Lecture 8 - Nausea, Vomiting, Diarrhea Flashcards
Drugs that target Cerebral Cortex
H1
Drugs that target Vestibular system
Ach-M
H1
Drugs that target GI tract
5-HT3,4
Substance P
Drugs that target Area Posterna (Chemoreceptor trigger zone)
5-HT3
D2
NK1
Complications of Vomiting
** Dehydration Electrolyte disturbances Malnutrition Aspiration Mallory-Weiss Syndrome = Esophageal tears
Self-care vomiting
Goal: ID + resolve underlying cause, prevent or eliminate N/V
Non-harm treatment of N/V
Acupuncture Acupressure wristbands Breathing and other relaxation techniques ID and avoidance of potential triggers Hypnosis Guided imagery
4 common causes of N/V
Viral Gastroenteritis in children
Pregnancy
Motion sickness
Excessvie eating
Txm for children dehydration
Pedialyte, Infalyte, Naturalyte
dont use sport drinks, plain water, carbonated Bev
dont use sugar-water or salt-water
Mild-moderate dehydration calc
50-100ml/kg over 2-4hrs + additional ORS for ongoing losses (10mL/kg for each stool and 2mL/kg for each emesis episode)
Admin slowly by caregiver at a rate of 5ml every 1-2min
Severe dehydration treatment
Medical emergency
bolus 20-30ml/kg lactated ringer or normal saline over 60min, followed by continuous infusion of 70ml/kg LR or NS over 5hrs ( < 12mnth) or 2.5 hrs ( > 12mnth)
once normalized, rehydration with ORS
Algorithm for Txm of children.
sxs severe dehydration - yes = refer
No = ORS, avoid antiemetics, stop feeding X 1hr..restard feeding with light solids/formula/boob milk as tolerated….restart ORS if vomiting occurs
If dont resolve, Refer to PCP
Prevention of Gastroenteritis
Wash hands
Vaccines
rotarix = 2 dose at 2/4 months
RotaTeq = 3 dose at 2/4/6 month
If RotaTeq or unknown, 3 dose series
“morning sickness”
N/V + missed menstrual cycle = refer to primary care provider
Severe vomiting resulting in hypovolemia + weight loss -> hyperemesis/gravidarum = refer to PCP/OB
~ 90% ppl pregnant
Related to HCG increase
Non-pharm is preferred
Non-pharm morning sickness treatment
Small snack before bed cold, clear,carbonated fluids eat multiple, small meals/snacks slowly rise from bed fresh air avoid greasy eat chilled v hot foods try ginger containing foods
Pharm morning sickness treatment
OTC: Pyridoxine = B6, antihistamines, ginger
Rx: DA agonist, Diclegis/Bonjesta, Serotonin antagonists
DA antagonist SE
Dizziness drowsiness anxiety sleep disturbances insomnia strange dreams urinary retention dry mouth movement disorders
Diclegis
N/V in preg in women who dont respond to conservative management
Doxylamine 10mg/pyridoxine 10mg DR tab
Diclegis Schedule
Initial: 2 tabs PO on empty stomach at bedtime on days 1/2
If symptoms persist: 1 qAM, 2 qHS on day 3
If symptoms persist: 1 qAM, 1 afternoon, 2 qHS on day 4 ( max 4/day)
Diclegis SE
somnolence
drowsiness
constipation
Bojesta
same as diclegis but its 20mg/20mg ER
Bojesta schedule
Initial: 1 tab po at Bedtime
If symptoms persist: 1 tab in morning, 1 tab at bedtime (2 max per day)
Ondansetron, Granisetron, Dolasetron MOA
Blocks serotonin on peripheral vagal nerve terminals and centrally on CTZ
Ondansetron uses
controversial in pregnancy, due to CV risks, oral cleft/septal defects
When to try ondansetron?
after failing 10 agents before 10 weeks of gestation
Ondansetron dosing
4mg PO/IV every 8 hrs prn
Ondansetron SE
Headache
fatigue
constipation**
drowsiness
Ondansetron precautions
Can cause QTc prolongation
Can cause Serotonin syndrome who combined with other serotenergic meds
non-pharm motion sickness options
Sit in a position allowing vision out a window aboard reading during travel keep line of vision straight ahead avoid excess food or alc avoid strong odors acupressure wristbands Reliefband
acupressure wrist bands
stimulation of pericardium 6 located on inner forearm, 3 finger widths from the 1st wrist crease
can use combo with antiemetics and for children 2<
Reliefband
Stimulates P6 acupuncture point by electricity
has 5 power settings, have a Rx and OTC version
SE: Mild, transient rash…avoid latex allergy bc use a gel
Antihistamine for motion sickness ADE
Anticholinergic
paradoxical reaction in children = wide awake
falls in older adults
decrease in milk supply when lactating
Meclizine shouldn’t be used in….
children < 12
Precautions of Antihistamines
Respiratory conditions glaucoma BPH seizures CVD
Scopolamine usage
1 patch every 72hrs prn, > 12 yrs old
dont use more than 1
rotate sites
CI Scopolamine
Hypersensitivity to scopolamine or belladonna alkaloids, narrow angle glaucoma
Scopolamine Precautions
Bradycardia CNS effects Idiosyncratic reactions withdrawal effects in pts with Parkinson's disease CVD Tachycardia Glaucoma GI obstruction
Scopolamine counseling
place patch 4hrs before exposure
press firmly for 30 sec
if need > 3 days, take off and apply new one
wash hands with soap and water after handling
Promethazine (rx) info
can be used children > 2
box warning for fatal respiratory depression in children < 2
non-pharm treatment for over eating
eat small, frequent meals avoid skipping meal avoid fried, fatty food eat more complex carbs limit alc intake, carbonated drinks exercise stress management
pharm treatments for over eating
Antacids
H2RA
Bismuth subsalicylate
Phosphorated carb solution
antacids for nausea
meh
antacids special pops?
no children < 12
Most safe for Preg/breast feeding
Caution renal impairment older adults
H2RA for nausea
help with indigestion, but not much towards nausea
dont use OTC children < 12
safe in pregnancy and breast-feeding (famotidine,cimetidine)
Bismuth subsalicylate warnings
Reyes syndrome (dont use children/teens recently had Varicella/flu)
avoid aspirin allergy
No pregnancy, hx of Gastric ulcers
Emetrol liquid
ADE: abdominal pain, diarrhea
Dosing: only use for 1hr
Dont dilute, drink other liquids after or for 15min after dose
dont use pts w/ diabetes or fructose intolerance
Emetrol dosing
> 12yrs = 15-30ml PO q15 min until symptoms resolve
max 5 doses per hour
2-12 = 5-10ml PO q15min or until symptoms resolve
Emetrol way it works
local action on hyperactive GI wall leading to reduction in smooth muscle contraction, delaying gastric emptying time
alcohol swap
inhale it
low risk
easy to do
What causes intestinal gas?
- Anaerobic fermentation of carbs by colonic bacteria
- Secretion of CO2 in the duodenum has HCO3
- Aerophagia
Signs and symptoms of gas
Flatuence belching Dyspepsia Gas pains Nausea Audible bowel sound Bloating
Exclusions for self-care gas
- symptoms persist for severe months or more than occasionally
- severe, debilitating
- sudden change in location, new onset in > 40rys old
- accompanied by significant abdominal discomfort
- accompanied by severe diarrhea, GI bleed, constipation,etc
Treatment approach of gas
- id underlying cause
- attempt non-pharm options
- pharm options
Non-pharm gas options
- change eating habits, relaxing and chew thoroughly
- dietary modifications…FODMAP diet
- control aerophagia
- regulate bowel function
FODMAP Diet
Eliminate Fermentable foods
Fermentable Oligosaccharides Disaccharides Monosaccharides And Polyols
Simethicone info
MOA: reduces surface tension of gas bubbles, gas bubbles break, increase ease of elimination of gas bubbles
Dose: max 500mg/day
AE: N/V/D, regurgitation
CI: known or suspected intestinal perforation and obstruction
OK to use in children
Simethicone efficacy
questionable in pediatrics
OK in pregnancy or breastfeeding
Activated charcoal for gas
AE: bad tase, black stool, diarrhea, vomiting, aspiration
Off-label for gas
CI in GI perforation, obstruction, recent surgery
Alpha-Galactosidase for gas
Hydrolyzes polysaccharides and oligosaccharides into simple sugars
for prevention of gas caused by high fiber foods
minimal ADE
Alpha-Galactosidase special pop
careful in ppl with galactosemia caution in diabetes pt on AG inhibitiors caution mold allergy not in children < 12 no studies preg/breastfeeding
Lactose enzymes
breaks down lactose into glucose and galactose to ease absorption
Well tolerated, no serious ADE
Special populations Lactose enzymes
Avoid pts with galactosemia
Safe in children > 4yrs old
Safe in pregnancy/breasteeding…1st line is change/elim dairy
Picking a product
Simethicone: IR relief of symptoms, gas not associated w/ certain foods, conditions such as Galactosemia + diabetes
Alpha-galactosidase = prevent gas related to ingestion of fiber
Lactase enzymes = intolerance to dairy
