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THE MORNING REPORT

The Best in FOAM Education

  • Asim Shahid, DO

Emesis: ad nauseum

Multiple individual pathophysiological pathways which require different approaches

Gastrointestinal Axis

  • MOA: Distension and inflammation of the GI tract, relaying signals back to the brain. Mediated by serotonin and dopamine receptors

  • Medications of choice

    • Anti-dopaminergic agents

      • Metoclopramide

        • IV/PO: 5-10mg q6hrs

        • Max dose: 40mg/d

        • Slower infusions help avoid adverse effects including extrapyramidal syndromes

      • Prochloperazine

        • IV: 2.5-5mg

        • IM: 5-10mg

        • Larger side effect profile: alpha blockade, antimuscarinic side effects, sedation from anti-histamine action

    • Serotonin inhibitors

      • Ondansetron

        • IV/PO: 4-8mg q4-6hrs

        • Adverse effects: QT prolongation

Vestibular Axis

  • Inner ear dysfunctions: BPPV, orthostasis, Meniere's disease

  • Mediated by histamine and muscarinic receptors

  • Medications of choice

    • Anti-histamines

      • Diphenydramine

        • IV/PO: 25-50mg q6hrs

      • Meclizine

        • PO: 12.5-25mg q6hrs

    • muscarinic receptor antagonist

      • Scopolamine

        • transdermal patch

Brainstem Mediated

  • Chemoreceptor trigger zone associated with dopamine, serotonin, muscarinic receptors

  • Patient presentations: DKA, Hyperemesis gravidarum, chemotherapy, etc.

  • Medications of choice

    • Anti-dopaminergic agents

      • Metoclopramide

        • IV/PO: 5-10mg q6hrs

        • Max dose: 40mg/d

        • Slower infusions help avoid adverse effects including extrapyramidal syndromes

      • Prochloperazine

        • IV: 2.5-5mg

        • IM: 5-10mg

        • Larger side effect profile: alpha blockade, antimuscarinic side effects, sedation from anti-histamine action

    • Serotonin inhibitors

      • Ondansetron

        • IV/PO: 4-8mg q4-6hrs

        • Adverse effects: QT prolongation

    • Direct Chemoreceptor trigger zone actor

      • Trimethobenzamide

        • IM/PO: 200mg

      • Alcohol Swabs

        • have the patient sniff it

        • thought to decrease signaling to chemoreceptor trigger zone

        • Systematic review and meta-analysis reviews isopropyl alcohol has statistically significant reduction in reported nausea by 2.18 points on a 10 point scale (99.6% CI 1.6-2.78)

Brain-Gut Axis

  • Peripheral hypersensitivity, hyperanalgesia, central dysregulation (brain misreading signals). Thought to be related to close connection between development of central and enteric nervous system (associated with embryonic tissues)

  • Patient presentations: cyclic vomiting syndrome, cannabinoid hyperemesis

  • Medications of choice

    • Anti-dopaminergic agents

      • Haloperidol

        • IV/PO: 2-5mg

      • Droperidol

        • IV: 1.25-2.5mg

      • Olanzapine

        • IV/PO: 5-10mg

    • Benzodiazepines

      • Diazepam

        • IV/PO: 5-10mg

EKG Prior to medication administration?

  • Not routinely indicated

  • Identify patients at high risk

    • Prior EKGs

    • Patient's current medication lists

  • Consider EKG if redosing medications

  • QT Prolongation is typically dose dependent, so the main culprits (droperidol, ondansetron, metoclopramide) are typically safe at lower doses


Asim Shahid, DO


References

  • Farkas J. Nausea, emesis, and antiemetics. EMCrit Project. Published August 17, 2020. Accessed July 6, 2023. https://emcrit.org/ibcc/antiemetic/

  • Furyk JS, et al. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. Cochrane Database Syst Rev. 2015;2015(9):CD010106. Published 2015 Sep 28. PMID: 26411330

  • Repanshek Z. Vomiting in a World Without Ondansetron Zachary Repanshek, MD FAAEM. www.youtube.com. Published 2018. Accessed July 6, 2023. https://www.youtube.com/watch?v=cewLtoKRzb0

  • Patanwala AE, et al. Antiemetic therapy for nausea and vomiting in the emergency department. J Emerg Med. 2010;39(3):330-336. PMID: 20022195

  • M. Camejo, et al. Rethinking Ondansetron as a First Line Agent for Nausea and Vomiting in the Setting of Abdominal Pain and Headache in the Emergency Department, Annals of Emergency Medicine, Volume 78, Issue 4, Supplement, 2021. Link

  • Egerton-Warburton D, et al. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Ann Emerg Med. 2014;64(5):526-532.e1.  PMID: 24818542

  • Braude D, et al. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med. 2006;24(2):177-182. PMID: 16490647

  • Cisewski D. Droperidol Use in the Emergency Department – What’s Old is New Again. emDOCs.net - Emergency Medicine Education. Published August 1, 2019. http://www.emdocs.net/droperidol-use-in-the-emergency-department-whats-old-is-new-again/

  • Shahsavari D, et al. Haloperidol Use in the Emergency Department for Gastrointestinal Symptoms: Nausea, Vomiting, and Abdominal Pain. Clin Transl Gastroenterol. 2021;12(6):e00362. Published 2021 Jun 1.  PMID: 34060494

  • J. McCoy, et al. Stop the Vomit: Haloperidol as a Superior First-line Antiemetic, Annals of Emergency Medicine, Volume 80, Issue 4, Supplement, 2022. Link

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