Chapter 7 Nausea, vomiting and fever
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.
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:
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.
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
Secondary survey
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
