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DEENT Exam 2 > Lecture 5 > Flashcards

Lecture 5 Flashcards

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1
Q

Why is nausea and vomiting hard to treat?

A

There are a wide variety of reasons the patient can be experiencing these symptoms, which both can and cannot be managed via self-care.

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2
Q

What are the possible causes of N/V?

A 
GI Obstruction
Infections
Drugs (NSAIDs, ABX, EtOH, chemotherapy)
CNS Infections
Pregnancy
Drug Withdrawal
Gastroparesis
Gastroenteritis
Motion Sickness
Migraine Headaches
Food Poisoning
Hepatitis A & B
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3
Q

What are the three distinct stages of N/V?

A

Nausea (a general feeling of uneasiness and need to vomit)
Retching (Involuntary abdominal contractions)
Vomiting

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4
Q

What are the signs of dehydration in children?

A

dry mucous membranes, decreased skin turgor, increased thirst, altered mental status/unexplained irritability, and decreased urine output.

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5
Q

What are the treatment goals of nausea and vomiting?

A

Provide symptomatic relief
Identify and correct the underlying cause
Prevent and correct complications
Prevent future occurrence.

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6
Q

What are the signs of dehydration in children (second list)?

A

Dry mouth and tongue
Sunken and/or dry eyes
Sunken fontanelle
Decreased urine output (dry diapers for several hours)
Dark urine
Fast heartbeat
Thirst (drinks extremely eagerly)
Absence of tears when crying
Decreased skin turgor (increased axillary skinfolds, “doughy” skin (may indicate hypernatremia), when “pinched” skin returns to normal very slowly)
Unusual listlessness, sleepiness, decreased alertness, or tiredness.
Weight loss (moderate 3-9% weight loss, severe 9% weight loss)

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7
Q

What is the non-pharmacologic therapy for nausea and vomiting?

A

Oral rehydration salt (ORS) prevents electrolyte imbalance.
ORS 3 sugars to 1 salt (Gatorade is 15 sugars to 1 salt)
Dilution of sports drinks with water is an option. Dosing of ORS should commence 10 minutes after their last episode of vomiting in small quantities (child 5ml/5min; adults and older children 15mL/5min)

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8
Q

What are some nonpharmacological measures to decrease motion sickness?

A

Avoid reading during travel.
Focus the line of vision fairly straight ahead.
Avoid excess food or alcohol before an during extended travel.
Stay where motion is least experienced (front of the car, near the wings of an airplane, or midship)
Avoid strong odors, particularly from food or tobacco smoke.

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9
Q

What are some nonpharmacological measures to prevent NVP?

A

Make sure you have fresh air in the room where you sleep, and put dry cracekrs beside your bed to eat in the morning.
Before arising, eat several crackers and relax in bed for 10-15 minutes.
Get out of bed very slowly, and do not make any sudden movements.
Before eating breakfast, nibble on dry toast or crackers.
Make sure there is plenty of fresh air in the area where meals are prepared and eaten.
Eat four to five small meals per day instead of three large meals. Do not overeat at meals.
Do not drink fluids or eat soups at mealtime. Instead, drink small sips of liquid between meals.
When nauseated, try small sips of carbonated beverages or fruit juices.
Avoid greasy foods such as fried foods, gravies, mayonnaise, and salad dressing, as well as spicy or acidic foods (citrus fruits and beverages, tomatoes).
If necessary, eat food that is chilled rather than warm or hot (cold foods tend to be less nauseating)

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10
Q

What is the pharmacological therapy for nausea and vomiting?

A

Treatment and prevention for N/V:
1st generation antihistamines (meclizine, cyclizine, dimenhydrinate, diphenhydramine, and doxylamine)
Prevention is 30 minutes before anticipated activity

Treatment of nausea with non-ulcer dyspepsia or consumption:
bismuth subsalicylate (don't use in children)

Treatment of nausea associated with overindulgence in food or beverage:
Antacids and histamine type-2 receptor antagonists

Treatement of upset stomach caused by intestinal or stomach influenza and disagreeable food and drink:
PCS (phosphorylated carbohydrate solution; Emetrol) -decreases the somooth muscle contraction and delaying gastric emptying time. 5-10 mL ever 15 minutes until vomiting ceases (no more than 1 hour or 5 doses) - do not use in patients with diabetes.

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11
Q

What are the ages for 1st generation antihistamines for nausea and vomiting?

A

2-6 diphenhydramine
6-12 cyclizine
12-18 meclizine

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12
Q

What is the pharmacological therapy for NVP?

A

Antishistamines should be reserved for severe cases of NVP that are unresponsive to other non-pharmacologic therapy.

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13
Q

What are PCS a mixture of?

A

fructose, glucose, and phosphoric acid

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14
Q

What are the complementary therapies for NV or NVP?

A

Prevention of nausea due to Pregnancy, motion, sickness, and surgery:
Ginger (Cochrane review suggested that it may be superior to placebo in preventing NVP)

Pyridoxine (Vitamin B6) - Overall data suggests efficacy

Acupressure - (Cochrane showed pericardium-6 stimulation is superior to antiemetics for nausea and equivalent to antiemetics for vomiting) The P6 point is around 2 thumb widths from the middle crease of the wrist. May use wrist band, fingers, or electrostimualtion.

Aromatherapy (peppermint oil showed no reliable evidence, isopropyl alcohol showed efficacy in comparison to placebo, but less effective than other standard antiemetic therapy. Evidence supporting aromatherapy is lacking)

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15
Q

What are the adverse effects and dosing options for ginger?

A

Adverse Effects: Heartburn, diarrhea, and irritation of the oral mucosa. Evidence suggests anticoagulant and hypotensive effects.

Dosing: 250 mg of root 4 times daily or 1 gram in 2-3 dived doses

Ginger ale won’t work because most are artificially flavored or contain subtherapeutic amounts of ginger.

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16
Q

What are the adverse effects and dosing options for pyridoxine (Vitamin B6)?

A

Adverse Effects: Large doses (200mg/day) over long periods of time (2 months) can cause peripheral neuropathy, weakness, lethargy, and nystagmus.

Dose: 10-25 mg three times daily

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17
Q

What are the dosing options for acupressure?

A

Variable, ranging from as needed, to 10 minutes three times daily, to continuous pressure.

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18
Q

What are the exclusions for self-treatment of nausea and vomiting in adults?

A

Symptoms of severe dehydration
Hyperglycemia and/or urine ketones with symptoms of dehydration in patients with diabetes.
Severe abdominal pain in MLQ/RLQ
Suspected food poisoning persisting for more than 24 hours.
N/V with fever and/or diarrhea
Severe RUQ pain, especially after eating fatty foods.
Blood in the vomit.
Yellow skin or eye discoloration and dark urine.
Stiff neck with or without headache and sensitivity to bright or normal lighting.
head injury with N/V, blurry vision, or numbness and tingling.
Drug-induced N/V
Bulemia or anorexia-induced N/V
Chronic disease induced N/V

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19
Q

What are exclusions for self-treatment for nausea and vomiting in pediatric patients?

A

Symptoms of severe dehydration
Caregiver unwillinig or unable to adequately manage at home.
N/v with 1 of the following:
(stiff neck)
(less than 6 months of age or weigh less than 8kg, vomited clear fluids 3 times, watery diarrhea)
(refusal to drink fluids)
(lack of urination for 8-12 hours)
(lethargy, unusually sleepy, listless or crying)
(Vomiting with each feeding)
(Vomiting is repeatedly projectile and/or has continued more than 8 hours)
(Vomitus contains red, black, or green fluid)
(Vomiting is associated with diarrhea, distended abdomen, fever, or severe headache)
(less than 1 month of age with 3 large diarrhea stools)
(less than 12 weeks of age with fever > 100.4F rectally; ages 3-36 months with fever greater than 102.2)
(less than 12 weeks of age with vomiting 2 times)
(less than 1 year of age with 8 diarrhea stools in last 8 hours)
(severe headache persists more than 2 hours)
(Vomiting following a head or abdominal injury)
(suspected poisoning)
(Vomiting occurs with recurrent, severe, acute abdominal pain)
(Child is high risk ex: DM, CNS disease, hernia)

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20
Q

What is allergic rhinitis?

A

The inflammation of the mucous membranes in the nose, can be classified as allergic or non-allergic.

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21
Q

What does non-allergic rhinitis include?

A

infectious, vasomotor, rhinitis medicamentosa, hormonal, anatomical

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22
Q

What is the classification qualifications for intermittent and persistent allergic rhinitis?

A

Intermittient - Symptoms occur less than 4 days per week or less than 4 weeks.
Persistent - Symptoms occur more than 4 days per week
AND greater than 4 weeks.

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23
Q

What are indoor and outdoor triggers of allergic rhinitis?

A

Indoor: House dust-mites, Cockroaches, Mold spores, Cigarette smoke, Pet dander.

Outdoor: Pollen, Mold spores, Pollutants (oxone and diesel exhaust particles.

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24
Q

What are the common symptoms of allergic rhinitis?

A

Rhinorrhea, nasal congestion, pruritus of the nose, eyes and throat, sneezing, and watery eyes.

Not allergic rhinitis symptoms: Epistaxis (nose bleed), pain, purulent(containing pus) rhinorrhea, or any symptom that presents unilaterally.

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25
What are the physical findings of allergic rhinitis?
Allergic salute/nasal crease, allergic shiners, ocular conjunctivitis, pale, blue turbinates, clear, water discharge, inflamed nasal mucosa, nasal polyps, nasal drainage in pharynx.
26
What are the exclusions for self-care for allergic rhinitis?
*Children less than 12 years old *Pregnant or lactating women Symptoms of non-allergic rhinitis Symptoms of otitis media, sinusitis, bronchitis, or other infection Symptoms of undiagnosed or uncontrolled asthma, COPD, or other respiratory disorder. Symptoms unresponsive to treatment *Excluded from self-treatment unless already diagnosed with allergic rhinitis and OTC treatment is approved by PCP.
27
What are the treatment goals of allergic rhinitis?
1. To minimize or prevent symptoms. 2. To allow patients the ability to undertake activities of daily living without limitation. 3. Minimize drug adverse reactions.
28
What are the nonpharmacologic treatments for allergic rhinitis?
The avoidance of allergens and nasal saline. Lower the humidity in the home, wash bedding in hot water weekly and encase pillows and mattresses in dust mite resistant coverings. Nasal saline to reduce irritation and dryness, as well as, to remove mucus and allergens from the nose.
29
What are the general instructions for using nasal dosage formulations?
Clear nasal passages before administering the product. Gently depress the other side of the nose with finger to close off the nostril not receiving the medication. Aim tip of product away from nasal septum to avoid accidental damage to the septum. Wait a few minutes after using the medication before blowing nose.
30
How should nasal sprays be used?
Gently insert the bottle tip into one nostril. | Keep head upright. Sniff deeply while squeezing the bottle.
31
How should nasal inhalers be used?
Warm the inhaler in hand just before use. Gently insert the inhaler tip into one nostril. Sniff deeply while inhaling. Wipe the inhaler after each use. Discard after 2-3 months even if the inhaler still smells medicated.
32
How should pump nasal sprays be used?
Prime the pump before using it the first time. Hold the bottle with the nozzle placed between the first two fingers and the thumb placed on the bottom of the bottle. Tilt the head forward. Gently insert the nozzle tip into one nostril. Sniff deeply while depressing the pump once. Repeat with other nostril.
33
How should nasal drops be used?
Lie on bed with head tilted back and over the side of the bed. Squeeze the bulb to withdraw medication from the bottle. Place the recommended number of drops into one nostril. Gently tilt head from side to side. Repeat with other nostril. Lie on bed for a couple of minutes after placing drops in the nose. Do not rinse the dropper.
34
What should you recommend if a patient's primary complaint is nasal congestion in allergic rhinitis?
Intranasal steroid or oral decongestant If poor control then Combination therapy, allergy testing, reassess for anatomic nasal obstruction or nonallergic inflammation, immunotherapy.
35
What should you recommend if a patient has intermittent sneezing, nasal itching, and rhinorrhea in allergic rhinitis?
An Oral antihistamine or intranasal antihistamine. | If poor control then recommend allergy testing, avoidance, or immunotherapy.
36
What should you recommend for a patient that has mild symptoms of allergic rhinitis?
Oral antihistamine | If poor control than recommend INS or Intranasal antihistamine.
37
What should you recommend for a patient that has moderate/severe symptoms of allergic rhinitis?
INS, Intranasal antihistamine, combination therapy. | If poor control than recommend allergy testing, aggressive environmental control, and immunotherapy.
38
What should you recommend for a patient that prefers complementary medicine for allergic rhinitis?
Acupuncture (limited studies) | If poor control than we can't recommend anything else because there is evidence lacking.
39
Who wrote the algorithm for Allergic Rhinitis Clinical Practice Guideline?
American Academy of Otolaryngology.
40
What classes of medications can be used in the treatment of allergic rhinitis?
``` antihistamines (topical and oral) decongestants (topical and oral) corticosteroids (topical and oral) mast cell stabilizers (also known as chromones) anticholinergics leukotriene receptor antagonists ```
41
What intranasal antihistamine is recommended for perennial/persistent allergic rhinitis?
Astepro
42
Oral antihistamines are not recommended for what allergic rhinitis symptoms?
Severe symptoms
43
What symptoms are leukotriene receptor antagonists NOT for?
Episodic intermittent not used as monotherapy for severe.
44
What is the single most effective agent for the treatment of allergic rhinitis?
Intranasal Corticosteroids because they treat all symptoms including ocular symptoms.
45
What are important counseling points when speaking with a patient about intranasal corticosteroids?
Benefit may not be seen until after 1 week of regular use, although some will se symptom reduction in 36 hours. Not as effective as PRN medications. When being used for intermittent allergic rhinitis, intranasal corticosteroids should be initiated several days prior to expected allergen exposure and continue for 2-3 weeks after the end of the season. Administration technique drastically alters efficacy. Counsel the patient to point the spray to the outside of the nostrils. the head should be pointed slightly downward when administering the spray so it doesn't drain down the throat. Must be primed prior to their first use and after 14 days without use.
46
What are the adverse effects of intranasal corticosteroids?
Nasal crusting Dryness Epistaxis Burning
47
What are the intranasal corticosteroids?
``` Triamcinolone (Nasacort) - OTC/Rx 1-2 sprays in each nostril once daily. Fluticasone propionate (Flonase) - OTC/Rx 2 sprays in each nostril once daily or 1 spray in each nostril BID Fluticasone furoate (Veramyst) - Rx Mometasone (Nasonex)- Rx Budesonide (Rhinocort) - Rx Ciclesonide (Omnaris and Zetonna) Flunisolide (Nasalide and Nasarel) Beclomethasone (Beconase and Qnasl) ```
48
What is the combination Intranasal products?
Azelastine/Fluticasone (Dymista) - Rx
49
What are the side effects associated with 1st generation antihistamines and what popultaions should you be cautious in or avoid?
Anticholinergic symptoms sedation confusion urinary retention constipation blurred vision dry mouth occur more in elderly and thus should be avoided in the elderly Use it with caution in patients with BPH, Glaucoma. ONLY USE in patients with postnasal drip.
50
What are the preferred agents for allergic rhinitis according to AAAAI?
Fexofenadine 180 mg daily OTC Loratadine 10 mg daily OTC Desloratadine 5 mg daily Rx (Cetirizine 10mg daily OTC and Levocetirizine 5 mg daily Rx may cause drowsiness at recommended doses)
51
What is important counseling points for antihistamines in allergic rhinitis?
Have less impact on nasal congestion and polyps. Exhibit efficacy within 1 day. Cetirizine and loratadine are pregnancy category B and can be used in pregnancy.
52
What are important counseling points for intranasal antihistamines?
May cause: Drowsiness, Headache (absorbed up to 40% systemically), Nasal dryness. Rapid onset of action at less than 15 minutes.
53
What are the intranasal antihistamines for allergic rhinitis?
Azelastine (asetpro) 1-2 sprays per nostril BID Rx | Olopatadine (Patanase) 2 sprays per nostril BID Rx
54
When should you use caution in patients when recommending oral decongestants?
``` Cardiovascular disease Hypertension Hyperthyroidism BPH Glaucoma Contraindicated with or within 14 days of MAOI therapy ```
55
What are the adverse events for oral decongestants?
Insomnia Agitation Tachycardia Anorexia
56
What are the oral decongestants that can be used for allergic rhinitis?
Pseduophedrine (Sudafed & Nexafed) 60mg Q4-6H OTC Pseudophedrine (Sudafed) 12 hour 120 mg BID OTC Pseudophedrine (Sudafed) 24 hour 240 mg daily OTC Phenylephrine (Sudafed PE) 10-20 mg daily OTC
57
What agents should not be used in the 1st trimester because of their ability to cause gastrocschisis?
Oral decongestants
58
What are the 2nd generation antihistamine/decongestant combinations?
Zyrtec D Claritin D Allegra D
59
What are the mast cell stabilizers?
``` Cromolyn sodium (Nasal Crom) OTC Cromolyn sodium Rx ```
60
Intranasal cromolyn targets all symptoms of allergic rhinitis except....
ocular
61
What are important counseling points for intranasal cromolyn for allergic rhinitis?
Less effective than intranasal corticosteroids or oral antihistamines. Most effective when used prior to allergen exposure. Few side effects with this agent. Requires dosing every 4-6 hours. The frequency can be decreased after 2-3 weeks of use.
62
What is 1st line therapy for treating allergic rhinitis in pregnancy?
Intranasal cromolyn sodium
63
What is an intranasal anticholinergic agent?
Used for rhinorrhea related to allergic rhinitis | Ipratropium (Atrovent) - 2 sprays per nostril BID or TID Rx
64
Intranasal anticholinergics should be used with caution in what patients and what are their adverse effects?
BPH Glaucoma Adverse Effects: Dryness of the nasal membranes (may be relieved with administration of nasal saline)
65
What is the LTRA?
leukotriene receptor antagonist Montelukast (Singulair) 10 mg daily Relieves sneezing, congestion, rhinorrhea, and nasal itching.
66
What are important counseling points for people on leukotriene receptor antagonists?
Approved for use in adults and children 6 months and older with allergic rhinitis. Similar efficacy to oral antihistamines, but less efficacy than intranasal corticosteroids. Usually used in combination with antihistamines. The dosing for allergic rhinitis is the same as for asthma. Pregnancy category B. Denied for OTC designation. Reports of aggressive behavior and abnormal dreams have occurred with use of this drug.
67
What is the recommendation to a patient that has inadequate control of symptoms on INS monotherapy?
Add Intranasal antihistamine or oxymetazoline (3 days or less) Do not add oral antihistamine or leukotriene receptor antagonists.
68
What is the recommendation to a patient that has inadequate control of symptoms on oral antihistamine monotherapy?
Add oral decongestant (increased side effects) Could add Leukotriene receptor Antagonist (evidence mixed) Do not add INS (reasonable to change to INS but adding not helpful)
69
What is the recommendation to a patient that has inadequate control of symptoms on intranasal antihistamine monotherapy?
Add INS
70
What is immunotherapy?
Allergy shots that are subcutaneous injections of dilute allergen extracts. Good for patients with perennial symptoms of allergic rhinitis, who do not tolerate or are inadequately controlled on the medications available.
71
What is anaphylaxis?
Can be defined as a serious, life threatening generalized or systemic hypersensitivity reaction and a serious allergic reaction that is rapid in onset and might cause death.
72
What are the signs and symptoms of anaphylaxis?
Skin, subcutaneous tissue, and mucosa: Flushing, itchin, urticarial, angioedema, morbilliform rash, pilor erection, periorbital itching, erythema, and edema, conjunctival erythema, tearing, itching of lips, tongue, palate, and external auditory canals, and swelling of lips, tongue, and uvula, itching of genitalia, palms, and soles. Respiratory: Nasal itching, congestion, rhinorrhea, sneezing, throat itching and tightness, dysphonia, hoarseness, stridor, dry staccato cough, lower airways, cyanosis, respiratory arrest. Gastrointestinal: Abdominal pain, nausea, vomiting, diarrhea, dysphagia Cardiovascular system: Chest pain, tachycardia, brady carida, other arrhythmias, palipitations, hypotension, feeling faint, urinary or fecal incontinence, shock, cardiac arrest. Central nervous system: Aura of impending doom, uneasiness, throbbing headache(pre-epinephrine), altered mental status, dizziness, confusion, tunnel vision Other Metallic taste in the mouth Cramps and bleeding due to uterine contractions in females.
73
What are immunologic mechanisms that are IgE dependent?
Foods, Venoms, Medications, natural rubber altex, occupational allergens, seminal fluid, aeroallergens, radiocontrast media
74
What are immunologic mechanisms that are IgE independent?
Radiocontrast media, NSAIDs, Dextrans, Biologic Agents
75
What are immunologic mechanisms that are direct mass cell activation?
Physical factors (heat, sunlight, ...) Ethanol Medications
76
What are immunologic mechanisms that are idiopathic anaphylaxis (no apparent trigger)?
Previously unrecognized allergen | Mastocytois/clonal mast cell disorder
77
What is the basic management of anaphylaxis?
Written emergency protocol Remove exposure to the trigger Assess the patient Call for help Inject epinephrine 0.01mg/kg max 0.5 mg in adult and 0.3 mg in child, repeat 5-15 minutes Place patient on back and elevate lower extremieties Give high-flow supplemental oxygen Establish intravenous access - give isotonic saline rapidly Perform cardiopulmonary resuscitation when indicated At frequent, regular intervals, monitor blood pressure, cardiac rate and function, respiratory status, and oxygenation
78
How should epinephrine be dosed?
0.01 mg/kg of a 1:1000 (1mg/1mL) solution to a maximum of 0.5 mg in adults and 0.3 mg in children. The dose may be repeated every 5-15 minutes.
79
What are adverse effects of epinephrine?
pallor, tremor, anxiety, palpitations, dizziness, and headache. Serious adverse effects: Ventricular arrhythmias, hypertensive crisis, and pulmonary edema.
80
What are second-line medications?
Antihistamines, beta-2 adrenergic agonists, and glucocorticoids but all the reviews say they haven't been shown to be effective or they have too bad of adverse effects.

DEENT Exam 2 (7 decks)

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