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PHARM 346 - Other > Nausea and Vomiting (Part 1) > Flashcards

Nausea and Vomiting (Part 1) Flashcards

1
Q

Nausea
- Definition

A

Subjective feeling of the need to vomit

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2
Q

Retching
- Definition

A

Non voluntary spasmodic contraction of the body preparing to vomit
- Epiglottis closed
- Diaphragm and intercostal muscles contract

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3
Q

Vomiting (Emesis)
- Definition

A

Forceful oral expulsion of gastric contents

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4
Q

Regurgitation

A

Contents rise to the pharynx, no forceful ejection

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5
Q

Vomiting
- Process

A
  1. Contraction of diaphragm + abdominal muscle
  2. Relaxation of lower esophageal sphincter
  3. Peristalsis reverses direction, pushes stomach contents to mouth
  4. Soft palate is raised to prevent GI contents entering nasopharynx
  5. Epiglottis is closed to prevent pulmonary aspiration
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6
Q

Vomiting
- Soft Palate

A

Is raised to prevent GI contents from entering nasopharynx

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7
Q

Vomiting
- Epiglotis

A

Is closed to prevent pulmonary aspiration (Entry of food or liquid into lungs)

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8
Q

Afferent Impulses
- Chemical Signals

A

Drug, toxins, metabolic disturbances act as signals
- Chemoreceptor trigger zone (CTZ) in the brainstem is triggered

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9
Q

Afferent Impulses
- Visceral Signals

A

Irritation or distension in GI tract sends signals
- Sent via Vagus Nerve and Splanchnic Nerves to Vomiting Center

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10
Q

Afferent Impulses
- Vestibular Input

A

Motion sickness or inner ear disturbances stimulate Vestibular Nuclei
- Mediated by H1 (Histamine) and M1 (Acetylcholine) receptors

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11
Q

Afferent Impulses
- Cortical Input

A
  • Psychological Factors like Anxiety, fear, or disgust
  • Sensory Input like bad smell or sight
    –> Activates the vomiting reflex
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12
Q

Receptors involved in Emetic Reflex

A

Serotonin (5-HT3)
Dopamine (D2)
Acetylcholine (Ach, M1)
Histamine (H1)
Neurokinin-1 (NK-1, Substance P)
Cannabinoid (CB1)
Opioid

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13
Q

Vomiting
- Complications

A
  1. Fluid, electrolyte, metabolic alterations
    - Dehydration, cardiac arrhythmias
  2. Aspiration Pneumonia
    - Backflow of vomit into lungs
  3. Prolonged Vomiting
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14
Q

Prolonged Vomiting
- Complications

A
  1. Malnutrition
  2. Esophagitis (Inflammation of esophagus)
  3. Lacerations at gastroesophageal junction
  4. Multiple purpuric lesions (pupils)
  5. Dental Erosion
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15
Q

Approach to NV

A
  1. Correct consequences of vomiting (dehydration, electrolyte imbalance)
  2. Identify and Treat underlying cause
  3. If no underlying cause use empiric therapy
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16
Q

NV
- Symptoms

A
  • Are you experiencing N, V. or both
  • Any abdominal pain, dizziness, fever, or diarrhea
  • Any change appetite or weight
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17
Q

NV
- Characteristics

A
  • Appearance of vomit
  • Frequency and timing of vomit
  • Severity of symptoms
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18
Q

NV
- History

A
  • Unusual food/drinks
  • New or recent medications
  • Travel history
  • Sick contacts
  • Pregnancy
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19
Q

NV
- Onset

A
  • Gradual or Sudden
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20
Q

NV
- Red Flags

A
  • Dehydration
  • Persistient vomiting
  • Blood or coffee ground appearance in vomit
  • Blood in stools
  • Severe pain
  • Altered mental status
  • Recent trauma
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21
Q

NV
- Referral Considerations

A
  • Difficulty swallowing
  • Age > 55
  • Unintentional weight loss
  • Signs of prolonged vomiting
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22
Q

NV
- Nonpharm Options

A
  • Hydration
  • Avoid noxious odours or foods causing nausea
  • Small and frequent meals
  • Decrease physical activity
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23
Q

NV
- Acupuncture

A

3 to 5 minutes of pressure every 4 hours
- Helpful for mild NV, motion sickness, AINV, PONV

24
Q

NV
- Acupuncture Wristbands

A

Have not shown to be effective in motion sickness
- Less effective than manual pressure
- No harm in trying for mild NV

25
Q

NV: Histamine Receptor Antagonists
- Role

A

Management of:
- Motion Sickness
- Vertigo
- Mild Gastroenteritis

25
Q

NV: Histamine Receptor Antagonists
- Examples

A
  • Dimenhydrinate
  • Diphenhydramine
  • Hydroxyzine
26
Q

NV: Histamine Receptor Antagonists
- Side Effects

A

Blocks H1 receptor and also has Anticholinergic Effects
- Drowsiness
- Confusion
- Dry mouth
- Blurred vision
- Urinary retention
- Constipation

27
Q

NV: Histamine Receptor Antagonists
- Considerations

A
  • Elderly at increased risk of anticholinergic side effects
28
Q

NV: Muscarinic Receptor Antagonist
- Role

A

Motion sickness

29
Q

NV: Muscarinic Receptor Antagonist
- Examples

A

Scopolamine

30
Q

NV: Muscarinic Receptor Antagonist
- Side Effects

A

Anticholinergic side effects
- Sedation
- Confusion
- Dry mouth
- Blurred vision
- Urinary retention
- Constipation
- Rash

31
Q

NV: Muscarinic Receptor Antagonist
- Considerations

A

Greater risk of anticholinergics and CNS effects. Do not use in:
- Children less than 12 years
- Elderly

Contraindications:
- Narrow-angle glaucoma
- Difficulty with urination (Prostatic Hypertrophy)

32
Q

NV: Dopamine Receptor Antagonist (Antipsychotics)
- Role

A
  • Severe nausea and vomiting
  • NVP (Refractory)
  • PONV
  • AINV
33
Q

NV: Dopamine Receptor Antagonist (Antipsychotics)
- Example

A

Phenothiazines
- Chlorpromazine
- Prochlorperazine
- Promethazine
- Perphenazine

Butyrophenones
- Haloperidol

2nd Generation Antipsychoticcs
- Olanzapine

34
Q

NV: Dopamine Receptor Antagonist (Antipsychotics)
- Side Effects

A

Anticholinergic and Antihistamine
- Drowsiness
- Extrapyramidal symptoms (Dystonic reaction, tardive dyskinesia)
- Postural hypotension
- Dry mouth and other anticholinergic
- Hyperprolactinemia
- QT interval prolongation with butyrophenones

35
Q

NV: Dopamine Receptor Antagonist (Antipsychotics)
- Considerations

A

Elderly more prone to EPS and anticholinergic effects

Olanzapine has less EPS

Butyrophenones (Haloperidol) can cause QT prolongation

36
Q

NV: Dopamine Receptor Antagonist (Other)
- Examples

A

Benzamide:
- Metoclopramide
Benzimidazole:
- Domperidone

37
Q

NV: Dopamine Receptor Antagonist (Other)
- Side Effects

A
  • Drowsiness
  • EPS (Dystonic reactions, tremor, tardive dyskinesia)
  • Prolongation of QT interval (Domperidone)
  • Increased prolactin release
38
Q

NV: Dopamine Receptor Antagonist (Other)
- Considerations

A

Elderly more prone to EPS symptoms

Domperidone has less CNS and EPS effects
- However, is used only short term due to QT prolongation

39
Q

NV: Serotonin (5-HT3) Receptor Antagonists
- Role

A

PONV, AINV, Radiation Induced

40
Q

NV: Serotonin (5-HT3) Receptor Antagonists
- Examples

A
  • Ondansetron (AINV, PONV)
  • Granisetron (AINV)
  • Palonosetron (AINV)
41
Q

NV: Serotonin (5-HT3) Receptor Antagonists
- Side Effects

A
  • Constipation
  • Headache
  • Lack of energy/weakness
  • Risk of serotonin syndrome
  • QT-prolongation
42
Q

NV: NK1- Receptor Antagonists
- Role

A

AINV: Used with 5-HT3 antagonists and dexamethasone

PONV

43
Q

NV: NK1- Receptor Antagonists
- Examples

A
  • Aprepitant (Oral)
  • Fosaprepitant (IV)
  • Netupitant + Palonosetron (Oral Combination)
44
Q

NV: NK1- Receptor Antagonists
- Considerations

A
  • Aprepitant is most common in practice
  • Many drug interactions with Dexamethasone and Oral Contraceptives
45
Q

NV: Glucocorticoids
- Role

A

PONV, AINV, Radiation Induced
- Used acutely

46
Q

NV: Glucocorticoids
- Examples

A

Dexamethasone

47
Q

NV: Glucocorticoids
- Side Effects

A

Short term:
- Fluid and Electrolyte Disturbances
- Hyperglycemia
- Infection
- Psychosis

Long Term:
- Osteoporosis

48
Q

NV: Cannabinoids
- Role

A

AINV

Or when patient is refractory to other treatments

49
Q

NV: Cannabinoids
- Examples

50
Q

NV: Cannabinoids
- Side Effects

A
  • Euphoria
  • Sedation
  • Dysphoria
  • Hallucinations
  • Paranoia
51
Q

NV: Medical Cannabis
- Role in NV

A

Used in AINV
- Limited evidence

52
Q

NV: Natural Health Products
- Examples

A

Commonly used:
- Ginger
- Vitamin B6

Others:
- Peppermint oil
- Green tea
- Lemon balm

53
Q

Ginger
- Adverse Effects

A
  • Heartburn
  • Diarrhea
  • Mouth irritation
  • Dermatitis when used topically
54
Q

Ginger
- Considerations

A

Anti-coagulants and antiplatelets
- High dose of ginger can inhibit thromboxane synthase and decrease platelet aggregation

55
Q

Ginger
- Dose

A

1 gram/day divided into doses BID-QID

Not more than 1 gram/day in pregnancy

PHARM 346 - Other (17 decks)

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