Self-Care of Nausea, Vomiting & Motion Sickness

Learning Objectives

• Design patient-specific plans for nausea, vomiting (N/V) and motion sickness (MS)
  • Apply “exclusions to self-care” tables to decide: self-treat, self-treat with referral, or no self-treat
  • Recall brand/generic, indications, and dosing frequencies for all OTC agents
  • Construct non-pharmacologic (non-Rx) strategies for each bucket (food indiscretion, MS, pregnancy)
  • Choose optimal agent by duration of action, contraindications (CI), precautions (PC), and ADE profile
  • Explain acupressure bands (Sea-Band, ReliefBand) role and counseling points
  • Counsel patients on adverse drug events (ADEs) and follow-up timing

Buckets of Self-Care N/V

• Food indiscretion / gastric acidity
• Motion sickness
• Pregnancy (morning sickness)

Pathophysiology Overview

• Central players
  • Chemoreceptor Trigger Zone (CTZ)
  • Vestibular apparatus (inner ear)
  • Cerebral cortex
  • Visceral afferent nerves from GI tract
• Common stimuli: travel, pregnancy, overeating, viral gastroenteritis, drugs, stress, food poisoning, bulimia, abdominal distention, disease states

Exclusions to Self-Care (STAT = emergency; ASAP = prompt appointment)

• STAT referral (no OTC, no non-pharm)
  • Diabetes + signs of dehydration
  • Suspected food poisoning > 24 h
  • Severe abdominal pain or RUQ pain
  • Fever with N/V
  • N/V with diarrhea or blood in vomit
  • Jaundice (yellow skin/eyes)
  • Stiff neck ± HA & photophobia
  • Head injury, blurred vision, numbness/tingling
  • Bulimia / anorexia
• ASAP referral (OTC + non-pharm permissible)
  • Pregnancy or breastfeeding
  • Drug-induced N/V
  • N/V secondary to chronic medical condition

Non-Pharmacologic Measures

Overeating / Food-Related N/V

• Maintain hydration (water, electrolyte solutions)
• Rest stomach (small sips; avoid solid food initially)
• Avoid known trigger foods & large/fatty meals
• Gentle ambulation to promote peristalsis
• Stress reduction techniques

Motion Sickness Prevention

• Choose vehicle placement: front seat of car, mid-ship on boat, over wing in plane
• Keep eyes fixed on horizon; avoid reading
• Adequate ventilation; cool air to face
• Head supported against seatback; minimize head movement
• Light meals; avoid alcohol, strong odors, heavy/fatty foods
• Stop motion when possible

Acupressure/Neuromodulation

• Sea-Band: elastic wrist band exerts pressure on P6 (Nei-Kuan) point 2–3 fingerbreadths above wrist crease between tendons
• ReliefBand (electro-stimulation): FDA-cleared device delivering small currents to P6

Pharmacologic Agents for Food-Associated N/V

Antacids (Ca, Mg, Al, Na bicarbonate)

• Brands: TUMS, Rolaids, Mylanta, Alka-Seltzer, Maalox
• Indications: infrequent heartburn, dyspepsia, acid indigestion, gastric-acidity-related upset stomach
• Dosing: product-specific; follow label
• Key counseling: separate from concomitant meds that need acidic pH; risk of constipation (Ca, Al) or diarrhea (Mg)

Bismuth Subsalicylate (BSS)

• Brands: Pepto-Bismol, Kaopectate
• MOA: antisecretory (salicylate) + antimicrobial (bismuth oxychloride); local gastric coating
• Indications: diarrhea, gas, upset stomach, indigestion, heartburn, nausea; ↓ BM frequency & ↑ stool consistency
• Adult dosing: $525\,\text{mg}$ every $30-60\,\text{min}$ PRN; max $4200\,\text{mg/24 h}$; do not use > $48\,\text{h}$
• ADEs: black tongue/stool (benign); tinnitus (dose-related salicylate); rare neurotoxicity with excess
• PCs: aspirin sensitivity, concurrent aspirin, anticoagulation, renal insufficiency
• CIs: < 18 y/o with viral illness (Reye’s); pregnancy, lactation; history GI bleed or coagulopathy
• DDIs: warfarin (↑ INR), valproic acid, methotrexate, tetracyclines & quinolones (↓ antibiotic absorption)

Phosphorated Carbohydrate Solution (PCS)

• Brands: Emetrol, Formula EM
• Composition: $\text{sucrose}$ $3.75\,\text{g}$ + $\text{dextrose}$ $3.75\,\text{g}$ + $\text{fructose}$ $3.75\,\text{g}$ per $5\,\text{mL}$ (hyperosmolar)
• MOA: direct effect on GI wall—relaxes smooth muscle & delays gastric emptying
• Indication: nausea from intestinal/stomach influenza or food/drink indiscretion
• Adult dosing: $15\text{–}30\,\text{mL}$ every $15\,\text{min}$ until vomiting stops; MAX 5 doses (≤ $1\,\text{h}$)
• Pediatric (> 2 y): $5\text{–}10\,\text{mL}$ same interval/max rules
• PCs: diabetes (high sugar load); hereditary fructose intolerance
• ADE: large doses → abdominal pain, diarrhea
• Counseling: do NOT dilute; avoid other liquids for 15 min; refrigerate for taste only (not required)

Pharmacologic Agents for Motion Sickness (Prevention > Treatment)

First-Generation Antihistamines

• Administration: TAKE FIRST DOSE $30\text{–}60\,\text{min}$ before travel (meclizine may be taken up to $60\,\text{min}$; dimenhydrinate/diphenhydramine closer to $30\,\text{min}$)
• MOA: competitive $H_1$ receptor antagonists (central & peripheral)
• ADEs: drowsiness, psychomotor impairment, anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation, tachycardia)
• CIs: newborns/premature infants, lactation, narrow-angle glaucoma, acute asthma, symptomatic BPH, stenosing PUD, bladder neck/pyloroduodenal obstruction, concomitant MAOI use
• PCs: elderly (↑ CNS & anticholinergic burden), BPH, dementia, children (paradoxical excitation)

Anticholinergic Patch

• Scopolamine 1.5 mg (Transderm-Scop)
  • Adults only: apply 1 patch behind ear ≥ $4\,\text{h}$ before need; press firmly 30 s; replace q72 h if needed
  • Counseling: avoid hair; wash hands; remove before MRI; may cause mydriasis if eye contact; ADE—dry mouth, drowsiness, blurred vision, urinary retention
  • CIs: hypersensitivity to belladonna alkaloids, glaucoma, BPH, pyloric obstruction, children

Herbal / Dietary

• Ginger (Dramamine Non-Drowsy): 500–1000 mg prior to travel then q4 h PRN; variable evidence; generally well tolerated (mild GI reflux, anticoag effect at high doses)

Special Populations / Clinical Pearls

• Children < 2 y: antihistamines not recommended; motion sickness rare
• Age 2–6 y: only dimenhydrinate has dosing; avoid meclizine, diphenhydramine cautioned
• Elderly (≥ 65 y): prefer meclizine (q24 h) if needed; watch anticholinergic ADEs; avoid diphenhydramine
• BPH or glaucoma: avoid anticholinergics & antihistamines; consider non-pharm or PCS
• Diabetes: limit PCS; monitor glucose; consider CaCO₃ antacid for mild post-prandial nausea
• Aspirin allergy, pregnancy, children/teens recovering from viral illness: AVOID BSS

Counseling Framework (All Agents)

• Review indication & expected benefit timeframe
• Stress prevention vs treatment: antihistamines & scopolamine best when taken before motion
• Emphasize max daily doses & duration limits (BSS 48 h; PCS 1 h; antihistamines as labeled)
• Warn about drowsiness → no driving, alcohol, CNS depressants
• Anticholinergic precautions: dry mouth → sugar-free candy; blurred vision → avoid hazardous tasks; urinary retention monitoring
• BSS: stool/tongue darkening benign; tinnitus → stop & seek care
• PCS: high sugar; check glucose; do not dilute or drink concurrently
• When to seek medical attention: persistent N/V > 24–48 h, blood in vomit/stool, severe abdominal pain, signs dehydration, fever, yellow skin/eyes, neurologic deficits
• Follow-up: typically within 24 h for acute use; sooner if ADEs or worsening

Practice Question Take-Aways

• 19 y/o M with N/V/D after buffet (3 h): self-care WITH referral (possible food poisoning; refer if > 24 h)
• 36 y/o F 13 weeks pregnant: self-care WITH referral (pregnancy = ASAP)
• 8 y/o boy with ice-cream cramps: self-care appropriate (non-pharm ± CaCO₃)
• 10 y/o stomach ache post-pizza: best = CaCO₃ (antacid) — BSS CI (< 12 y)
• 56 y/o diabetic after overeating: choose CaCO₃ (avoid PCS sugar; BSS caution with aspirin)
• Aspirin-allergic patient: choose PCS or CaCO₃, NOT BSS
• Motion sickness: antihistamine 30 min prior; meclizine preferred for > 12 y & long trips; dimenhydrinate for 2–11 y; diphenhydramine less preferred due to sedation q6–8 h dosing

“Good to Know” Exam Reminders

• Match clinical scenario to exclusions list
• Know adult & pediatric dosing ranges, especially:
  • BSS: $525\,\text{mg q30–60 min; max 4.2 g/48 h}$
  • PCS: $15–30\,\text{mL q15 min; max 5 doses}$
  • Dimenhydrinate: $50–100\,\text{mg q4–6 h}$
  • Meclizine: $25–50\,\text{mg q24 h}$
• Duration of action hierarchy: meclizine ≈ scopolamine (≈24–72 h) > dimenhydrinate > diphenhydramine
• Anticholinergic burden & contraindications list for exams
• Mechanisms: BSS (antisecretory/antimicrobial), PCS (hyperosmolar smooth-muscle relaxation), antihistamines (H1 block), scopolamine (muscarinic block), acupressure (P6 neuromodulation)