Literature Review: Ondansetron for Nausea & Vomiting

   Salvucci AA, Squire B, Burdick M, et al. Ondansetron is safe and effective for prehospital treatment of nausea and vomiting by paramedics. Prehosp Emerg Care 15(1): 34-8, Jan 2011.

Abstract

   Methods--Patients with severe nausea or intractable vomiting who were transported by paramedic-staffed ambulances in eight California counties were treated with intravenous (IV), intramuscular (IM) or oral dissolving tablet (ODT) administration of ondansetron. Data was collected prospectively for a six-month period using an online database. Prospectively defined outcome measures were 1) efficacy as measured by a quantitative visual analog nausea scale and 2) incidence of adverse effects. There were no control or placebo groups.

   Results--Data was collected for 2,072 patients, but one patient did not receive the medication. Therefore, ondansetron was administered to 2,071 patients (3.7% of transported patients). Most patients were adult, with only 66 patients less than 18 years old. Of the 2,071 patients, 1,320 (64%) received IV administration, 77 (4%) received IM administration, and 674 (33%) received ODT administration of ondansetron. Intravenous administration resulted in the largest improvements in nausea scores (mean 4.4; 95% confidence interval, 4.2-4.5), followed by IM (mean 3.6; 95% CI, 3.0-4.3) and ODT (mean 3.3; 95% CI, 3.1-3.5). Overall, the mean decrease in nausea score was 4.0 (95% CI, 3.9-4.1; p < 0.001) on a 10-point scale. After medication administration, four patients had mild hypotension, one had hypertension, two had itching or rash, and one had a brief episode of supraventricular tachycardia that resolved spontaneously.

   Conclusions--Ondansetron is safe and effective for out-of-hospital treatment of nausea and vomiting when administered by paramedics via the IV, IM or oral route. When available to paramedics, ondansetron is used frequently.

Comment

   This is a report on a multicounty project in California. Nausea and vomiting are common patient complaints in emergency medical services systems, both prehospital and during interfacility transfers. Nausea is often a significant concern, and many patients consider it to be a more uncomfortable symptom than pain.

   Ondansetron (Zofran) was approved almost 20 years ago and is well known as a highly effective medication for nausea and vomiting. Because of its past expense (greater than $100/dose), for many years it was only used for patients undergoing cancer chemotherapy or after certain surgical procedures. As the cost dropped (now under a $1 a dose) and with more clinical experience, it is now used in many hospital and outpatient settings.

   This study shows it is safe, effective, frequently indicated, substantially improves patient care and, for the goal of reducing suffering, is likely our most important medication. It has been widely adopted throughout California and EMS systems that haven't added it should consider doing so.

   Angelo Salvucci, Jr., MD, FACEP, is medical director for the Santa Barbara County and Ventura County (CA) EMS agencies and a member of EMS World Magazine's editorial advisory board.