Nausea and vomiting Flashcards
What are the most common causes of nausea and vomiting?
GI disorders
Other causes include hyperemesis gravidarum, intracranial lesions and infections, myocardial infarction, diabetic ketoacidosis, and drug toxicities.
What syndrome has seen an increased prevalence due to heightened access to marijuana?
Cannabinoid hyperemesis syndrome (CHS)
A study noted a near doubling of presentations for cyclical vomiting associated with marijuana use after legalization in one state.
What are the three phases of vomiting?
Nausea, retching, vomiting
Nausea may occur without retching or vomiting, and retching may occur without vomiting.
What physiological changes occur during the nausea phase?
Increased tone in duodenum and jejunum, decreased gastric tone
This leads to reflux of intestinal contents into the stomach, often with hypersalivation and tachycardia.
What is the definition of retching?
Rhythmic contraction of muscles against a closed glottis without expulsion of gastric contents.
What is the role of the vomiting center located in the medulla?
Coordinates the act of vomiting
Contains muscarinic receptors that trigger the vomiting reflex.
What types of stimuli activate the vomiting center?
- Visceral afferent impulses from the GI tract
- Visceral afferent impulses from outside the GI tract
- Extramedullary CNS afferents
- Chemoreceptor trigger zone (CTZ) impulses
What is the primary neurotransmitter associated with the CTZ in the context of vomiting?
Dopamine D2 and serotonin
The CTZ is rich in these receptors, influencing the vomiting response.
What is a key difference between vomiting and rumination?
Vomiting is forceful expulsion; rumination is non-forceful dribbling of stomach contents.
What is the main diagnostic consideration for acute vomiting?
Acute conditions lasting less than 1 week.
What characterizes chronic vomiting?
Occurs longer than 1 month, often associated with motility disorders or systemic treatments.
What is the pathognomonic sign for gastric outlet obstruction?
Vomiting of material eaten more than 12 hours previously.
What findings may suggest elevated intracranial pressure?
Symptoms occurring primarily in the morning.
What is cyclical vomiting syndrome (CVS)?
Discrete episodes of vomiting with intervening asymptomatic periods.
What is the significance of the patient’s social history in vomiting cases?
It may reveal substance use, which can be a contributing factor.
What diagnostic imaging is preferred for posterior fossa pathologies?
MRI.
What should be performed in all women of childbearing capacity with nausea or vomiting?
Urine or serum pregnancy test.
What is the recommended follow-up for patients with unclear diagnoses but controllable symptoms?
Follow-up arranged within 24 to 48 hours.
What type of patients do not generally require diagnostic testing in the ED for vomiting?
Patients with cyclical or recurrent vomiting syndromes.
What is the role of serum drug levels in the assessment of nausea and vomiting?
To determine the cause in patients on specific medications.
What is Nausea and vomiting of pregnancy (NVP)?
Acute vomiting that may occur in the morning or throughout the day, typically starting in weeks 4–7, peaking in weeks 10–16, and disappearing by week 20.
NVP affects 75% of all pregnancies and is associated with a decreased risk of miscarriage, fetal growth retardation, and fetal mortality.
What are the common signs of Nausea and vomiting of pregnancy (NVP)?
Associated breast tenderness and benign abdomen.
Vomiting that begins after week 12 or continues past week 20 should prompt a search for another cause.
What tests are useful for diagnosing Nausea and vomiting of pregnancy (NVP)?
Urine pregnancy test, serum electrolytes, urine ketones.
These tests help to exclude hyperemesis gravidarum.
What characterizes Hyperemesis gravidarum?
Severe, protracted form of NVP with 5% weight loss, ketonuria, and electrolyte disturbance.
Affects 0.3%–3% of pregnancies and is associated with multiple gestation and molar pregnancy.
What are the common signs of Hyperemesis gravidarum?
Signs of dehydration and benign abdomen.
Studies on fetal outcomes are conflicting, though there may be an association with low fetal birth weight and maternal weight loss.
What tests are useful for diagnosing Hyperemesis gravidarum?
β-hCG, urinalysis for ketones, serum electrolytes, ultrasound examination.
Ultrasound helps exclude molar pregnancy or multiple gestations.
What are common symptoms of Gastroenteritis?
Fever, diarrhea, and crampy abdominal pain, with vomiting occurring early.
Diarrhea usually follows vomiting within 24 hours.
What is a key diagnostic consideration for Gastroenteritis?
Early gastroenteritis may be confused with early appendicitis.
Diarrhea is usually key in diagnosing gastroenteritis.
What are common symptoms of Gastritis?
Epigastric pain, belching, bloating, fullness, heartburn, food intolerance.
Use of NSAIDs or alcohol is common among patients.
What tests may be necessary for Gastritis?
Lipase, LFTs, and pregnancy test.
These tests help exclude other diagnoses.
What is a major cause of Peptic ulcer disease (PUD)?
NSAIDs, Helicobacter pylori infection, and hypersecretory states.
Epigastric pain is present in 90% of cases.
What are common symptoms of Biliary disease?
Abdominal pain may be midepigastric or RUQ, often after a fatty meal.
History of similar episodes may be present.
What tests are useful for diagnosing Biliary disease?
WBCs, Lipase, serum bilirubin, LFTs, RUQ ultrasound examination.
Normal findings suggest biliary colic; fever and Murphy sign suggest cholecystitis.
What are common symptoms of Myocardial infarction (MI)?
Patients typically have substernal chest pain, which may be accompanied by vomiting.
Not all patients with MI have chest pain, especially women and diabetics.
What diagnostic tests are used for Myocardial infarction (MI)?
ECG and troponin tests.
ECG may show new Q waves, ST segment changes, or T wave inversions.
True or False: Hyperemesis gravidarum is a benign condition with no serious implications.
False.
It is a severe form of NVP and can lead to significant complications.
Fill in the blank: The prognosis for mother and infant in cases of Nausea and vomiting of pregnancy (NVP) is _______.
excellent.
NVP is common and usually resolves without complications.
What is diabetic ketoacidosis (DKA)?
A metabolic condition characterized by hyperglycemia and ketone production, often leading to altered mental status and coma.
Commonly associated with uncontrolled diabetes.
What are early symptoms of diabetic ketoacidosis?
Polydipsia and polyuria
These symptoms occur early and indicate high blood glucose levels.
What physical examination findings are common in DKA?
Fruity breath odor, tachypnea, signs of dehydration
Fruity breath results from serum acetone.
What laboratory tests are useful in diagnosing DKA?
Serum glucose, electrolytes, serum beta-hydroxybutyrate, VBG
A fingerstick glucose test is critical in cases of protracted vomiting.
What is the primary presenting symptom of pancreatitis?
Epigastric pain that often radiates to the back
Most cases are caused by gallstones or alcoholism.
What are common physical examination findings in pancreatitis?
Epigastric tenderness, abdominal distention, decreased bowel sounds
Severe cases may present with frank shock.
What laboratory tests are important for pancreatitis?
Lipase, WBC, serum glucose, LDH, AST, hematocrit, BUN, calcium, VBG
Early intravenous hydration is crucial for severe vomiting cases.
What is the classic presentation of appendicitis?
Abdominal pain starting in the periumbilical region and moving to the right lower quadrant
Anorexia is also a common symptom.
What physical examination findings are associated with appendicitis?
Localized tenderness in the right lower quadrant, low-grade fever
Diagnosis can be challenging in early appendicitis.
What diagnostic tests are useful for appendicitis?
WBC count, ultrasound, abdominal CT
Imaging helps confirm the diagnosis.
What symptoms are associated with bowel obstruction?
Abdominal pain, vomiting, obstipation, constipation
Surgical history is often present in patients.
What physical examination findings may indicate bowel obstruction?
Abdominal distention, mild diffuse tenderness, high-pitched ‘tinkling’ bowel sounds
A thorough search for hernias is critical.
What laboratory tests are important in diagnosing bowel obstruction?
Electrolytes, lactate, POCUS, abdominal CT
Adhesions, hernias, and tumors account for 90% of cases.
What is a common cause of carbon monoxide (CO) poisoning?
Exposure during winter months when furnaces are turned on
Family members or pets may show similar symptoms.
What are common symptoms of CO poisoning?
Headache, no reliable early signs
CO is a tasteless, odorless gas, making detection difficult.
What laboratory test is used to confirm CO poisoning?
CO level
Measurement helps confirm exposure.
What is Boerhaave syndrome?
A condition resulting from a tear in the esophagus, often due to forceful vomiting
It can follow heavy eating, drinking, or other strenuous activities.
What are common symptoms of Boerhaave syndrome?
Neck, chest, or epigastric pain, tachypnea, tachycardia, hypotension
Classic presentation includes severe chest pain and subcutaneous emphysema.
What diagnostic tests are definitive for Boerhaave syndrome?
CXR showing mediastinal air, CT, esophagogram with water-soluble contrast
Diagnosis can be difficult in subtle presentations.
What characterizes cannabinoid hyperemesis syndrome?
Cyclic severe retching and vomiting in the context of daily marijuana use
Symptoms are often relieved by hot showers.
What are common findings in patients with cannabinoid hyperemesis syndrome?
Severe distress from vomiting, dehydration, occasional epigastric tenderness
Inquiry about marijuana use is essential in recurrent vomiting cases.
Fill in the blank: A common cause of bowel obstruction includes _______.
Adhesions, hernias, tumors
Vomting process flowchart
Pathophysiology of nausea and vomiting
Causes of nausea and vomiting
Ddx of nausea and vomting
Ddx based of vomitus
Physical examination of the patient with nausea and vomiting
Rome IV Criteria for Cannabinoid Hyperemesis Syndrome
What solution should be administered to mildly or moderately dehydrated patients who can take oral liquids?
A solution containing sodium, carbohydrate, and water.
What is the preferred treatment for severely dehydrated patients who cannot take oral fluids?
IV crystalloid solution, including correction of electrolyte abnormalities as needed.
When is the placement of a nasogastric tube indicated?
Rarely indicated, except in patients with severe bowel obstruction.
How can the need for antiemetics and response to therapy be measured?
With scales similar to those used for pain assessment, such as a visual analog scale and verbal categorical scale.
What does the 2015 Cochrane review indicate about antiemetic agents for adult patients?
Limited evidence to support the use of one antiemetic agent over another, except for droperidol in a single study.
What are the categories of pharmacologic therapies for nausea and vomiting?
- Serotonin antagonists
- Histamine antagonists
- Muscarinic antagonists
- Dopamine antagonists
Which serotonin antagonist is considered first-line therapy for nausea and vomiting in the ED?
Ondansetron.
What is the initial dose of ondansetron for most patients?
4 to 8 mg PO/IV.
What is the maximum safe single dose of ondansetron in the non-elderly population?
Up to 16 mg.
What precautions should be taken before administering ondansetron?
ECG should be performed to check for QT prolongation; correct electrolytes, particularly potassium and magnesium.
What is the initial dose of metoclopramide for nausea and vomiting?
10 to 20 mg IV or IM.
Which phenothiazine is more sedating and associated with more extrapyramidal effects?
Promethazine.
What is the recommended dose of droperidol for nausea and vomiting?
1.25 mg IV.
What should be done if ondansetron and metoclopramide are ineffective?
Consider using droperidol or haloperidol if safe.
What is the preferred method of administering promethazine if IV route is desired?
Dilute in 10 to 20 mL 0.9% NaCl and administer over 10 to 15 minutes.
What alternative can be used instead of promethazine, but should not be used together?
Dimenhydrinate.
What should be considered for patients remaining highly symptomatic after antiemetic treatment?
Observation or hospitalization for continued management and evaluation for the etiology of the vomiting.
Approach to unstable patient with nausea and vomiting
Approach to stable patient with nausea and vomiting
Approach to stable but acute patients with nausea and vomiting
Potential sequelae of vomiting
Commonly used medications for treatment of nausea and vomiting
Management algorithm of patient with nausea and vomiting
What is the most common cause of vomiting in the pediatric population?
Acute gastroenteritis
What is the first-line agent for treating vomiting in children?
Ondansetron
According to a 2016 meta-analysis, what did ondansetron improve compared to placebo?
Cessation of vomiting after 1 hour, reduced failure of oral rehydration, need for IV hydration, and hospitalization rate
What is a significant finding regarding ondansetron administration in children?
Benefit was observed only in children with at least mild dehydration
What was the outcome of a randomized control trial on pediatric patients with no dehydration regarding ondansetron?
No benefit over placebo
What is the recommended dosage range for prochlorperazine in pediatric patients?
0.1 to 0.2 mg/kg IV or PO
What percentage did prochlorperazine decrease the intensity of vomiting at 1 hour?
88%
What percentage did prochlorperazine decrease the intensity of vomiting at 3 hours?
92%
What is the recommendation regarding prochlorperazine for children younger than 2 years?
Not recommended
What is the preferred first-line agent for patients with nausea or vomiting associated with a headache?
Metoclopramide
What agents have shown effectiveness in treating nausea and vomiting of pregnancy?
- Ginger
- Vitamin B6 (pyridoxine)
- Vitamin B6 combination products (e.g., doxylamine with pyridoxine)
- Ondansetron
- Phenothiazines
- Metoclopramide
What did a recent meta-analysis conclude about the teratogenic effects of ondansetron?
No conclusive evidence for teratogenicity, but some statistical significance in cardiac anomalies and cleft palate
What is the first-line IV agent for pregnant patients presenting with nausea and vomiting?
Metoclopramide
What is the starting dose of ondansetron for chemotherapy-induced nausea and vomiting?
4 mg IV
What is the function of palonosetron in chemotherapy-induced nausea and vomiting?
Decreases vomiting after 24 hours
What should be considered for patients with cyclical vomiting syndrome (CVS)?
IV hydration and high doses of antiemetic medications
What is a common treatment for cannabinoid hyperemesis syndrome (CHS)?
Benzodiazepines
What is the role of capsaicin cream in treating CHS?
Reported to be helpful in case series
What is the first-line treatment for nausea and vomiting associated with motion sickness and vertigo?
Antihistamines
What are common side effects of antihistamines?
- Drowsiness
- Blurred vision
- Dry mouth
- Hypotension
What is the primary cause of gastroparesis?
Impaired mobility of the stomach, commonly associated with diabetes
What is the first-line agent for treating gastroparesis?
Metoclopramide
What factors warrant hospital observation or admission for patients with vomiting?
- Significant underlying disease
- Poor response to fluid or antiemetic therapy
- Uncontrolled emesis refractory to medication
What should patients be instructed to do upon discharge after treatment for vomiting?
Restart oral intake with small feedings of a liquid diet, gradually returning to a regular diet
