Nausea and vomiting

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Nausea and vomiting
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intro

• Primary GI bowel obstruction, gastroenteritis
• CNS - increased intracranial pressure, tumor
• psychiatric conditions - bulimia nervosa, anxiety
• endocrine or metabolic abnormalities - diabetic
  ketoacidosis, hyponatremia
• iatrogenic causes - medications, toxins
• MCC is US viral gastroenteritis

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pathophys

• Coordinated in medulla oblongata
• Chemoreceptive trigger zone in fourth ventricle
• Also a vagal afferent pathway
• Nausea, retching, emesis

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Clinical features

• History
• Timing
• Severity
• Prior surgeries
• Physical exam

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Diagnostic tests

• Labs
• Cbc
• Cmp
• Lipase
• UA
• Drug levels in overdose
• Imaging
• AXR
• CT
• US

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Medication Class Route Common Side Effects Comments
Antihistamines PO Drowsiness Also show efficacy in prevention of motion sickness.
Diphenhydramine (Benadryl) IV Drowsiness Use in migraines and vertigo, which are vestibular in origin.
Meclizine (Antivert) IM Drowsiness Use in migraines and vertigo, which are vestibular in origin.
Dimenhydrinate (Dramamine) Drowsiness Use in migraines and vertigo, which are vestibular in origin.
Benzodiazepines PO Sedation Adjunct for chemotherapy-induced nausea and vomiting.
Alprazolam (Xanax) IV Sedation Adjunct for chemotherapy-induced nausea and vomiting.
Diazepam (Valium) IM Sedation Adjunct for chemotherapy-induced nausea and vomiting.
Lorazepam (Ativan) PR (diazepam) Sedation Adjunct for chemotherapy-induced nausea and vomiting.
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Butyrophenones PO Agitation, restlessness, sedation Treatment of acute chemotherapy-induced symptoms.
Haloperidol (Haldol) IM Agitation, restlessness, sedation Treatment of acute chemotherapy-induced symptoms.
Corticosteroids PO Insomnia Used as an adjunct in severe cases of chemotherapy-induced nausea and vomiting, reduces prostaglandin formation.
Dexamethasone IV Insomnia Used as an adjunct in severe cases of chemotherapy-induced nausea and vomiting, reduces prostaglandin formation.
Dexamethasone IM Insomnia Used as an adjunct in severe cases of chemotherapy-induced nausea and vomiting, reduces prostaglandin formation.
Serotonin antagonist PO Constipation, dizziness Well tolerated, uncommon side effects include headache, rare case report of anaphylaxis.
Ondansetron (Zofran) IV Constipation, dizziness Well tolerated, uncommon side effects include headache, rare case report of anaphylaxis.
Granisetron (Kytril) IM Constipation, dizziness Well tolerated, uncommon side effects include headache, rare case report of anaphylaxis.
Dolasetron (Anzemet) Constipation, dizziness Well tolerated, uncommon side effects include headache, rare case report of anaphylaxis.
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Phenothiazines PO Extrapyramidal symptoms, sedation, orthostatic hypotension Treatment in migraines, vertigo and motion sickness, rare side effects include neuroleptic malignant syndrome, blood dyscrasias, and cholestatic jaundice.
Prochlorperazine (Compazine) IV Extrapyramidal symptoms, sedation, orthostatic hypotension Treatment in migraines, vertigo and motion sickness, rare side effects include neuroleptic malignant syndrome, blood dyscrasias, and cholestatic jaundice.
Promethazine (Phenergan) IM Extrapyramidal symptoms, sedation, orthostatic hypotension Treatment in migraines, vertigo and motion sickness, rare side effects include neuroleptic malignant syndrome, blood dyscrasias, and cholestatic jaundice.
Promethazine (Phenergan) PR Extrapyramidal symptoms, sedation, orthostatic hypotension Treatment in migraines, vertigo and motion sickness, rare side effects include neuroleptic malignant syndrome, blood dyscrasias, and cholestatic jaundice.
Benzamides PO Extrapyramidal symptoms, hyperprolactinemia Used in treatment of gastroparesis and children with reflux.
Metoclopramide (Reglan) IV Extrapyramidal symptoms, hyperprolactinemia Used in treatment of gastroparesis and children with reflux.
Trimethobenzamide (Tigan) IM Extrapyramidal symptoms, hyperprolactinemia Used in treatment of gastroparesis and children with reflux.
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references

• Tintinalli, ch 75