Self Care: GI Part 2 - Nausea and Vomitting

what is nausea?

subjective feeling of the need to vomit

forceful expulsion of GI tract content

vomitting or emesis

Can the following be treated with OTC antiemetics?

• motion sickness

• ACUTE viral gastroenteritis

• upset stomach related to overeating or indigestion

YES

_____ million people visit the ED for vommtiting what percentage of ALL US ED visits do these account for?

2.8 million

1.9% of ALL visits

What are some signs and symptoms of Nausea and Vomitting?

• regurgitation

  • Gastric or esophageal contents rise to the pharynx but are NOT associated with forceful ejection

• retching

  • Involuntary rhythmic diaphragmatic and abdominal contractions

Nausea and vomiting: Pathophysiology

• triggered by impulses to vommiting center in the _______

medulla

What are some centers that receive the impulses from the vomiting center in the medulla?

1. chemoreceptor trigger zone (CTZ)

2. cerebral cortex (sensory inputs—> sights, smells, toxins)

3. visceral afferents (pharynx, GI tract)

4. Vestibular apparatus (detects changes in equilibrium)

which neurotransmitters are involved in nausea and vomitting?

• neurokinin

• opiod

• dopamine

• acetylcholine

• seretonin

• histamine

What are the primary causes of Nausea and Vomitting?

• visceral stimulation

• CNS disorders

• Irritation of the CTZ (chemoreceptor trigger zone)

What are some examples of visceral stimulation that could cause nausea and vomitting?

• obstruction

• motility disorders (gastroperesis)

• peritoneal irritation (pancreatitis, appendictis)

• Infections

• Topical GI irritants (alcohol + NSAIDS + iron)

What are some examples of CNS disorders that could cause nausea and vomitting?

• vestibular disorders (motion sickness)

• migraine

• increased intracranial pressure

• infections

• psychogenic (anticipatory, vomiting, anxiety)

What are some examples of Irritation of the CTZ (chemoreceptor trigger zone) that could cause nausea and vomitting?

• chemotherapy

• radiation therapy

• opiates

• digoxin toxicity

• antibiotics

• drug withdrawal

• systemic disorders

What are some other primary causes of nausea/vomitting beyond visceral stimulation, CNS disorders, and irritation of the CTZ?

• pregnancy

• caridac disease

• urologic disease

• overeating

Motion Sickness:

What are the three sources of sensory input regarding movement?

1. visual

2. proprioception

   • ability to sense body position and movements in space

   • sensory fibers in muscles, tendons, and internal tissues

3. vestibular apparatus

Motion Sickness Pathophysiology:

• ______ cues do not match input from _________ and _______ systems

• Can it go both ways?

• visual cues DONT match proprioreceptive or vestibular systems

DOES go both ways:

body is moving but visual filed remains still OR

body is not moving but visual cues reflect movement

What are some symptoms of motion sickness?

• headache

• malaise

• restlessness

• drowsiness

• feelings of warmth

What are some exclusions for self treatment in ADULTS:

• food posiing with symptoms lasting ___ hours

• fever and/or _______ WITH the nausea + vomiting

• SEVERE ________ pain especially after eating fatty foods

• _______ in vommit

• ______ urine + ________

• SEVERE symptoms in _______ or nursing

• head injury, severe headache, stiff neck, photophobia

• nausea caused by

  • _______

  • _______

  • psychogenic etiology (anorexia + bulimia)

• Gastroparesis WITH ___, _______, or _______

• Chronic Disease States: ________, ______, ______, or __________

• 24 hours

• diarhea

• Right upper quadrant pain

• blood in vomit

• dark urine + jaundice

• severe symptoms in pregnancy

• nausea caused by

  • cancer

  • medications

  • anorexia

• gastroparesis with DM, DKA, or HSS

• chronic disease: glaucoma, COPD, asthma, BPH

If a patient has any of the following chronic disease states, would you send them a REFFERAL instead of OTC medication?

glaucoma

COPD

asthma

BPH

gastoporesis w/ DM, DKA, or HSS

When a patient is comming to you for an OTC recommendation, what are some sources you should check that the nausea could be comming from?

1. pregnancy

2. motion sickness

3. overeating

4. food poisoning

5. medication use

What would you give to an ADULT patient who is experiencing nausea and vomiting due to

• pregnancy

nonpharmacological mesasure — REFFERAL

What would you give to an ADULT patient who is experiencing nausea and vomiting due to

• motion sickness

OTC antihistamines

What would you give to an ADULT patient who is experiencing nausea and vomiting due to

• overeating

• Antacids

• H2RAs

• Bismuth- containing products

• phosphorylated carbohydrate solution

What would you give to an ADULT patient who is experiencing nausea and vomiting due to

• food poisoning

• oral rehydration solutions (Pedialyte)

What would you give to a patient who is experiencing nausea and vomiting due to

• medication use

• take your medications with food and consult w/ prescirber about making changes

What are some EXCLUSIONS for self-treatment in CHILDREN:

• stiff ______

• age < ___ _______ OR weight (< __kg)

• projectile or CONTINUOUS vomiting for more than _____ hours

• refusal to ___________

• lack of urination in prior __ - __ hours

• lethargic, ________, or listless

• vomitting with EACH feeding

• signs of ____________

• vomit that contians ____, ______, or ______ fluid

• vomiting associated with _______, _______ abdomen, severe pain, fever, or SEVERE headache

neck

less than 6 MONTHS or weigh less thann 8 kg

8-12 hours

drink fluids

8-12 hours prior

sleepy

dehydration

red, black, green fluid in vomit

diarhea, distended abdmen

what would you give to a peds patient who is vomiting due to

• motion sickness

OTC antihistamines +

avoid precipiatating factors

(same as adults)

what would you give to a peds patient who is vomitting due to

• gastroenteritis (stomach flu w/o symptoms of dehydration)

oral rehydration solutions

AVOID antiemetics

restart feeing w/ formula / light solids

What would you give. peds patient who is experiencing episodic or situational nausea or vomitting?

phosphorylated carbohydrate solution

How would you counsel a pregnant patient who is experiencing nausea/ vomitting WITHOUT medications?

• Take a _______ ______ for 1 month before planned conception

• nibble on dry toast crackers before/after breakfast

• drink SIPs of liquid in between meals (_____ + juices are best)

• eat 4-5 small meals a day instead of large meals (avoid greasy, spicy, acidic)

• avoid areas that are excessively ___ or ______

• avoid sensory stimuli such as _____, ______, or flickering lights

• AVOID ______ containing suplements

• pre natal

• before

• sodas

• avoid hot/humid areas

• odors, noises

• iron

What are some counseling points you could give to patients experiencing MOTION SICKNESS without medications?

• avoid strong ________, excess _______/ ________

• Sit in a position that allows vision out of the car window and where motion is least/most expected

ACUPUNCTURE:

• apply direct pressure of _______ point

• using finger or wristband

• SeaBands and Travelaids - worn on both wrists

• indicated for nausea associated w/ motion sickness, pregnancy, chemotherapy, anesthesia

___________ bands:

• reliefband NST- worn on one wrist

• avoid strong odors and excess food/alcohol

• pericardium - 6 (6P point)

acustimulations bans worn on ONE wrist

What is the pharmacoligal therapy that you would give for nausea and vomitting due to motion sickness?

What about nausea/vmitting related to food?

motion sickeness=

• antihistamines

food:

• antacids

• H2RAs

• PPIs

• Biscmuth subsalicylate

• phosphorylated carbohydrate solution (PCS)

Antihistamines (for motion sickness nausea) :

• reduce stimulation of bony _______ in the _____ lobal

• Can they be used for nausea in pregnant women as well?

• What are some adverse effects of antihistamines?

• labrynth in temporal lobe

• NO only motion sickness

• ADES

  • drowsiness/ confusion

  • anticholinergic effects: dry mouth, constipation, taachycardia

YOU NEED to get phsyician approval before using antihistamines for motion sickness if you have which of the following consitions?

• glaucoma

• COPD / astham

• BPH / gentrourinary disease

• Obstructive GI

• 
  

What are some of the drug interactions of antihistamines?

Which medications should you avoid?

• CNS depressants (alcohol, sedatives, hypnotics, opioids)

  • could lead to EVEN MORE sedative effects

  • Avoid concurrent use

• Anticholinergic agents

  • increase anticholinergic effects

• Buproprion + Donepezil

  • lower seizure threshold — use low doses

What are some antihistamines that are used for motion sickness?

• meclizine (bonine)

• dimenhydramine (dramamine)

• diphenhydramine (benadryl)

should you recommend an OTC medication for a patient who is experiencing prolonged nausea and bloating?

NO

Phosphorylated Carbohydrate Solution (for food induced nausea/vomitting):

• besides n/v caused by food, when else can you use PCS?

• What are the components of phosphorylated carbohydrate solution?

• MOA: _______ effect delays gastric emptying and GI motility

• n/v caused by intestinal flu and emotional upset

• Dextrose (glucose) + levulose (fructose) + phosphoric acid

• osmotic

What are some adverse effects of Phosphorylated Carbohydrate Solution (glucose+ fructose + phosphoric acid)?

When would it be contraindicated?

ade: stomach pain + diarhea

contraindications =

• Diabetes

• heridary fructose intolerate

Can you use gaterade as a rehydration soliution for nausea/ vomitting?

NO you should use oral pedialyte

Oral Rehydration Solution:

• correct dehydration and prevent electrolyte imabalnces (____, ____, and ___)

• provides fluid replacements that mimics ______ fluid losses

• can it be used for dehydration due to vomiting or diarrhea?

• recommended to replace ___- ____% of fluid loss within the first 24 hours

  • initiatie ___ minutes after last episode of vommiting

• dependent on severity of dehydration (weight loss)

• if they loss more than ___% of their body weight then you shoudl get IV HYDRATION INSTEAD

• Is it based on age and weight?

• Na, Cl, K, citrate, carbohydrates

• extracellular

• 30-50% within first 24 hours

• intiiate 10 minutes after vomitting

• 9% or more weight loss than —> IV

• yes based on age and weight

Special Patient Populations:

Pregnancy + Lactation—>

When can you give OTC antiemetics to pregnant women?

Children —>

• _____ and ________ only if recommended by phsyicain

• avoid _______ _________

Elderly —>

• prone to ________

• increase risk of falls so DONT give _______

pregnant: ONLY IF REFERRAL

children: antacids and H2RAs

AVOID bismuth subsalicylate

elderly: prone to DEHYDRATION + falls so DONT GIVE antihistames