VOMITING Flashcards
When should anti-emetics be given in vomiting
Only when the cause of vomiting
is known as they may delay diagnosis
Causes of vomiting
Disorders of the GIT and liver
Neurological disorders
Endocrine and metabolic disorders
Psychiatric disorders
Drugs
Infections
Cardiovascular disorders
Renal disorders
Pregnancy
Cyclical vomiting syndrome
Labyrinthitis
Otitis media
GIT and liver disorders that can cause vomiting
Intestinal obstruction
Peptic ulcer
Pancreatitis
Cholecystitis
Gastroenteritis
Hepatitis
Neurological disorders that can cause vomiting
Severe pain
Migraine
Raised ICP (i.e. tumours, haemorrhage, meningitis)
Seizures
Stroke
Endocrine and metabolic disorders that can cause vomiting
diabetic ketoacidosis
uraemia,
hypercalcaemia
intestinal pseudo-obstruction
Psychiatric disorders that can cause vomiting
depression
severe emotional upset
psychogenic vomiting
Infections that can cause vomiting
Malaria
UTI
Vomiting may be associated with these symptoms
Abdominal pain
Diarrhoea
Abdominal distension
Heartburn
Chest pain
Jaundice
Vertigo and nystagmus
Anxiety
Depression
Vomiting associated with diarrhea can be due to
Gastroenteritis
Vomiting associated with abdominal distension may be due to…
Suspected bowel obstruction
Vomiting associated with heartburn can be due to
GERD
Vomiting associated with jaundice may be due to
Hepato-biliary disease
Vomiting associated with vertigo and nystagmus may be due to
Suspected vestibular neuronitis
Vomiting of food eaten several hours earlier is diagnostic of……
Gastroparesis or Gastric-outlet obstruction
Faeculent vomiting is diagnostic of …………
Intestinal obstruction
Gastro-colic fistula
Vomiting with blood is diagnostic of ……..
oesophageal, gastric or duodenal lesion
Early morning vomiting in women can be diagnostic of ……
Pregnancy
Projectile vomiting may be diagnostic of …………
Pyloric stenosis
Signs in vomiting
Abdominal tenderness
Dehydration
Abdominal distension
Succussion splash
Jaundice
Signs of peritonitis
Signs of peritonitis
rebound tenderness
rigidity
guarding
Investigations in vomiting
FBC
BUE and Creatinine
LFT
Blood glucose
Serum amylase
Urine RE
Urine Pregnancy test
ECG (if myocardial infarction suspected)
Abdominal X-ray: Intestinal obstruction
Erect Chest X-ray
Purpose of Erec Chest X-ray
Diagnose bowel perforation with air under diaphragm
Investigations in persistent vomiting
Upper gastro-intestinal endoscopy
Serum calcium level
CT scan of brain
Treatment objectives in vomiting
To identify and treat the underlying cause
To prevent dehydration and electrolyte imbalance
To maintain nutrition by ensuring adequate dietary intake during
illness
To maintain personal hygiene
To eliminate infecting organisms where appropriate
Non-pharmacological management treatment of vomiting
Maintain adequate oral fluid intake
Maintain adequate nutrition
Place naso-gastric tube when needed
Surgical intervention in suspected intestinal obstruction, peritonitis
Anti-emetics for use in migraine
Metoclopramide oral, IV or IM
or
Domperidone oral
or
Promethazine oral, IV or IM
Dose of metoclopramide
Adults
PO, IV, IM
10 mg 8 hourly
Maximum duration of domperidone for vomiting in migraine
7 days
Dose of domperidone
Adults
10 mg, 8 hourly
Children
> 12 years (Body weight ≥ 35 kg); 10 mg 8-12 hourly (max. 30 mg
per day)
1 month-12 years (Body weight ≤ 35 kg); 250 micrograms/kg 8-12
hourly (max. 750 microgram/kg per day
Promethazine dose in vomiting associated with migraine
Promethazine, IV/IM
Adults
12.5-25 mg 6-8 hourly as needed (max. 100 mg in 24 hours)
Or
Promethazine, oral,
Children
2-12 years; 0.25-1 mg 6-8 hourly as needed (max. 25 mg per
dose)
< 2 years; Not recommended
Suggested anti-emetics for use in vestibular nausea and vomiting
Promethazine PO/IV/IM
or
Cyclizine PO
or
Cinnarizine IV/IM
Dose of promethazine in vestibular nausea and vomiting
Promethazine, oral,
Adults
20-25 mg 12 hourly
Children
2-12 years; 0.25-1 mg 6-8 hourly as needed (max. 25 mg per
dose)
< 2 years; Not recommended
Or
Promethazine, IV/IM
Adults
12.5-25 mg 6-8 hourly as needed (max. 100 mg in 24 hours)
Dose of cyclizine in vestibular nausea and vomiting
Cyclizine, oral,
Adults
50 mg 8 hourly as needed
Children
6-12 years; 25 mg 8 hourly as needed (max. 75 mg in 24 hours)
Dose of cinnarizine for vestibular nausea and vomiting
Cinnarizine, IV/IM,
Adults and children > 12 years
30 mg 8 hourly as needed
Children
5-12 years; 15 mg 8 hourly as needed
< 5 years; not recommended
Anti-emetics for use in gastroenteritis
Metoclopramide
or
Domperidone
Metoclopramide dose in vomiting due to gastroenteritis
Metoclopramide, oral/IV/IM,
Adults
10 mg 8 hourly
Domperidone dose in vomiting due to gastroenteritis
Domperidone, oral,
Adults
10 mg, 8 hourly
Children
> 12 years (Body weight ≥ 35 kg); 10 mg 8-12 hourly (max. 30 mg per day)
1 month-12 years (Body weight ≤ 35 kg); 250 micrograms/kg 8-12
hourly (max. 750 microgram/kg per day)
Anti-emetics for use in post-operative vomiting
Metoclopramide
or
Cyclizine
Metoclopramide dose in post-operative vomiting
Adults
10 mg 8 hourly
Dose of cyclizine in post-operative vomiting
Cyclizine, oral/IV/IM,
Adults
50 mg 8 hourly as needed
Children
6-12 years; 25 mg 8 hourly as needed (max. 75 mg in 24 hours)
Dose of ondansetron for chemotherapy induced vomiting
Ondansetron, IV,
Adults
8 mg/ 0.15 mg/kg (pre-chemotherapy) infused over 15 minutes
Children
> 6 months; 0.15 mg/kg (pre-chemotherapy) infused over 15 minutes, then repeated 4 and 8 hours after first dose. (max is 16 mg/dose)
Or
Ondansetron, oral,
Adults
8 mg 12 hourly
Children
4-12 years; 4 mg 30 minutes before chemotherapy,
then 4 mg 8 hourly for 24-48 hours as needed
< 4 years; not recommended
Antiemetics for chemotherapy induced vomiting
Ondansetron
or
Granisetron
or
Dexamethasone
or
Lorazepam
Dose of dexamethasone for chemotherapy induced vomiting
Adults
8-12 mg before chemotherapy, then 8 mg 24 hourly from days 2-4
Children
Not recommended
Dose of granisetron for chemotherapy induced vomiting
Granisetron IV
Adults
1mg/10 microgram/kg (30 minutes before Chemotherapy)
Children
2-16 years; same as adults
<2 years; not recommended
Or
Granisetron, oral,
Adults
1mg 1 hour before chemotherapy, then 1 mg 12 hours after 1st dose
Or
2 mg 1 hour before chemotherapy
Children
Not recommended
Dose of lorazepam for chemotherapy induced vomiting
Lorazepam, oral/IV,
Adults
0.5-2 mg 6 hourly as required
Antiemetics for use in pregnancy
Metoclopramide
or
Promethazine
Metoclopramide dose in pregnancy
Metoclopramide, oral,
10 mg 8 hourly
Or
Metoclopramide, IV/IM,
10 mg 8 hourly as needed
Promethazine dose in pregnancy
Promethazine teoclate, oral,
10-20 mg 8 hourly as needed
Or
Promethazine, IM,
12.5-25 mg 8 hourly as needed
