Everybody thanks for thanks for being here anybody who is planning on engaging in twitter with this talk i can be found at zacchara yeah here we go so my brother was diagnosed with cancer a couple years ago and when he was getting chemotherapy i asked him you know where they are they prescribed you anything for nausea and he said i can’t pronounce the name of the
Medication but it sounds like the name of a dancing robot and i thought that was a really good explanation for us so we love and dance-a-tron it is our most popular antiemetic we give it for everyone who’s vomiting you know my nurses will ask me can i give this patient zofran before i’ve even seen the patient but it’s not the only antiemetic that’s out there and
Even though it’s a great anti medic i think that we probably can treat vomiting a little bit better if we try to treat the underlying cause with specific medications targeting at that cause so in order to do that we know where vomiting comes from to begin with and vomiting starts at the vomiting center which is in the medulla oblongata and there’s four different
Parts of the body that send signals to the vomiting center that cause a person to vomit and we’re going to talk about each one of those four areas because the place where that signal to vomit originates from is going to help you decide how to treat it so the first area is the chemoreceptor trigger zone which is at the base of the skull a lot of different neurotoxins
And inflammatory markers when they come through the ci the brain they stimulate this area and cause vomiting this is why cases with dka vomit so there’s a couple of different neurotransmitters that work at this site and the knowing the specific neurotransmitter is important because that’s how we can decide which medication is going to be best to work on that area
So for gi related vomiting so your patient with gastroenteritis gets inflammation and stretch of their gi tract when that happens there’s vagal activation it goes up to the vomiting center location vomits this is mediated by serotonin and dopamine specifically so we want to use medications that are gonna address that in comparison vestibular related vomiting your
Vertigo patient that just can’t stop vomiting that’s caused by a completely different thing that’s caused by his to be and musker it so these are two completely different types of vomiting so why would we treat them as the same in the same way well we shouldn’t the fourth area where vomiting comes from is a little bit more hard to understand it’s the cerebral cortex
This is your patient who’s vomiting due to emotional stress due to anxiety fear we don’t really have a great understanding of where this type of vomiting comes from but it’s definitely the hardest one to control okay so now that we have a better understanding of the different areas where vomiting comes from we can talk about how we’re going to treat it and for the
Purpose of this activity i went to you all to imagine that the entire world store of ondansetron one day just dried up you no longer have access to zofran you can’t give it to your patients so without that all-encompassing antiemetic let’s talk about how we can treat vomiting based on its underlying etiology so we’ll start with metoclopramide probably the second
Most common antiemetic and there’s a good reason why it works dopamine serotonin histamine it basically covers all the bases it’s great for gi motility related vomiting it’s great for headaches and vomiting it’s great for vertigo and vomiting this is a great thing to use but there’s another medication similar to metoclopramide that you might not be using for nausea
And vomiting and that’s how a pair at all we always think of this as an anti-psychotic or a sedative but it has great antiemetic property many of you probably use compazine for vomiting in the pass and haloperidol works the same way as a dopamine agonist to stop vomiting i’ve had a lot of luck using haloperidol in a very specific patient population and it’s these
Patients the patient that the bombing is coming from the cerebral cortex you know that patient you’ve all had this patient they’re a little bit agitated maybe there’s a little bit hysterical maybe you’re thinking there’s not really a good underlying reason why this person is vomiting but i can’t get them to stop vomiting haloperidol is the perfect drug to use in
That situation and there’s another one that you probably don’t think goes an antiemetic and that’s benzodiazepines they have been used as adjutant treatment for nausea and vomiting and chemotherapy related vomiting for years but we hardly ever use does an antiemetic emergency department so if you’ve gone through all your other antiemetics and that patients still
Vomiting maybe they seem really anxious about the fact they can’t stop vomiting consider using a low dose of lorazepam and it histamine same thing we don’t primarily think of them as an antiemetic but promethazine or phenergan is a commonly used antiemetic especially in post-operative patients and it’s an antihistamine diphenhydramine has antiemetic property okay
So these are really good for that vestibular related knowledge evolving the vertigo patients that can’t tolerate pos for the ones who can obviously we use meclizine which again is another antihistamine and then halloween which we can give transdermally we use for patients with motion sickness because it works on musk rims so again these are things that work in the
Persistent vestibular system one final patient population that’s very special that we’re going to end with talking about here today is that pregnant vomiting patient how do we want to treat those patients specifically now this woman is not upset because she’s been vomiting throughout her pregnancy she’s upset because she just found out the dance at ron that she’s
Been taking throughout her pregnancy is gonna hurt her unborn child well let’s be honest there’s no good data that links on dance-a-tron to birth defects but that’s not gonna stop people from trying to scare all the pregnant women out there but this right this is these are real these all exist so the good news is we for our patients who are worried about taking
Zofran during pregnancy we have another choice in fact we have a better option the american college of obstetrics and gynecology first-line agent for nausea vomiting pregnancy is a combination of doxylamine another antihistamine and pure doxy vitamin b says you can get this in a combo pill called diplegia s’ which is pretty expensive so an easier way for most of
Our patients to do this is by some over-the-counter doc’s alameen unisom and by some over-the-counter vitamin b sets and take them together now if the patient needs something iv you can consider an iv antihistamine such as diphenhydramine or metoclopramide as first-line agents so let’s wrap this up there’s a lot of different reasons why people vomiting and everyone
Who’s vomiting is not vomiting for the same reason so we shouldn’t treat them the same and remember there’s a ton of antiemetics out there don’t get caught using just on dance-a-tron use your full toolbox man timex that’s all i have today thank you guys so much for your time
Transcribed from video
Vomiting in a World Without Ondansetron Zachary Repanshek, MD FAAEM By SLED
