Lecture 8 - Nausea, Vomiting, Diarrhea

Question 1

Drugs that target Cerebral Cortex

Answer 1

H1

Question 2

Drugs that target Vestibular system

Answer 2

Ach-M

H1

Question 3

Drugs that target GI tract

Answer 3

5-HT3,4

Substance P

Question 4

Drugs that target Area Posterna (Chemoreceptor trigger zone)

Answer 4

5-HT3
D2
NK1

Question 5

Complications of Vomiting

Answer 5

** Dehydration
Electrolyte disturbances
Malnutrition
Aspiration
Mallory-Weiss Syndrome = Esophageal tears

Question 6

Self-care vomiting

Answer 6

Goal: ID + resolve underlying cause, prevent or eliminate N/V

Question 7

Non-harm treatment of N/V

Answer 7

Acupuncture
Acupressure wristbands
Breathing and other relaxation techniques
ID and avoidance of potential triggers
Hypnosis
Guided imagery

Question 8

4 common causes of N/V

Answer 8

Viral Gastroenteritis in children
Pregnancy
Motion sickness
Excessvie eating

Question 9

Txm for children dehydration

Answer 9

Pedialyte, Infalyte, Naturalyte

dont use sport drinks, plain water, carbonated Bev
dont use sugar-water or salt-water

Question 10

Mild-moderate dehydration calc

Answer 10

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

Question 11

Severe dehydration treatment

Answer 11

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

Question 12

Algorithm for Txm of children.

Answer 12

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

Question 13

Prevention of Gastroenteritis

Answer 13

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

Question 14

“morning sickness”

Answer 14

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

Question 15

Non-pharm morning sickness treatment

Answer 15

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

Question 16

Pharm morning sickness treatment

Answer 16

OTC: Pyridoxine = B6, antihistamines, ginger
Rx: DA agonist, Diclegis/Bonjesta, Serotonin antagonists

Question 17

DA antagonist SE

Answer 17

Dizziness
drowsiness
anxiety
sleep disturbances
insomnia
strange dreams
urinary retention
dry mouth
movement disorders

Question 18

Diclegis

Answer 18

N/V in preg in women who dont respond to conservative management

Doxylamine 10mg/pyridoxine 10mg DR tab

Question 19

Diclegis Schedule

Answer 19

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)

Question 20

Diclegis SE

Answer 20

somnolence
drowsiness
constipation

Question 21

Bojesta

Answer 21

same as diclegis but its 20mg/20mg ER

Question 22

Bojesta schedule

Answer 22

Initial: 1 tab po at Bedtime

If symptoms persist: 1 tab in morning, 1 tab at bedtime (2 max per day)

Question 23

Ondansetron, Granisetron, Dolasetron MOA

Answer 23

Blocks serotonin on peripheral vagal nerve terminals and centrally on CTZ

Question 24

Ondansetron uses

Answer 24

controversial in pregnancy, due to CV risks, oral cleft/septal defects

Question 25

When to try ondansetron?

Answer 25

after failing 10 agents before 10 weeks of gestation

Question 26

Ondansetron dosing

Answer 26

4mg PO/IV every 8 hrs prn

Question 27

Ondansetron SE

Answer 27

Headache fatigue constipation** drowsiness

Question 28

Ondansetron precautions

Answer 28

Can cause QTc prolongation | Can cause Serotonin syndrome who combined with other serotenergic meds

Question 29

non-pharm motion sickness options

Answer 29

``` 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 ```

Question 30

acupressure wrist bands

Answer 30

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<

Question 31

Reliefband

Answer 31

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

Question 32

Antihistamine for motion sickness ADE

Answer 32

Anticholinergic paradoxical reaction in children = wide awake falls in older adults decrease in milk supply when lactating

Question 33

Meclizine shouldn't be used in....

Answer 33

children < 12

Question 34

Precautions of Antihistamines

Answer 34

``` Respiratory conditions glaucoma BPH seizures CVD ```

Question 35

Scopolamine usage

Answer 35

1 patch every 72hrs prn, > 12 yrs old dont use more than 1 rotate sites

Question 36

CI Scopolamine

Answer 36

Hypersensitivity to scopolamine or belladonna alkaloids, narrow angle glaucoma

Question 37

Scopolamine Precautions

Answer 37

``` Bradycardia CNS effects Idiosyncratic reactions withdrawal effects in pts with Parkinson's disease CVD Tachycardia Glaucoma GI obstruction ```

Question 38

Scopolamine counseling

Answer 38

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

Question 39

Promethazine (rx) info

Answer 39

can be used children > 2 box warning for fatal respiratory depression in children < 2

Question 40

non-pharm treatment for over eating

Answer 40

``` eat small, frequent meals avoid skipping meal avoid fried, fatty food eat more complex carbs limit alc intake, carbonated drinks exercise stress management ```

Question 41

pharm treatments for over eating

Answer 41

Antacids H2RA Bismuth subsalicylate Phosphorated carb solution

Question 42

antacids for nausea

Answer 42

meh

Question 43

antacids special pops?

Answer 43

no children < 12 Most safe for Preg/breast feeding Caution renal impairment older adults

Question 44

H2RA for nausea

Answer 44

help with indigestion, but not much towards nausea dont use OTC children < 12 safe in pregnancy and breast-feeding (famotidine,cimetidine)

Question 45

Bismuth subsalicylate warnings

Answer 45

Reyes syndrome (dont use children/teens recently had Varicella/flu) avoid aspirin allergy No pregnancy, hx of Gastric ulcers

Question 46

Emetrol liquid

Answer 46

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**

Question 47

Emetrol dosing

Answer 47

> 12yrs = 15-30ml PO q15 min until symptoms resolve max 5 doses per hour 2-12 = 5-10ml PO q15min or until symptoms resolve

Question 48

Emetrol way it works

Answer 48

local action on hyperactive GI wall leading to reduction in smooth muscle contraction, delaying gastric emptying time

Question 49

alcohol swap

Answer 49

inhale it low risk easy to do

Question 50

What causes intestinal gas?

Answer 50

1. Anaerobic fermentation of carbs by colonic bacteria 2. Secretion of CO2 in the duodenum has HCO3 3. Aerophagia

Question 51

Signs and symptoms of gas

Answer 51

``` Flatuence belching Dyspepsia Gas pains Nausea Audible bowel sound Bloating ```

Question 52

Exclusions for self-care gas

Answer 52

1. symptoms persist for severe months or more than occasionally 2. severe, debilitating 3. sudden change in location, new onset in > 40rys old 4. accompanied by significant abdominal discomfort 5. accompanied by severe diarrhea, GI bleed, constipation,etc

Question 53

Treatment approach of gas

Answer 53

1. id underlying cause 2. attempt non-pharm options 3. pharm options

Question 54

Non-pharm gas options

Answer 54

1. change eating habits, relaxing and chew thoroughly 2. dietary modifications...FODMAP diet 3. control aerophagia 4. regulate bowel function

Question 55

FODMAP Diet

Answer 55

Eliminate Fermentable foods ``` Fermentable Oligosaccharides Disaccharides Monosaccharides And Polyols ```

Question 56

Simethicone info

Answer 56

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

Question 57

Simethicone efficacy

Answer 57

questionable in pediatrics OK in pregnancy or breastfeeding

Question 58

Activated charcoal for gas

Answer 58

AE: bad tase, black stool, diarrhea, vomiting, aspiration Off-label for gas CI in GI perforation, obstruction, recent surgery

Question 59

Alpha-Galactosidase for gas

Answer 59

Hydrolyzes polysaccharides and oligosaccharides into simple sugars for prevention of gas caused by high fiber foods minimal ADE

Question 60

Alpha-Galactosidase special pop

Answer 60

``` careful in ppl with galactosemia caution in diabetes pt on AG inhibitiors caution mold allergy not in children < 12 no studies preg/breastfeeding ```

Question 61

Lactose enzymes

Answer 61

breaks down lactose into glucose and galactose to ease absorption Well tolerated, no serious ADE

Question 62

Special populations Lactose enzymes

Answer 62

Avoid pts with galactosemia Safe in children > 4yrs old Safe in pregnancy/breasteeding...1st line is change/elim dairy

Question 63

Picking a product

Answer 63

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