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Nausea and vomiting. GABA 5HT Vestibular nuclei ACh H1 CTZ 5HT 3 D 2 Cerebral cortex Gut wall 5HT 3 Vomiting centre ACh H1 5HT 2 Gastric atony Retroperistalsis.

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Presentation on theme: "Nausea and vomiting. GABA 5HT Vestibular nuclei ACh H1 CTZ 5HT 3 D 2 Cerebral cortex Gut wall 5HT 3 Vomiting centre ACh H1 5HT 2 Gastric atony Retroperistalsis."— Presentation transcript:

1 Nausea and vomiting

2 GABA 5HT Vestibular nuclei ACh H1 CTZ 5HT 3 D 2 Cerebral cortex Gut wall 5HT 3 Vomiting centre ACh H1 5HT 2 Gastric atony Retroperistalsis Thoracic and abdominal muscle contractions Vagal/splanchnic afferents

3 Vestibular nuclei CTZ Vomiting centre Gastric atony Retroperistalsis Thoracic and abdominal muscle contractions Movement/vertigo

4 Vestibular nuclei CTZ Vomiting centre Gastric atony Retroperistalsis Thoracic and abdominal muscle contractions Raised ICP Hyponatraemia Fear/anxiety

5 Vestibular nuclei CTZ Vomiting centre Gastric atony Retroperistalsis Thoracic and abdominal muscle contractions Hypercalcaemia Uraemia Morphine Cytotoxic chemotherapy

6 Vestibular nuclei CTZ Vomiting centre Gastric atony Retroperistalsis Thoracic and abdominal muscle contractions Cytotoxic chemotherapy Intestinal Distension Abdominal RXT Gastric irritants

7 Case studies Pick the most appropriate antiemetic in each case

8 Management Treat reversible causes Remember unrelated causes e.g gastroenteritis Choose the most appropriate antiemetic for the cause Prescribe the same antiemetic regularly and prn If oral absorption in doubt, use sc route Remember non-drug treatments Consider dexamethasone REVIEW

9 Common anti-emetics Prokinetic for gastric stasis, functional bowel obstruction Metoclopramide 10mg tds or 30-60mg/24hr CSCI Acting on CTZ trigger zone for chemical causes of vomiting eg morphine, renal failure Haloperidol 1.5-3mg stat/nocte or 2.5-5mg sc stat and mg/24hr CSCI

10 Common anti-emetics Antispasmodic and antisecretory if bowel colic and/or need to reduce GI secretions Buscopan 20mg stat 60 – 120mg/24hr CSCI Acting in the Vomiting Centre for raised ICP, motion sickness or mechanical bowel obstruction Cyclizine 50mg tds 150mg/24hr CSCI Broad-spectrum for mechanical obstruction, or if others fail Levomepromazine mg nocte

11 Nausea and Vomiting CauseClinical PictureRx Metabolic (drugs, uraemia, hypercalcaemia) Persistent nausea1)Haloperidol 2)Levomepromazine Gastric stasisOcc. nausea relieved by vomiting 1)Metoclopramide 2)Domperidone Bowel obstruction (abdo. ca./autonomic neuropathy) Nausea relieved by vomiting ± colic ± faecal vomit 1)Metoclopramide 2)Buscopan/ levomepromazine 3)Cyclizine ICP, brainstem disease HeadacheCyclizine ± dex. Vestibular diseaseMovement related1)Cyclizine 2) Levomepromazine Bentley A, Boyd K. Palliative Medicine 2001;15:

12 Summary Try to establish the cause and choose an appropriate antiemetic, rather than picking your favourite Avoid combinations that may antagonise each other Choose an appropriate route


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