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! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align="center" |{{fontcolor|#2B3B44|Vomiting<BR>Resident Survival Guide}}
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" |{{fontcolor|#2B3B44|Vomiting Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Overview|Overview]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Vomiting resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Vomiting resident survival guide#Diagnosis|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Vomiting resident survival guide#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Treatment|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Vomiting resident survival guide#Dos|Dos]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Do's|Do's]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Vomiting resident survival guide#Don'ts|Don'ts]]
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{{WikiDoc CMG}}; {{AE}} {{RAB}}
{{WikiDoc CMG}}; {{AE}} {{RAB}}
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==Overview==
==Overview==
This section provides a short and straight to the point overview of the disease or symptom.  The first sentence of the overview must contain the name of the disease.
[[Nausea and vomiting|Vomiting]] or [[Emesis]] means forcible emptying of the contents of [[stomach]] in which the [[stomach]] has to overcome the pressures that are normally in place to keep food and secretions within the [[stomach]].[[Nausea and vomiting|Nausea]] and [[Nausea and vomiting|vomiting]] are most common causes for patients to seek primary care treatment, so it is very important to identify  and properly manage the underlying problems causing vomiting.Though the mechanisms causing of [[Nausea and vomiting|nausea]] and [[Nausea and vomiting|vomiting]] are not completely understood, it is thought that the activation of a [[medullary]] [[vomiting]] centre by either afferent input from the [[gastrointestinal tract]] due to presence of local [[irritants]] or stimulation of the central [[chemoreceptor]] trigger zone by circulating [[Emesis|emetogenic]] substances may cause [[vomiting]].[[Dopamine]] and [[serotonin]] are the main transmitters both in central nervous system and [[gastrointestinal tract]] related [[vomiting]]. The most common causes of vomiting are [[Gastroenteritis]], [[Migraine]], Gastro peresis,Post operative, [[radiation]] and [[chemotherapy]] related [[vomiting]], [[tumor]], increased intracranial pressure,[[Hepatitis]], [[Cholecystitis]],[[Labyrinthitis|Labyrithitis]], [[Alcohol]] abuse, [[pregnancy]] induced [[Nausea and vomiting|vomiting]]. The management of  most cases of [[Nausea and vomiting|nausea]] and [[Nausea and vomiting|vomiting]] depends on a good history and a detailed complete physical examination. Most episodes of [[Nausea and vomiting|vomiting]] that lasts for less than 48 hours have an existing triggering factor such as [[infection]], viral illness, or [[food poisoning]] and can be managed by removing the triggering factor and by supportive therapy. Chronic and unexplained [[Nausea and vomiting|nausea]] and [[Nausea and vomiting|vomiting]] can be a difficult to treat as the cause is often obscure and requires special investigation.


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==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of Vomiting
Shown below is an algorithm summarizing the diagnosis of Vomiting<ref name="ChepyalaOlden2008">{{cite journal|last1=Chepyala|first1=Pavan|last2=Olden|first2=Kevin W.|title=Nausea and vomiting|journal=Current Treatment Options in Gastroenterology|volume=11|issue=2|year=2008|pages=135–144|issn=1092-8472|doi=10.1007/s11938-008-0026-6}}</ref><ref name="HaslerChey2003">{{cite journal|last1=Hasler|first1=William L|last2=Chey|first2=William D|title=Nausea and vomiting|journal=Gastroenterology|volume=125|issue=6|year=2003|pages=1860–1867|issn=00165085|doi=10.1053/j.gastro.2003.09.040}}</ref><ref name="SinghYoon2015">{{cite journal|last1=Singh|first1=Prashant|last2=Yoon|first2=Sonia S.|last3=Kuo|first3=Braden|title=Nausea: a review of pathophysiology and therapeutics|journal=Therapeutic Advances in Gastroenterology|volume=9|issue=1|year=2015|pages=98–112|issn=1756-283X|doi=10.1177/1756283X15618131}}</ref>
 
 
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | |A01=    Patient comes with vomiting  }}
{{Family tree | | | | | | | A01 | | | |A01=    Patient comes with vomiting  }}
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;"> '''Ask the following questions about vomiting'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;"> '''Ask the following questions about vomiting'''<br>
----
----
❑How long have you had nausea and vomiting?<br><br>❑How much have you vomitted?<br><br>❑What is the colour of the vomitus?<br><br>❑Have you had previous episodes like this or this is the first time?<br><br>❑Is there any foul smell of the vomitus?<br><br>❑Is there only food particle or any other mucous/substance present with the vomitus?<br><br>❑Have you notice any blood streaks mixed with vomitus?<br><br></div>}}
❑ How long have you had [[nausea]] and [[vomiting]]?<br><br>❑ How much have you vomited?<br><br>❑ What is the colour of the [[vomitus]]?<br><br>❑ Have you had previous episodes like this or this is the first time?<br><br>❑ Is there any foul smell of the vomitus?<br><br>❑ Is there only food particle or any other mucous/substance present with the vomitus?<br><br>❑ Have you notice any blood streaks mixed with [[vomitus]]?<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;"> '''Ask the related questions'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;"> '''Ask the related questions'''<br>
----
----
❑Did your nausea and vomiting occur right after eating?<br><br> ❑Do you have a fever?<br><br>❑Do you take any other medication<br><br>❑Have you recently eaten out?<br><br>❑Have you eaten any canned product?<br><br>❑Have you suffered from headache or photophobia along with this vomiting?<br><br> ❑Did you have any abdominal pain?</div>}}
❑ Did your [[nausea]] and [[vomiting]] occur right after eating?<br><br> ❑ Do you have a [[fever]]?<br><br>❑ Do you take any other medication?<br><br>❑ Have you recently eaten out?<br><br>❑ Have you eaten any canned product?<br><br>❑ Have you suffered from [[headache]] or [[photophobia]] along with this vomiting?<br><br> ❑ Did you have any abdominal pain?</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
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----
----
❑ [[Blood pressure]]<br><br>❑ [[Weight]] <br><br>
❑ [[Blood pressure]]<br><br>❑ [[Weight]] <br><br>
❑ [[Body Mass Index]]<br><br>❑Temperature<br><br>❑Heart rate<br><br>❑Respiratory rate </div>}}
❑ [[Body Mass Index]]<br><br>❑ [[Temperature]]<br><br>❑ [[Heart rate]] <br><br>❑ [[Respiratory rate]] </div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 52em; width: 30em; padding:1em;"> '''Do general [[physical examination]]:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 52em; width: 30em; padding:1em;"> '''Do general [[physical examination]]:'''<br>
----
----
❑'''Look for signs of dehydration'''<ref name="urlAdult Dehydration - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK555956/ |title=Adult Dehydration - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid30518346">{{cite journal
❑'''Look for signs of [[dehydration]]'''<ref name="urlAdult Dehydration - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK555956/ |title=Adult Dehydration - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid30518346">{{cite journal
|vauthors=Shaheen NA, Alqahtani AA, Assiri H, Alkhodair R, Hussein MA
|vauthors=Shaheen NA, Alqahtani AA, Assiri H, Alkhodair R, Hussein MA
|title=Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics
|title=Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics
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|url=
|url=
|issn=
|issn=
}}</ref><br><br> *Orthostatic blood pressure drop,tachycardia<ref name="pmid30518346">{{cite journal
}}</ref><br><br> *[[Orthostatic blood pressure]] drop,[[tachycardia]]<ref name="pmid30518346">{{cite journal
|vauthors=Shaheen NA, Alqahtani AA, Assiri H, Alkhodair R, Hussein MA
|vauthors=Shaheen NA, Alqahtani AA, Assiri H, Alkhodair R, Hussein MA
|title=Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics
|title=Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics
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|url=
|url=
|issn=
|issn=
}}</ref><br><br>*Light-headedness<br><br> *Dark urine or decreased urine output<br><br>*Increased capillary refill time<ref name="urlAdult Dehydration - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK555956/ |title=Adult Dehydration - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><br><br>*Poor skin turgor<br><br>*Tiredness<br><br>*Appetite<br><br>❑ '''Perform abdominal examination'''<br><br>*Look for any abdominal tenderness<br><br>*Presence of bowel sound</div>}}
}}</ref><br><br>*Light-headedness<br><br> *Dark urine or decreased urine output<br><br>*Increased capillary refill time<ref name="urlAdult Dehydration - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK555956/ |title=Adult Dehydration - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><br><br>*Poor skin [[turgo]]r<br><br>*Tiredness<br><br>*[[Appetite]]<br><br>❑ '''Perform abdominal examination'''<br><br>*Look for any abdominal [[tenderness]]<br><br>*Presence of [[bowel sound]]</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | h01 | | |h01=<div style="float: left; text-align: left; height: 55em; width: 20em; padding:1em;"> '''Do the following invetigations'''<br>
----
❑ [[Complete blood count]]<br><br>❑ [[Electrolytes]]<br><br>❑ [[Liver function test]]<br><br>❑ [[Pancreatic enzymes]]<br><br>❑ [[USG of the abdomen]] if complains of [[abdominal pain]].<br><br>❑ [[Pregnancy test]] if applicable.<br><br>❑ [[Abdominal X-ray]] and abdominal [[CT scan]] if any symptoms of mechanical obstruction<br><br>❑ [[Esophagogastroduodenoscopy]] if [[mucosal]] diseases such as [[ulcer]] or mass are suspected.<br><br>❑ [[Scintigraphic]] measures of solid phase [[gastric]] emptying (such as 99mTc-sulfur colloid in egg) are commonly used to evaluate [[gastric motion]] function in suspected [[gastroparesis]].</div> | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= If patient gives history of}}
{{Family tree | | | | | | | B01 | | | |B01= If patient gives history of}}
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{{familytree  | |,|-|-|-|-|-|+|-|-|-|-|-|v|-|-|-|-|.| | }}
{{familytree  | |,|-|-|-|-|-|+|-|-|-|-|-|v|-|-|-|-|.| | }}
{{familytree  | |!| | | | | |!| | | | | |!| | | | |!| | | }}
{{familytree  | |!| | | | | |!| | | | | |!| | | | |!| | | }}
{{familytree  | D01 | | | D02 | | | | | D04 | | | D05 |D01=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''History of'''<br>
{{familytree  | D01 | | | D02 | | | | | D04 | | | D05 |D01=<div style="float: left; text-align: left; height: 17em; width: 10em; padding:1em;"> '''History of'''<br>
----
❑ [[Abdominal pain]]<br><br>❑ Eating out or eating reheated canned food. <br><br>
❑ Abdominal [[bloating]]<br><br>❑ Passage of loose [[stool]]<br><br> </div>|D02=<div style="float: left; text-align: left; height: 5em; width: 10em; padding:1em;"> '''History of'''<br>
----
❑[[Headache]]</div>|D03=D03|D04=<div style="float: left; text-align: left; height: 10em; width: 10em; padding:1em;"> '''History of'''<br>
----
----
Abdominal pain<br><br>❑ Eating out or eating reheated canned food <br><br>
[[Acidosis]]<br><br>❑ [[Dehydration]]<br><br> </div>|D05=<div style="float: left; text-align: left; height: 10em; width: 10em; padding:1em;"> '''History of'''<br>
❑ Abdominal bloating<br><br>❑Passage of loose stool<br><br> </div>|D02=<div style="float: left; text-align: left; height: 5em; width: 15em; padding:1em;"> '''History of'''<br>
----
----
❑Headache</div>|D03=D03|D04=D04|D05=D05}}
❑ [[Abdominal pain]] </div>}}
{{familytree  | |!| | | | | |!| | | | | |!| | | | |!| | | }}
{{familytree  | |!| | | | | |!| | | | | |!| | | | |!| | | }}
{{familytree  | |!| | | | | |!| | | | | |!| | | | |!| }}
{{familytree  | |!| | | | | |!| | | | | |!| | | | |!| }}
{{familytree  | |!| | | | |,|^|.| | | | |!| | | |!| | | }}
{{familytree  | |!| | | | |,|^|.| | | | |!| | | | |!| | | }}
{{familytree  | |!| | | | |!| |!| | | | |!| | | |!| | | }}
{{familytree  | |!| | | | |!| |!| | | | |!| | | | |!| | }}
{{familytree  |D09| |D01| |D02| | | | | |!| | | | |D09=Gastroenteritis|D01=<div style="float: left; text-align: left; height: 20em; width: 15em; padding:1em;">  
{{familytree  |D09| |D01| |D02| | |!| | | | |!| | | |D09=[[Gastroenteritis]]|D01=<div style="float: left; text-align: left; height: 19em; width: 10em; padding:1em;">  
❑Photophobia<br><br>❑Triggered by smell, light or loud sound<br><br>❑Unilateral headache usually,maybe bilateral which stays for 2-3 days<br><br>❑May have history of taking wine, chocolate<br><br></div>||||| }}
❑ [[Photophobia]]<br><br>❑ Triggered by smell, light or loud sound<br><br>❑ Unilateral [[headache]] usually, maybe bilateral which stays for 2-3 days.<br><br>❑ May have history of taking wine, chocolate.<br><br></div>|D02=<div style="float: left; text-align: left; height: 17em; width: 10em; padding:1em;">
{{familytree  | | | | | |!| | | | |!| | | | | | | | | | | }}
❑ [[Dizziness]]<br><br>❑ Altered behaviour<br><br>❑ [[Vision]] changes<br><br>❑ [[Weakness]] of any part of body/ [[paralysis]]<br><br></div>|||| }}
{{familytree  | | | | |a01| | | |b01| | | | | | | | |a01=Migraine |b01=Tumor | | | | }}
{{familytree  | | | | | |!| | | | |!| | |!| | | | |!| | | }}
{{familytree  | | | | |a01| | |b01| |c02| | |!|a01=[[Migraine]] |b01=[[Tumor]] |c02=Metabolic disorder | | | }}
{{familytree  | | | | | | | | | | |,|-|-|-|-|-|-|-|^|-|.| }}
{{familytree  | | | | | | | | | |f01| | |f02| | |f09| |f01= [[Weight]] loss, loss of [[appetite]]|f02=Pain related to food, radiates to the back|f09=presence of [[jaundice]], [[hepatomegaly]]| }}
{{familytree  | | | | | | | | | |!| | | | |!| | | | |!| | | | | | | | | | | | | | | }}
{{familytree  | | | | | | | | h01 | | | | h02 | | | h03 | | | | | | | | | |h01=[[Gastric carcinoma]] |h02=[[Pancreatitis]] |h03=[[Hepatitis]] | | | | | }}
{{familytree/end}}
{{familytree/end}}


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|<br>10–20 mg q6–8 hours<br>10 mg q8–24 hours<br>
|<br>10–20 mg q6–8 hours<br>10 mg q8–24 hours<br>
|
|
*Sedation
*[[Sedation]]
*Anxiety
*[[Anxiety]]
*Mood disturbances
*[[Mood]] disturbances
*Sleep disruption
*Sleep disruption
*Dystonic reactions
*[[Dystonic]] reactions
*Tardive dyskinesia
*[[Tardive dyskinesia]]
*Galactorrhea
*[[Galactorrhea]]
*Sexual dysfunction
*Sexual dysfunction
|-
|-
|'''Phenothiazines'''
|'''[[Phenothiazines]]'''
|<br>
|<br>


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|
|
*[[Drowsiness]]
*[[Drowsiness]]
*[[Blurred vision]]  
*[[Blurred vision]]
*[[Dry mouth]]
*[[Dry mouth]]
*[[constipation]]
*[[constipation]]
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|}
|}


==Do's==
Below is the algorithm showing the treatment of [[vomiting]] :
 
{{familytree/start}}
{{familytree | | | | | | | | | C02 | | | | | | | |C02=Patient comes with [[vomiting]]|}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.| | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| |}}
{{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | D01=Motion sickness with [[labirynthitis]]<ref name="urlPractical selection of antiemetics - PubMed">{{cite web |url=https://pubmed.ncbi.nlm.nih.gov/15023018/ |title=Practical selection of antiemetics - PubMed |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>|D02=Migraine|D03=Post-operative or [[chemotherapy]] related vomiting|D04=[[Gatroenteritis]]|D05=[[Gastroperesis]]|D06= [[Pregnancy]] induced [[vomiting]]}}
{{familytree | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| |}}
{{familytree | E01 | |E02| | |E03| |E04| | |E05| |E06| |E01=[[Antihistamines]]|E02=[[Phenothiazines]]|E03=[[Phenothiazines]],[[Cannabinoids]],[[Corticosteroids]],[[Aprepitant]]|E04=[[Antibiotics]]|E05=[[Prokinetic]] medications|E06=❑ [[Doxylamine succinate]]/[[pyridoxine hydrochloride]]<ref name="urlThe pharmacologic management of nausea and vomiting of pregnancy - PubMed">{{cite web |url=https://pubmed.ncbi.nlm.nih.gov/24527483/ |title=The pharmacologic management of nausea and vomiting of pregnancy - PubMed |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><br>❑ Complementary and alternative therapies, such as ginger, [[acupressure]], and vitamin B6<ref name="urlPractical selection of antiemetics - PubMed">{{cite web |url=https://pubmed.ncbi.nlm.nih.gov/15023018/ |title=Practical selection of antiemetics - PubMed |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}<br>❑ [[Metoclopramide]] <br>❑ [[Ondansetron]] <br>❑ [[Phenothiazines]]</ref>|}}
{{familytree | | | | | | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | | | | | |r09| | |r09=<div style="float: left; text-align: left; height: 15em; width: 10em; padding:1em;"> '''Prokinetic Medications'''<br>
----
❑ [[Metoclopramide]] <br><br>❑ [[Domperidone]]<br><br>❑ [[Erythromycin]]</div>}}
{{familytree/end}}
 
==Dos==


*Encourage patient to keep taking small sips of water frequently so that they don't become dehydrated.<ref name="urlVomiting in adults | NHS inform">{{cite web
*Encourage patient to keep taking small sips of water frequently so that they don't become dehydrated.<ref name="urlVomiting in adults | NHS inform">{{cite web
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==Don'ts==
==Don'ts==


*Patient who is vomiting continuously and also has past medical history of Diabetes corrected with Insulin should consult with their physicians before taking insulin as vomiting alters blood sugar levels.
*Patient who is vomiting continuously and also has past medical history of [[Diabetes]] corrected with Insulin should consult with their physicians before taking [[insulin]] as vomiting alters blood sugar levels.
*Renal consultation should be acquired especially with severe hyponatremia
*Renal consultation should be acquired especially with severe [[hyponatremia]]
 


==References==
{{Reflist|2}}


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Latest revision as of 11:12, 9 April 2021


Vomiting Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

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Overview

Vomiting or Emesis means forcible emptying of the contents of stomach in which the stomach has to overcome the pressures that are normally in place to keep food and secretions within the stomach.Nausea and vomiting are most common causes for patients to seek primary care treatment, so it is very important to identify and properly manage the underlying problems causing vomiting.Though the mechanisms causing of nausea and vomiting are not completely understood, it is thought that the activation of a medullary vomiting centre by either afferent input from the gastrointestinal tract due to presence of local irritants or stimulation of the central chemoreceptor trigger zone by circulating emetogenic substances may cause vomiting.Dopamine and serotonin are the main transmitters both in central nervous system and gastrointestinal tract related vomiting. The most common causes of vomiting are Gastroenteritis, Migraine, Gastro peresis,Post operative, radiation and chemotherapy related vomiting, tumor, increased intracranial pressure,Hepatitis, Cholecystitis,Labyrithitis, Alcohol abuse, pregnancy induced vomiting. The management of most cases of nausea and vomiting depends on a good history and a detailed complete physical examination. Most episodes of vomiting that lasts for less than 48 hours have an existing triggering factor such as infection, viral illness, or food poisoning and can be managed by removing the triggering factor and by supportive therapy. Chronic and unexplained nausea and vomiting can be a difficult to treat as the cause is often obscure and requires special investigation.


Causes

Life Threatening Causes

Life-threatening causes of vomiting include[1]:

Common Causes

Common causes include: [3]

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Vomiting[4][5][6]


 
 
 
 
 
 
Patient comes with vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about vomiting

❑ How long have you had nausea and vomiting?

❑ How much have you vomited?

❑ What is the colour of the vomitus?

❑ Have you had previous episodes like this or this is the first time?

❑ Is there any foul smell of the vomitus?

❑ Is there only food particle or any other mucous/substance present with the vomitus?

❑ Have you notice any blood streaks mixed with vomitus?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the related questions

❑ Did your nausea and vomiting occur right after eating?

❑ Do you have a fever?

❑ Do you take any other medication?

❑ Have you recently eaten out?

❑ Have you eaten any canned product?

❑ Have you suffered from headache or photophobia along with this vomiting?

❑ Did you have any abdominal pain?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do general physical examination:

Look for signs of dehydration[7][8]

*Look for sunken eyes[8]

*Dry mouth/tongue, thirst[8]

*Dry skin

*Dizziness and a lack of focus[8]

*Orthostatic blood pressure drop,tachycardia[8]

*Light-headedness

*Dark urine or decreased urine output

*Increased capillary refill time[7]

*Poor skin turgor

*Tiredness

*Appetite

Perform abdominal examination

*Look for any abdominal tenderness

*Presence of bowel sound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do the following invetigations

Complete blood count

Electrolytes

Liver function test

Pancreatic enzymes

USG of the abdomen if complains of abdominal pain.

Pregnancy test if applicable.

Abdominal X-ray and abdominal CT scan if any symptoms of mechanical obstruction

Esophagogastroduodenoscopy if mucosal diseases such as ulcer or mass are suspected.

Scintigraphic measures of solid phase gastric emptying (such as 99mTc-sulfur colloid in egg) are commonly used to evaluate gastric motion function in suspected gastroparesis.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient gives history of
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of

Abdominal pain

❑ Eating out or eating reheated canned food.

❑ Abdominal bloating

❑ Passage of loose stool

 
 
History of

Headache
 
 
 
 
History of

Acidosis

Dehydration

 
 
History of

Abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gastroenteritis
 
Photophobia

❑ Triggered by smell, light or loud sound

❑ Unilateral headache usually, maybe bilateral which stays for 2-3 days.

❑ May have history of taking wine, chocolate.

 
Dizziness

❑ Altered behaviour

Vision changes

Weakness of any part of body/ paralysis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Migraine
 
 
Tumor
 
Metabolic disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight loss, loss of appetite
 
 
Pain related to food, radiates to the back
 
 
presence of jaundice, hepatomegaly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gastric carcinoma
 
 
 
Pancreatitis
 
 
Hepatitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is the treatment of Vomiting. [9]

Medications used to treat Nausea and Vomiting[9]
Mechanism Name Dose Side effects
5-HT3 antagonists

4–8 mg q4–8 hours
1–2 mg q24 hours
0.075–0.25 mg q24 hours
Benzamides

10–20 mg q6–8 hours
10 mg q8–24 hours
Phenothiazines

5–10 mg q6–8 hours
12.5 –25 mg q4–6 hours
10–25 mg q4–6 hours
4–8 mg q8–12 hours
Cannabinoids

2.5–10 mg q6–8 hours
1–2 mg q8–12 hours
Anticholinergics
0.3–0.6 mg q24 hours
Antihistamines
25–50 mg q24 hours
25–50 mg q6–8 hours
25–75 mg q8 hours
25–100 mg q6–8 hours
Benzodiazepines 0.5–2 mg
0.25–1 mg
Corticosteroids
4–8 mg q4–6 hours
Butyrophenones
0.625–1.25 mg q24hours
NK-1 Receptor Antagonists
80–125 mg q24 hours

Below is the algorithm showing the treatment of vomiting :

 
 
 
 
 
 
 
 
Patient comes with vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Motion sickness with labirynthitis[10]
 
Migraine
 
Post-operative or chemotherapy related vomiting
 
Gatroenteritis
 
Gastroperesis
 
Pregnancy induced vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antihistamines
 
Phenothiazines
 
 
Phenothiazines,Cannabinoids,Corticosteroids,Aprepitant
 
Antibiotics
 
 
Prokinetic medications
 
Doxylamine succinate/pyridoxine hydrochloride[11]
❑ Complementary and alternative therapies, such as ginger, acupressure, and vitamin B6[10]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prokinetic Medications

Metoclopramide

Domperidone

Erythromycin
 
 

Dos

  • Encourage patient to keep taking small sips of water frequently so that they don't become dehydrated.[12]
  • Recommend patients to take sweet drink such as fruit juice for replacing lost sugar, although they should avoid sweet drinks if those make them feel sick.
  • Recommend to have salty snacks, such as crisps, can help replace lost salt.

Don'ts

  • Patient who is vomiting continuously and also has past medical history of Diabetes corrected with Insulin should consult with their physicians before taking insulin as vomiting alters blood sugar levels.
  • Renal consultation should be acquired especially with severe hyponatremia



Template:WikiDoc Sources


References

  1. Hayes B, Murtagh C, Mann GB (August 2008). "A case of life-threatening nausea and vomiting". J Pain Symptom Manage. 36 (2): 206–10. doi:10.1016/j.jpainsymman.2007.10.022. PMID 18495417.
  2. 2.0 2.1 Frese T, Klauss S, Herrmann K, Sandholzer H (February 2011). "Nausea and vomiting as the reasons for encounter in general practice". J Clin Med Res. 3 (1): 23–9. doi:10.4021/jocmr410w. PMC 3194022. PMID 22043268.
  3. Scorza K, Williams A, Phillips JD, Shaw J (July 2007). "Evaluation of nausea and vomiting". Am Fam Physician. 76 (1): 76–84. PMID 17668843.
  4. Chepyala, Pavan; Olden, Kevin W. (2008). "Nausea and vomiting". Current Treatment Options in Gastroenterology. 11 (2): 135–144. doi:10.1007/s11938-008-0026-6. ISSN 1092-8472.
  5. Hasler, William L; Chey, William D (2003). "Nausea and vomiting". Gastroenterology. 125 (6): 1860–1867. doi:10.1053/j.gastro.2003.09.040. ISSN 0016-5085.
  6. Singh, Prashant; Yoon, Sonia S.; Kuo, Braden (2015). "Nausea: a review of pathophysiology and therapeutics". Therapeutic Advances in Gastroenterology. 9 (1): 98–112. doi:10.1177/1756283X15618131. ISSN 1756-283X.
  7. 7.0 7.1 "Adult Dehydration - StatPearls - NCBI Bookshelf".
  8. 8.0 8.1 8.2 8.3 8.4 Shaheen NA, Alqahtani AA, Assiri H, Alkhodair R, Hussein MA (December 2018). "Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics". BMC Public Health. 18 (1): 1346. doi:10.1186/s12889-018-6252-5. PMC 6282244. PMID 30518346.
  9. 9.0 9.1 Singh P, Yoon SS, Kuo B (January 2016). "Nausea: a review of pathophysiology and therapeutics". Therap Adv Gastroenterol. 9 (1): 98–112. doi:10.1177/1756283X15618131. PMC 4699282. PMID 26770271.
  10. 10.0 10.1 "Practical selection of antiemetics - PubMed".
  11. "The pharmacologic management of nausea and vomiting of pregnancy - PubMed".
  12. "Vomiting in adults | NHS inform".

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