Nausea

Question 1

Nausea definition

Answer 1

The conscious recognition that the vomiting centre has been stimulated

Question 2

Vomiting definition

Answer 2

The forcible ejection of stomach contents through the mouth

Question 3

Vertigo definition

Answer 3

Spinning feeling can accompany and predict the vomiting (similar aetiology(causes))

Question 4

Nausea and vomiting dietary causes (3)

Answer 4

1. Overeating
2. food poisoning
3. excess alcohol

Question 5

Nausea and vomiting Infection causes (2)

Answer 5

1. Viral infections
2. bacterial infections

Question 6

Nausea and vomiting disease causes (8)

Answer 6

1. peptic ulcer disease
2. gastroesophageal reflux disease
3. gastric cancers
4. obstructions
5. renal failure
6. diabetic ketoacidosis
7. chronic obstructive pulmonary disease
8. Myocardial Infarction (heart attack)

Question 7

Nausea and vomiting CNS disease causes (3)

Answer 7

1. migraines
2. Meniere’s (inner ear disorder)
3. motion sickness

Question 8

Nausea and vomiting drug-induced causes (3)

Answer 8

1. cytotoxic chemotherapy
2. opiods
3. anaesthetics

Question 9

Other nausea and vomiting causes

Answer 9

pregnancy

Question 10

What are the N&V receptors outside the brain (5)

Answer 10

1. Chemoreceptor trigger zone (CTZ)

Contains:

1. Serotonin 5HT3 receptors
2. Dopamine D2 receptors
3. Acetylcholine M receptors
4. Histamine H1 receptors

Question 11

What are the N&V receptors in the brain (5)

Answer 11

1. Vomiting centre

Contains:

1. Serotonin 5HT3 receptors
2. Dopamine D2 receptors
3. Acetylcholine M receptors
4. Histamine H1 receptors

Question 12

What are the N&V drug types (6)

Answer 12

1. 5HT3 antagonists
2. D2 antagonists
3. D2/5HT3 antagonists
4. Antimuscarinics
5. Antihistamines
6. Other

Question 13

What are the N&V 5HT3 antagonist drug examples (3)

Answer 13

1. Ondansetron
2. Granisetron
3. Dolasetron

Question 14

What are the N&V D2 antagonist drug examples (5)

Answer 14

1. Phenothiazines: prochlorperazine, levomepromazine
2. Butyrophenones: Droperidol,
3. Domperidone. Previously P, now POM
4. Centrally acting D2 antagonists = extrapyramidal symptoms
5. Phenothiazines and butyrophenones are also used in psychosis

Question 15

What is the N&V D2/5HT3 antagonist drug examples

Answer 15

Metoclopramide - MHRA warning

Question 16

What are the N&V antimuscarinics drug examples (2)

Answer 16

1. Hyoscine HYDRObromide (scopolamine)
2. Glycopyrrolate

Question 17

What are the N&V antihistamine drug examples (3)

Answer 17

1. Cinnarizine
2. Cyclizine
3. Promethazine (drowsy)

Question 18

What are the N&V other drug examples (4)

Answer 18

1. Prokinetic stimulants
2. Benzodiazepines (for conscious causes)
3. Cannabinoids
4. Dexamethasone (with ondansetron as pre-med for chemo)

Question 19

How is vestibular (ears and balance) N&V pharmacologically managed (5)

Answer 19

1. Hyoscine hydrobromide - 30 mins before a journey
2. Antihistamines - less effective but have fewer side effects
3. Cinnarazine (antihistamine) - 2 hrs before journey
4. Promethazine - VERY SEDATIVE, not often used now
5. For Meniere’s Disease Hyoscine hydrobromide or antihistamines are used plus phenothiazines

Question 20

How is pregnancy N&V pharmacologically managed (2)

Answer 20

1. Avoid ALL drug treatment in first trimester
2. In severe cases: 24-48 hours of promethazine or metoclopramide: REFER to SPECIALIST

Question 21

How is cancer N&V pharmacologically managed (3)

Answer 21

1. Prevent pre-exposure: phenothiazine, domperidone, dexamethasone
2. Highly emetogenic: as on a 5HT3 antagonist (ondansetron)
3. Second line: dexamethasone, phenothiazines, aprepitant, cannabinoids

Question 22

How is Parkinson’s N&V pharmacologically managed (2)

Answer 22

1. Domperidone (not centrally acting, but risk of QT prolongation)
2. Cannabinoids

Question 23

How is post-operative N&V pharmacologically managed (2)

Answer 23

1. Often local guidelines
2. 5HT antagonists and3 Cyclizine common

Question 24

What is the relevance of the presence of abomination pain presentation in N&V (2)

Answer 24

1. Various conditions would present with abdominal pain and it’s common to be associated with N&V
2. severe pain would warrant referral

Question 25

What is the relevance of the timing in N&V (3)

Answer 25

1. Morning vomiting associated with alcohol intake and pregnancy 2. If vomiting is immediately after food → Gastritis- → referral 3. If vomiting is an hour after food → ulcer? → referral

Question 26

What is the relevance of signs of infection presentation in N&V (2)

Answer 26

1. Gastroenteritis – Diarrhoea, fever and abdominal discomfort 2. Social history – if from food see if other people have it

Question 27

What are the OTC treatments for travel sickness (3)

Answer 27

1. Hyoscine bromide - 30 mins before travelling then every 6 hrs 2. Cinnarazine - 2 hrs before driving then every 8 hrs as needed 3. Promethazine - very drowsy, often abused - avoid

Question 28

What is the OTC treatments for nausea associated with migraines (4)

Answer 28

1. Promethazine - 18+ 2. placed on top gum under lip to dissolve 3. Likely to cause drowsiness (aggravated with alcohol, opioids and antidepressants) 4. Avoid use: Parkinson’s, epilepsy, glaucoma

Question 29

What are the referral points for N&V (7)

Answer 29

1. AB-PAIN 2. Abdominal pain- moderate to severe 3. Blood 4. Potential pregnancy 5. Age- Children under 1 y/o for >24 hours 6. Identifiable cause? If not → refer 7. Not responding to OTC treatment (limited OTC + hydration)

Question 30

How does hydration affect N&V and how can this be sorted (6)

Answer 30

1. need to make up about 2000 mL in food and drink 2. Keep drinking and eating as normally as you can 3. Use electrolyte solutions - Make up as instructed 4. WHO recipe if can’t buy - 1 L water, ½ level teaspoon salt & 6 level teaspoons sugar (glucose) 5. Bland things typically to start with: Crackers & toast 6. If severely dehydrated refer – see signs of dehydration in diarrhoea later