VOMITING Flashcards by Qúophy Calbert

When should anti-emetics be given in vomiting

Only when the cause of vomiting
is known as they may delay diagnosis

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Causes of vomiting

Disorders of the GIT and liver
Neurological disorders
Endocrine and metabolic disorders
Psychiatric disorders
Drugs
Infections
Cardiovascular disorders
Renal disorders
Pregnancy
Cyclical vomiting syndrome
Labyrinthitis
Otitis media

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GIT and liver disorders that can cause vomiting

Intestinal obstruction
Peptic ulcer
Pancreatitis
Cholecystitis
Gastroenteritis
Hepatitis

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Neurological disorders that can cause vomiting

Severe pain
Migraine
Raised ICP (i.e. tumours, haemorrhage, meningitis)
Seizures
Stroke

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Endocrine and metabolic disorders that can cause vomiting

diabetic ketoacidosis
uraemia,
hypercalcaemia
intestinal pseudo-obstruction

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Psychiatric disorders that can cause vomiting

depression
severe emotional upset
psychogenic vomiting

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Infections that can cause vomiting

Malaria
UTI

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Vomiting may be associated with these symptoms

Abdominal pain
Diarrhoea
Abdominal distension
Heartburn
Chest pain
Jaundice
Vertigo and nystagmus
Anxiety
Depression

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Vomiting associated with diarrhea can be due to

Gastroenteritis

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Vomiting associated with abdominal distension may be due to…

Suspected bowel obstruction

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Vomiting associated with heartburn can be due to

GERD

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Vomiting associated with jaundice may be due to

Hepato-biliary disease

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Vomiting associated with vertigo and nystagmus may be due to

Suspected vestibular neuronitis

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Vomiting of food eaten several hours earlier is diagnostic of……

Gastroparesis or Gastric-outlet obstruction

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Faeculent vomiting is diagnostic of …………

Intestinal obstruction
Gastro-colic fistula

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Vomiting with blood is diagnostic of ……..

oesophageal, gastric or duodenal lesion

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Early morning vomiting in women can be diagnostic of ……

Pregnancy

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Projectile vomiting may be diagnostic of …………

Pyloric stenosis

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Signs in vomiting

Abdominal tenderness
Dehydration
Abdominal distension
Succussion splash
Jaundice
Signs of peritonitis

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Signs of peritonitis

rebound tenderness
rigidity
guarding

Investigations in vomiting

FBC
BUE and Creatinine
LFT
Blood glucose
Serum amylase
Urine RE
Urine Pregnancy test
ECG (if myocardial infarction suspected)
Abdominal X-ray: Intestinal obstruction
Erect Chest X-ray

Purpose of Erec Chest X-ray

Diagnose bowel perforation with air under diaphragm

Investigations in persistent vomiting

Upper gastro-intestinal endoscopy
Serum calcium level
CT scan of brain

Treatment objectives in vomiting

To identify and treat the underlying cause
To prevent dehydration and electrolyte imbalance
To maintain nutrition by ensuring adequate dietary intake during
illness
To maintain personal hygiene
To eliminate infecting organisms where appropriate

Non-pharmacological management treatment of vomiting

Maintain adequate oral fluid intake Maintain adequate nutrition Place naso-gastric tube when needed Surgical intervention in suspected intestinal obstruction, peritonitis

Anti-emetics for use in migraine

Metoclopramide oral, IV or IM or Domperidone oral or Promethazine oral, IV or IM

Dose of metoclopramide

Adults PO, IV, IM 10 mg 8 hourly

Maximum duration of domperidone for vomiting in migraine

7 days

Dose of domperidone

Adults 10 mg, 8 hourly Children > 12 years (Body weight ≥ 35 kg); 10 mg 8-12 hourly (max. 30 mg per day) 1 month-12 years (Body weight ≤ 35 kg); 250 micrograms/kg 8-12 hourly (max. 750 microgram/kg per day

Promethazine dose in vomiting associated with migraine

Promethazine, IV/IM Adults 12.5-25 mg 6-8 hourly as needed (max. 100 mg in 24 hours) Or Promethazine, oral, Children 2-12 years; 0.25-1 mg 6-8 hourly as needed (max. 25 mg per dose) < 2 years; Not recommended

Suggested anti-emetics for use in vestibular nausea and vomiting

Promethazine PO/IV/IM or Cyclizine PO or Cinnarizine IV/IM

Dose of promethazine in vestibular nausea and vomiting

Promethazine, oral, Adults 20-25 mg 12 hourly Children 2-12 years; 0.25-1 mg 6-8 hourly as needed (max. 25 mg per dose) < 2 years; Not recommended Or Promethazine, IV/IM Adults 12.5-25 mg 6-8 hourly as needed (max. 100 mg in 24 hours)

Dose of cyclizine in vestibular nausea and vomiting

Cyclizine, oral, Adults 50 mg 8 hourly as needed Children 6-12 years; 25 mg 8 hourly as needed (max. 75 mg in 24 hours)

Dose of cinnarizine for vestibular nausea and vomiting

Cinnarizine, IV/IM, Adults and children > 12 years 30 mg 8 hourly as needed Children 5-12 years; 15 mg 8 hourly as needed < 5 years; not recommended

Anti-emetics for use in gastroenteritis

Metoclopramide or Domperidone

Metoclopramide dose in vomiting due to gastroenteritis

Metoclopramide, oral/IV/IM, Adults 10 mg 8 hourly

Domperidone dose in vomiting due to gastroenteritis

Domperidone, oral, Adults 10 mg, 8 hourly Children > 12 years (Body weight ≥ 35 kg); 10 mg 8-12 hourly (max. 30 mg per day) 1 month-12 years (Body weight ≤ 35 kg); 250 micrograms/kg 8-12 hourly (max. 750 microgram/kg per day)

Anti-emetics for use in post-operative vomiting

Metoclopramide or Cyclizine

Metoclopramide dose in post-operative vomiting

Adults 10 mg 8 hourly

Dose of cyclizine in post-operative vomiting

Cyclizine, oral/IV/IM, Adults 50 mg 8 hourly as needed Children 6-12 years; 25 mg 8 hourly as needed (max. 75 mg in 24 hours)

Dose of ondansetron for chemotherapy induced vomiting

Ondansetron, IV, Adults 8 mg/ 0.15 mg/kg (pre-chemotherapy) infused over 15 minutes Children > 6 months; 0.15 mg/kg (pre-chemotherapy) infused over 15 minutes, then repeated 4 and 8 hours after first dose. (max is 16 mg/dose) Or Ondansetron, oral, Adults 8 mg 12 hourly Children 4-12 years; 4 mg 30 minutes before chemotherapy, then 4 mg 8 hourly for 24-48 hours as needed < 4 years; not recommended

Antiemetics for chemotherapy induced vomiting

Ondansetron or Granisetron or Dexamethasone or Lorazepam

Dose of dexamethasone for chemotherapy induced vomiting

Adults 8-12 mg before chemotherapy, then 8 mg 24 hourly from days 2-4 Children Not recommended

Dose of granisetron for chemotherapy induced vomiting

Granisetron IV Adults 1mg/10 microgram/kg (30 minutes before Chemotherapy) Children 2-16 years; same as adults <2 years; not recommended Or Granisetron, oral, Adults 1mg 1 hour before chemotherapy, then 1 mg 12 hours after 1st dose Or 2 mg 1 hour before chemotherapy Children Not recommended

Dose of lorazepam for chemotherapy induced vomiting

Lorazepam, oral/IV, Adults 0.5-2 mg 6 hourly as required

Antiemetics for use in pregnancy

Metoclopramide or Promethazine

Metoclopramide dose in pregnancy

Metoclopramide, oral, 10 mg 8 hourly Or Metoclopramide, IV/IM, 10 mg 8 hourly as needed

Promethazine dose in pregnancy

Promethazine teoclate, oral, 10-20 mg 8 hourly as needed Or Promethazine, IM, 12.5-25 mg 8 hourly as needed