Nausea/Vomiting

Question 1

Causes of N/V

Answer 1

1. General N/V (Gastroenteritis, Pancreatitis)
2. Balance Disorders
3. Pregnancy
4. Post-Operative [PONV]
5. Gastroparesis
6. Oncology

Question 2

Dramamine (Generic, Class)

Answer 2

Dimenhydrinate
H1 Antagonist

Question 3

Benadryl (Generic, Class)

Answer 3

Diphenhydramine
H1 Antagonist

Question 4

Bonine

Answer 4

Meclizine
H1 Antagonist
Least Drowsy

Question 5

Which H1 Antagonist causes the least drowsiness?

Answer 5

Meclizine

Question 6

Unisom (Generic, Class)

Answer 6

Doxylamine
H1 Antagonist

Question 7

Scopolamine (Class)

Answer 7

H1 Antagonist
72 hour patch

Question 8

Hydroxyzine (Class)

Answer 8

H1 Antagonist
Not Common

Question 9

H1 Antagonist Common ADE

Answer 9

1. Drowsiness
2. Dry Mouth
3. Constipation

Caution in geriatics–> Fall Risk

Question 10

What are the phenothiazines covered in this course?

Answer 10

Phenergan [Promethazine]
Compazine [Prochloroperazine]

Question 11

Phenothiazine Mechanism

Answer 11

1. Inhibits Dopamine Receptors
2. Inhibits Muscarinic Receptors

Question 12

Phenothiazine Common ADEs

Answer 12

1. Hypotension [DO NOT GIVE AS IV BOLUS]
2. QT prolongation
3. EPS Symptoms

Question 13

Phenergan (Generic, Class, BBW)

Answer 13

Promethazine
Phenothiazine
BBW: Tissue Damage upon IV Administration. Do not give IV.

Question 14

Compazine (Generic, Class)

Answer 14

Prochlorperazine
Phenothiazine

Question 15

Zofran (Generic, Class)

Answer 15

Ondansetron
5-HT-3 Antagonist

Question 16

5-HT-3 Antagonist ADEs

Answer 16

1. Constipation
2. Headache
3. QT prolongation (low risk at 8mg dose)

Question 17

When is dexamethasone most commonly used for nausea and vomiting?

Answer 17

Post-Operative N/V

Question 18

What is the mechanism for Dexamethasone in N/V?

Answer 18

Decrease prostaglandins and serotonin in the gut.

Question 19

What are our go-to non-QT prolonging anti-emetics?

Answer 19

1. Dexamethasone
2. Antihistamines

NO-order here

Question 20

Reglan (Generic, Class, Indications, Mechanism, ADE)

Answer 20

Metoclopramide
Prokinetic
Use: General, PONV, Gastroparesis
ADE: EPS, QT prolongation, Diarrhea
Mechanism: Inhibits Dopamine, Inhibits serotonin and enhances acetylcholine. —> speed motility, enhance gastric emptying, and increase esophageal tone.

Question 21

Erythromycin (Class, Mechanism, ADE)

Answer 21

Prokinetic

Mechanism: Agonizes Motlin receptors, increasing peristalsis

ADE: N/V, Diarrhea, QT prolongation

Question 22

How do we typically manage general N/V?What are the first line agents? What is the 2nd lin option?

Answer 22

1st Line = Ondansetron or Metoclopramide

2nd Line = Phenothiazines

Question 23

How do we typically manage N/V caused by gastroparesis?

Answer 23

1st Line = Metoclopramide

2nd Line = Erythromycin

Question 24

What do we use to manage N/V caused by balance disorders?

Answer 24

Meclizine(well any antihistamine)

Question 25

How do we typically manage N/V of Pregnancy?

Answer 25

1st Line = Diclegis or Bonjesta 2nd Line = 5-HT-3 Antagonist or Metoclopramide

Question 26

What is the Apfels Risk Score Used for and what are the componets.

Answer 26

Apfels is for determining risk for Post-Operative Nausea and Vomiting. Females = +1 Non-smokers = +1 Hx of motion sickness or PONV = +1 Planned use of opioids post-op = +1 High Risk = 4 points Moderate Risk = 2-3 Points Low Risk = 1 or less

Question 27

How do we treat patients who are at high risk for PONV (4 points)?3 OPTIONS

Answer 27

1. Scopolamine Patch (2 hours before induction) 2. IV-Dexamethasone (After induction) 3. 5-HT-3 Antagonist (Post-Op)

Question 28

How do we manage patients who are moderate risk for PONV? (2-3 points)

Answer 28

5-HT-3 Antagonist

Question 29

How do we manage patients who are low risk for PONV?

Answer 29

No planned anti-emetic.

Question 30

Describe how rescue therapy works for PONV. For example, what would we do if a patient is still vomiting despite preventative treatment.

Answer 30

If treated with a 5-HT-3. Ask has it been longer than 4-6 hours since the last dose. Yes = redose. No = add agent with different mechanism of action. If a 5-HT-3 has not been added yet, then it should be added.