomiting in this setting.

The objective of this article is to briefly review the evidence supporting the use of antiemetic agents for the treatment of nausea or vomiting for adults in the ED, and to provide recommendations to help guide therapy.

The antiemetic agents studied include droperidol, promethazine, prochlorperazine, metoclopramide, and ondansetron. Droperidol was commonly used in the past, and is more effective than prochlorperazine or metoclopramide, but due to the US Food and Drug Administration black box warning regarding the potential for QT prolongation with this drug, its use is limited to refractory cases. Promethazine is more sedating than other comparative agents, and also has the potential for vascular damage upon intravenous administration. It may be a suitable option when sedation is desirable. Patients given prochlorperazine or metoclopramide must be monitored for akathisia that can develop at any time over 48 h post administration. Decreasing the infusion rate can reduce the incidence of this adverse effect, and the effect can be treated with intravenous diphenhydramine. Ondansetron is as effective as promethazine, and is not associated with sedation or akathisia.

Based on the safety and efficacy of ondansetron, it may be used as a first-line agent for relief of nausea or vomiting for most patient populations in the ED.