Adult ECAT protocol

Diarrhoea and/or vomiting

A7.3 Published: December 2023. Printed on 24 Dec 2024.

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Any person, 16 years and over, presenting with liquid stool and/or vomiting.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

  • Exercise caution in patients presenting with vomiting only.
  • Consider alternate causes, such as sepsis, raised intracranial pressure, infection or gastrointestinal obstruction. Switch protocol if indicated.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

  • Presenting complaint
  • Onset and duration of symptoms
  • Fluid input and output
  • Pain assessment – PQRST
  • Pre-hospital treatment
  • Past admissions
  • Medical and surgical history
  • Current medications
  • Known allergies
  • Current weight
  • Associated events, such as travel, food poisoning or recent sick contacts

Signs and symptoms

  • Dry mucous membranes
  • Thirst
  • Fever
  • Abdominal cramping
  • Concentrated dark urine, anuria
  • Reduced oral intake
  • Nausea
  • Lethargy
  • Weight loss or anorexia

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

  • Over 65 years
  • Diabetes mellitus, consider DKA
  • Recent surgery
  • Post-organ transplant
  • Immunocompromised and/or chemotherapy
  • Pregnancy

Clinical

  • Altered level of consciousness, confusion or agitation
  • Poor perfusion
  • Severe dehydration
  • Severe abdominal pain or tenderness
  • Haematemesis
  • Faecal vomit
  • Green vomit, bile
  • Vomiting without diarrhoea
  • Blood and/or mucous in stool
  • Melaena
  • Absent or high-pitched bowel sounds

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

AssessmentIntervention

General appearance/first impressions

Position of comfort

Airway

AssessmentIntervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

AssessmentIntervention

Respiratory rate and effort

Auscultate chest (breath sounds)

Oxygen saturations (SpO2)

Assist ventilation as clinically indicated

Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93%

Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

AssessmentIntervention

Perfusion (capillary refill, skin warmth and colour)

Pulse

Blood pressure

Cardiac rhythm

Assess circulation

Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern

IVC and/or pathology

Insert IV cannula, if trained and clinically indicated

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present and/or SBP less than 90 mmHg give 250 mL of sodium chloride 0.9% IV/intraosseous bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

AssessmentIntervention
ACVPU

If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength

GCS, pupillary response and limb strength

Obtain baseline and repeat assessment, as clinically indicated

Pain

Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

AssessmentIntervention
Temperature

Measure temperature

Skin inspection, including posterior surfaces

Check and document any abnormalities

Assess for a non-blanching petechial or purpuric rash

Fluids

AssessmentIntervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited Commence fluid balance chart
Nausea and/or vomiting If present, see nausea and/or vomiting section
Gastrointestinal Commence stool chart

Glucose

Assessment Intervention
BGL

Measure BGL

If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria):

  • give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal
  • reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L

If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake:

  • give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access
  • give 10% glucose 200 mL by IV infusion over 15 minutes, once only
  • if delay in IV access, give glucagon 1 mg IM, once only
  • reassess BGL in 15 minutes

If the patient is unconscious or peri-arrest:

  • give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis
  • if delay in IV access, give glucagon 1 mg IM, once only
  • reassess BGL in 15 minutes

Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete dehydration focused assessment.

Complete abdominal focused assessment.

Precautions and notes

  • Most cases are self-limiting and only require encouragement of fluid intake and monitoring of hydration.
  • Isolation, contact precautions and use of personal protective equipment are required.
  • Consider special populations at risk of severe dehydration, e.g. the elderly, those with significant comorbidities or pregnant women.

Interventions and diagnostics

Specific treatment

Mild dehydration

Moderate dehydration or ongoing losses

  • Give antiemetic– see nausea and/or vomiting section.
  • If not tolerating oral fluids, give 250 mL sodium chloride 0.9% IV over 60 minutes. Repeat once. Maximum dose 500 mL.

Analgesia

If pain score 1–6 (mild–moderate), give:

  • paracetamol 1000 mg orally once only
  • and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.


Nausea and/or vomiting

If nausea and/or vomiting is present, give:

  • metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
  • or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
  • or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.


Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.


Pathology

  • Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
  • Moderate to severe dehydration: FBC, UEC, LFT
  • Infective cause suspected: stool culture
  • Temp less than 35ºC or 38.5ºC and over: take two sets of blood cultures from two separate sites
  • Female of childbearing age: urine βHCG. If positive and within the first trimester, send serum βHCG for quantitative analysis

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Drag the table right to view more columns or turn your phone to landscape

Drug Dose Route Frequency

1 mg

IM

Once only

200 mL

IV infusion over 15 minutes

Once only

Glucose 40% gel
(0.4 g/mL)

15 g

Buccal

Repeat after 15 minutes if required

50 mL

Slow IV injection

Once only

Ibuprofen H, R

400 mg

Oral

Pain score 1–10

Once only

Metoclopramide R

Over 20 years:
10 mg

Oral/IV/IM

Once only

Ondansetron

4 mg

Maximum dose 8 mg

Oral/IV/IM

Repeat once if required after 60 minutes

Oral rehydration solution (Hydralyte)

50 mL

Oral

Every 15–30 minutes

Oxygen

2–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

1000 mg

Oral

Pain score 1–10

Once only

5 mg

Oral

Once only

OR

12.5 mg

IV/IM

Once only

Sodium chloride 0.9%

250 mL

Maximum dose 1000 mL

IV/intraosseous

Signs of shock

Bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Sodium chloride 0.9%

250 mL

Maximum dose 500 mL

IV/intraosseous

Moderate dehydration

Infusion

Repeat once after 60 minutes

Medications with contraindications or requiring dose adjustment are marked:

  • H for patients with known hepatic impairment
  • R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

  • Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
  • Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. Cochrane Database Syst Rev. 2015 Sep 28;2015(9): Cd010106. DOI: 10.1002/14651858.CD010106.pub2
  • Longstreth G. Approach to the adult with nausea and vomiting. UpToDate: Wolters Kluwer; 2022 [cited 8 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/approach-to-the-adult-with-nausea-and-vomiting
  • MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
  • NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
  • Therapeutic Guidelines. Rehydration for acute gastroenteritis in adults. Australia: Therapeutic Guidelines Limited; 2022 [cited 8 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/

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Evidence informed

Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.

Collaboration

This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.

Currency Due for review: Jan 2026. Based on a regular review cycle.
Feedback Email ACI-ECIs@health.nsw.gov.au

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/diarrhoea-vomiting

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