Background About Vomiting

Your triage nurse complains of numerous patients in the waiting room complaining of nausea, retching, and emesis. They ask you “why can’t we have an antiemetic on hand in triage?” Turns out they might have had an effective antiemetic on hand, or rather in their scrub pocket the entire time. They just didn’t know about it yet.

Nausea and vomiting are two of the most common presenting symptoms in the emergency department (ED) and has led to ondansetron being the most documented medication given to ED patients in the United States.1 Emetogenic events transpire from neurotransmission activation of the medulla due to feedback received from the chemoreceptor trigger zone, vagal afferent nerves, cerebral cortex, and/or vestibular apparatus.1,2 Current antiemetic treatment most commonly ordered is ondansetron, promethazine, metoclopramide, and prochlorperazine.3 Droperidol is sorely missed in the United States, as it has been shown to be one of the most efficacious antiemetic treatments in the ED, if you are okay with the akathisia apects.4 Despite ondansetron’s incredibly common use in the ED, the onset of effect (50% decrease in nausea severity) for the intravenous formulation is about 30 minutes.5,6 Futhermore, ondansetron was recently compared to placebo in a randomized controlled trial of ED patients and found no difference in nausea severity at 30 minutes.7

Trick of the Trade: Isopropyl Alcohol Vapor Inhalation

Initially brought to the medical community’s attention as a South American folk remedy for nausea, the use of isopropyl alcohol has been well studied in the anesthesia literature and shown positive results in decreasing nausea severity by more than 50% in a much faster time than ondansetron, promethazine, and placebo.5,6,8,9 The majority of these studies found less than 10 minutes were needed for this reduction and there was no statistical difference in rescue therapy requirements. Additionally, an observational study found that transporters were able to provide relief in 84% of their patients that experienced nausea during transit with isopropyl alcohol.10 Even a 2012 Cochrane Review concluded that isopropyl alcohol was effective in reducing the need for rescue antiemetics.11 The only pediatric study available had positive results, but concluded that the treatment was too noxious for this patient population.12

Newest study

Most recently a randomized, double-blinded, placebo-controlled trial by Beadle et al. was performed in an ED population complaining of nausea and/or emesis comparing saline versus isopropyl alcohol inhalation.13 This study found that isopropyl alcohol provided significantly greater relief from nausea in the first 10 minutes of aromatherapy compared to saline (p <0.001) and is the first to look specifically at the ED patient population.

The mechanism of action is not certain, but theorized that isopropyl alcohol influences neurotransmission at several sites that activate the chemoreceptor trigger zone.9

Simple Technique

Three nasal inhalations every 15 minutes and may repeat twice

Conclusion

Isopropyl alcohol has no reported adverse reactions in the adult population as an inhaled vapor

Extremely cheap and readily available

Potential for additional time to diagnose and treat underlying cause prior to using additional antiemetic therapy and/or give the antiemetic time to work

Potential to increase patient satisfaction with “immediate” treatment

Image used with written permission from Medline Industries, Inc.

1. N Engl J Med. 2005;352(8):817-825. PubMed] Krakauer E, Zhu A, Bounds B, Sahani D, McDonald K, Brachtel E. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 6-2005. A 58-year-old man with esophageal cancer and nausea, vomiting, and intractable hiccups.. 2005;352(8):817-825. 2. Clin Interv Aging. 2011;6:243-259. PubMed] Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review.. 2011;6:243-259. 3. Am J Emerg Med. 2014;32(1):89-92. PubMed] Barlow-Savko E, Forehand B, Carlson J. Antiemetic use in US EDs.. 2014;32(1):89-92. 4. Am J Emerg Med. 2006;24(2):177-182. PubMed] Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents.. 2006;24(2):177-182. 5. AANA J. 2003;71(2):127-132. PubMed] Winston A, Rinehart R, Riley G, Vacchiano C, Pellegrini J. Comparison of inhaled isopropyl alcohol and intravenous ondansetron for treatment of postoperative nausea.. 2003;71(2):127-132. 6. AANA J. 2007;75(1):21-26. PubMed] Cotton J, Rowell L, Hood R, Pellegrini J. A comparative analysis of isopropyl alcohol and ondansetron in the treatment of postoperative nausea and vomiting from the hospital setting to the home.. 2007;75(1):21-26. 7. Ann Emerg Med. 2014;64(5):526-532.e1. PubMed] Egerton-Warburton D, Meek R, Mee M, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo.. 2014;64(5):526-532.e1. 8. Nurs Res. 2002;51(2):125-128. PubMed] Merritt B, Okyere C, Jasinski D. Isopropyl alcohol inhalation: alternative treatment of postoperative nausea and vomiting.. 2002;51(2):125-128. 9. AANA J. 2009;77(4):293-299. PubMed] Pellegrini J, DeLoge J, Bennett J, Kelly J. Comparison of inhalation of isopropyl alcohol vs promethazine in the treatment of postoperative nausea and vomiting (PONV) in patients identified as at high risk for developing PONV.. 2009;77(4):293-299. 10. Anesth Analg. 1998;87(5):1214. PubMed] Smiler B, Srock M. Isopropyl alcohol for transport-related nausea.. 1998;87(5):1214. 11. Cochrane Database Syst Rev. 2012;(4):CD007598. PubMed] Hines S, Steels E, Chang A, Gibbons K. Aromatherapy for treatment of postoperative nausea and vomiting.. 2012;(4):CD007598. 12. J Clin Anesth. 1999;11(3):231-234. PubMed] Wang S, Hofstadter M, Kain Z. An alternative method to alleviate postoperative nausea and vomiting in children.. 1999;11(3):231-234. 13. Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015; doi: http://dx.doi.org/10.1016/j.annemergmed.2015.09.031

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Latest Posts Mark Culver, PharmD, BCPS Emergency Medicine Pharmacist

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Clinical Instructor - Pharmacy Practice & Science @EMcritRX EM/Critical Care Pharmacist. Level 1 Trauma Center. Views are my own. Latest posts by Mark Culver, PharmD, BCPS see all)