Nausea is ubiquitous in EDs. Our reflexive treatment is to pop an ondansetron order in the queue and be done with it. Of course, we are often not actually done, and we have to dose again or escalate treatment, sometimes to effect, sometimes not. Occasionally, we belatedly recognize that the most effective nausea therapy is to imprison the patient's shoes and socks in an airtight bag.
Some researchers have asserted that EDs fail to administer antiemetics appropriately to a significant proportion of patients with nausea and vomiting and are guilty of oligoantiemesis, a shortcoming of patient care akin to oligoanalgesia, the inadequate treatment of pain. (J Emerg Med 2016;50:818.)
The body of evidence, however, would suggest the opposite. Consider a 2015 Cochrane systematic review identifying eight randomized trials of drugs used in the ED to treat nausea and vomiting among adults. It concluded that no definite evidence supports “the superiority of any one drug over any other drug or the superiority of any drug over placebo” for nausea. (Cochrane Database Syst Rev 2015:CD010106; http://bit.ly/2L4MAzM.)
Are we wasting time and rapidly-dissolving tablets on our ED patients, and, if so, are there viable alternatives?
The New Evidence
Does standard ED antiemetic treatment work? The review says the answer is not really, but the evidence doesn't stop there. A multicenter trial of more than 200 adults with nausea from any cause measuring more than 3 on an 11-point verbal rating scale randomized patients to 1.25 mg IV droperidol, 8 mg IV ondansetron, or placebo. All received 1L of normal saline. Most patients (75-80%) in all groups had a clinically meaningful reduction in nausea scores at 30 minutes with similar mean score reductions, but the authors concluded that droperidol and ondansetron were not superior to placebo. (Acad Emerg Med 2018 Oct 11 [Epub ahead of print] doi: 10.1111/acem.13650.)
What about isopropyl alcohol wipes? Aromatherapy inhalation of isopropanol treats nausea, but we don't really know how; putative mechanisms include olfactory distraction and controlled breathing.
Building on literature from the post-operative arena and a small 2016 randomized controlled trial (Ann Emerg Med 2016;68:1; http://bit.ly/2G3qoaD), a single-center RCT randomized more than 120 patients with nausea of more than 2 on an 11-point verbal scale who did not (yet) have IV access to inhaled isopropyl alcohol (one pad, refreshed every 10 minutes as needed) and 4 mg oral ondansetron, inhaled isopropanol, and oral placebo, or inhaled placebo and oral ondansetron. (Ann Emerg Med 2018;72:184.) The mean decrease in the visual analog scale score at 30 minutes in the two isopropanol arms was 30 mm (95% confidence interval 22-37 mm) and 32 mm (95% CI 25-39 mm), respectively. No adverse events were reported, and pain scores also intriguingly decreased! Not surprisingly, adding ondansetron to inhaled isopropyl alcohol added no benefit. Isopropyl alcohol significantly outperformed oral ondansetron in this well-done trial.
The Bedside Trial
This practice-changer trial was simple and cheap. We decided to test this, and gave patients without an abdominal complaint or headache a Webcol alcohol prep. Six of eight consecutive assigned patients were enrolled. One patient had abdominal pain and was on his way to an appendicitis diagnosis; he initially reported no change in symptoms, but several minutes later reported relief. The second patient also had a positive result, but was disappointed that the effect lasted only 10 minutes.
The next patient had post-concussive vertigo and nausea from taking a header at the skate park. The aromatherapy failed him, consistent with existing evidence (or lack thereof) of antiemetics' effectiveness for vertigo. Two other moderately positive results were seen, and a patient with suspected biliary colic reported that it didn't help with the pain. It had, however, helped with her nausea.
Clearly, this case series has more than a few limitations—reporting bias, social desirability bias, small sample size, and lack of a control arm. Nonetheless, the advantages of the therapy—it is quick, cheap, and available without a code to the Pyxis—are sufficient enough for us to keep a stash of wipes in our pockets. In fact, one of us kept a few on hand while flying from Sacramento to Honolulu in case of nausea from turbulence or airline food.?
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