Drugs that speed gastric emptying, such as metoclopramide Reglan and powdered ginger root may be helpful in managing emesis Grontved et al, Patients are informed that pain is subjective and that our goal is to make them comfortable so that they are able to participate in physical therapy. Br J Clin Pharmac, 27, These changes are more prominent with dolasetron. They may increase alertness and thereby counterbalance the sedative effects of vestibular suppressants.
Zofran is very expensive, and Compazine causes sedation. In fact, peppermint proved so effective that those in the control group demanded the peppermint, and the control part of the study collapsed. One patient found that it enhanced his appetite. Inhaled peppermint is now routinely offered in many chemotherapy units in the United States and in the UK. Chalifour conducted a pilot study using peppermint to ease nausea in patients detoxing from opiate and crack addiction at the Cooley-Dickenson Hospital, Northampton, Massachusetts.
Peppermint was inhaled 30 minutes before meals. This scale was used before meals breakfast and lunch. Piotroswki offered an aromastick containing peppermint to 17 hospital patients with nausea in Madison, Wisconsin. Nausea was rated pre- and post-test with the Edmonton Symptom Assessment System numerical scale. All participants 8 were taking antinausea medication Compazine or Zofran. Seven participants had marked relief from inhaling peppermint that lasted from 30 minutes to several hours.
Lowdermilk offered her participants a choice of either peppermint or ginger for their chemo-induced nausea. All participants 10 were taking conventional antiemetic drugs but were having breakthroughs. All preferred peppermint to ginger, and all found it helpful. Obtain as much historical information as possible and completely examine the patient. Always consider pregnancy in women of childbearing age who present with vomiting.
If there is any suspicion of a more serious underlying disorder especially in the older patient , perform those tests needed to rule out myocardial infarction, perforated ulcer, aortic aneurysm, or any of the catastrophes that can present in a similar fashion. Always maintain a high index of suspicion for acute appendicitis or other surgical conditions in the patient who presents with abdominal pain and vomiting. In the meantime, rapidly infuse 0.
Fluid and electrolyte replenishment is the mainstay of medical treatment. In adults who have the renal and cardiovascular reserve to handle rapid hydration, 1 to 2 L infused over an hour often provides dramatic improvement of all symptoms. Older patients require more cautious rehydration and are more likely to require a comprehensive diagnostic workup. The use of antiemetics for acute gastritis or gastroenteritis is somewhat controversial.
With mild symptoms, there is probably no need to add this treatment and incur additional expense as well as risk the potential side effects of some of these drugs. For someone who is actively vomiting, however, these drugs can provide comfort and improve the process of rehydration. In adults, ondansetron Zofran , 4 mg IV is particularly advantageous, because it has minimal side effects.
Alternatives include prochlorperazine Compazine , 10 mg, which can also be given IV, along with diphenhydramine Benadryl , Metoclopramide Reglan can also be given slowly to reduce risk of akathisia in a dose of 10 mg IV. During pregnancy, metoclopramide and ondansetron because they are classified as pregnancy category B drugs.
For children who are older than 6 months of age, ondansetron Zofran , 0. Ondansetron although very expensive under the brand name can also be given as an oral disintegrating tablet ODT which is reasonably priced as a generic. Half of a 4-mg tablet 2 mg is an appropriate dose for an average 2-year-old weighing 8 to 15 kg.
The 4-mg tablet can be given to children weighing 16 to 30 kg, and 8 mg can be given to heavier children. Alternatively, metoclopramide Reglan , 0. If after 1 to 2 hours the pediatric patient is improving and beginning to tolerate oral fluids and has a benign repeat abdominal examination, discharge him with instructions to advance his diet over the next 24 hours, starting with an oral rehydration solution, such as the following recipe from the World Health Organization: Children can be rehydrated using the techniques described in Chapter If symptoms resolve more slowly, discharge the patient with a single dose of an antiemetic as described earlier.
Patients should always be encouraged to return for further evaluation and treatment if their symptoms return or if pain continues or worsens. If hypotension or other significant signs or symptoms persist, if the patient cannot tolerate parenteral rehydration, or if he cannot resume oral intake, he may have to be admitted to the hospital for further evaluation and treatment.
Carl Menckhoff, in Essential Emergency Medicine , Some patients may be quite ill, especially elderly persons. The ABCs of life support i. Oxygen administration and cardiac monitoring should be used at least until a cardiac cause is ruled out. The treatment of biliary colic consists of the administration of IV fluids, analgesics, and antiemetics and, rarely, nasogastric suctioning for intractable vomiting.
Analgesia can be accomplished with ketorolac or ibuprofen if tolerating oral and narcotics. Some practitioners prefer meperidine over morphine because it is thought to cause less spasm to the sphincter of Oddi. However, many authorities feel this is not clinically relevant. Antiemetics include promethazine Phenergan , prochlorperazine Compazine , metoclopramide Reglan , or ondansetron Zofran. If symptoms are initially thought to be due to symptomatic cholelithiasis but they do not resolve, early acute cholecystitis should be considered.
Treatment of acute cholecystitis consists of all of the above plus antibiotic coverage and immediate surgical evaluation. All patients with cholecystitis should be admitted to the hospital. Their definitive care will require surgery and a cholecystectomy. The timing of surgery is not universally accepted, however. Emphysematous cholecystitis is a rare form of cholecystitis.
Treatment in the ED is the same, but surgery is performed emergently. Supportive care for children with brain tumors is required throughout the course of RT. Short-term side effects may include nausea, vomiting, fatigue, loss of appetite, headache, and recurrence of neurologic symptoms present at the time of diagnosis.
Prophylactic treatment with antiemetics may be appropriate because many children are not able to articulate their feelings of nausea and reversal of appetite suppression may be difficult once established. First-line medications may include ondansetron Zofran or a similar serotonin antagonist, second-line medications include promethazine Phenergan , or diphenhydramine Benadryl , and third-line medications include corticosteroids, which should be reserved for patients with intractable nausea, vomiting, and neurologic symptoms including headache.
Persistent nausea over several months after treatment has been observed in patients whose tumors arose along the dorsum of the brainstem. Children are unlikely to require antiseizure medication after surgery and corticosteroids during RT. It is important to determine the need for antiseizure medications when encountering a patient who is in the immediate postoperative period and destined to receive RT. Those administered phenytoin are at increased risk for Stevens-Johnson syndrome and toxic epidermal necrolysis.
Those administered levetiracetam risk interactions with a broad range of commonly used over-the-counter and prescribed medications used commonly for ongoing care. It is important to encourage and monitor corticosteroid tapering. Patients treated with corticosteroids preferentially gain weight, which increases head size, affecting immobilization. Those taking corticosteroids need to be monitored for oral candidiasis and require gastrointestinal prophylaxis. For some patients, the need for CSF shunting may not be apparent in the perioperative period and should be monitored carefully.
The need for CSF shunting is highest among children who have more than one surgical procedure. Headache is a complaint that spans the time from diagnosis to beyond treatment for many patients. And although it is a relatively common complaint attributed to the effects of tumor and surgery it may represent a number of underlying conditions: In the absence of an obvious cause there are a number of first-line medications e. Sedation and anesthesia are imperative in the treatment of young children with brain tumors.
The demand has increased because of the requirements of focal radiation delivery protocols and the need to reduce the setup margin component of the planning target volume. At most centers, the majority of children younger than the age of 6 to 7 years require RT. Sedation or anesthesia is generally safe and does not appear to add to the acute effects of treatment, but the use of sedation on a repeated basis does not appear to be as effective as anesthesia.
Dorr, in Surgical Treatment of Hip Arthritis , Before surgery, each patient attended a preoperative class that reviewed the operation, the preoperative and postoperative care, and the postoperative recovery and rehabilitation. Our preoperative class is conducted by a person who is personable, confident, and knowledgeable. It includes all aspects of care, ranging from preoperative logistics to the expectations during the hospital stay and the general recovery.
Special emphasis is placed on the pain management aspect, especially the scaling of pain scores. Patients are informed that pain is subjective and that our goal is to make them comfortable so that they are able to participate in physical therapy. Patients are taught to use the Visual Analog Scale so that they will be able to grade their pain during postoperative period.
Reviewing the pain scale strengthens the team approach by allowing the patient to respond appropriately. Knowing about the type of pain medications given after surgery prepares the patient to interact in a coordinated manner with the nurses and other members of the team when it comes to pain control in the perioperative setting.
Preoperatively, the patients were educated that severe postoperative pain and nausea were unusual. Patients were told that pain was subjective, but that we were confident that we could control their pain without routine use of parenteral narcotics. The patients were instructed that they would be safe and able to function enough to go home and families were told to prepare for that discharge plan. All these factors ultimately enhance recovery. Patients did not stop any COX-2 inhibitor medication before surgery.
During surgery, medications were used to produce a local response. No narcotics were used in the epidural block. The epidural catheter was removed in the operating room at the completion of the anesthesia. Patients were not intubated, and the airway was controlled with laryngeal mask anesthesia. No intravenous narcotics were used during the operation. Clonazepam Klonopin , appears as effective a vestibular suppressant as lorazepam.
The author prefers to avoid use of alprazolam Xanax for vestibular suppression, because of the potential for a difficult withdrawal syndrome. Long acting benzodiazepines are not helpful for relief of vertigo. Peracitam is a derivative of GABA that has a wide range of neurological effects, including relief of vertigo Winbald, Table 2 lists the drugs that are commonly used for control of nausea in vertiginous patients. Relatively new are the 5HT3 agents Zofran, Kytril.
In theory, these agents might not be ideal for emesis related to vestibular imbalance. The choice of agent depends mainly on considerations of the route of administration and the side effect profile. The oral agents are used for mild nausea. Suppositories are commonly used in outpatients who are unable to absorb oral agents because of gastric atony or vomiting. Injectables are used in the emergency room or inpatient settings.
The new agents are used when all else fails. Some antihistamines commonly used as vestibular suppressants have significant antiemetic properties for example, meclizine. When an oral agent is appropriate, this agent is generally the first to be used, because it rarely causes adverse effects any more severe than drowsiness.
Phenothiazines, such as prochlorperazine Compazine and promethazine Phenergan , are effective antiemetics, probably because of their dopamine blocking activity, but they also act at other sites. For example, promethazine is also an H1 blocker. Because these drugs can induce significant side effects, such as dystonia, they are considered second-line drugs whose use should be brief and cautious. Drugs that speed gastric emptying, such as metoclopramide Reglan and powdered ginger root may be helpful in managing emesis Grontved et al, Metoclopramide, a dopamine antagonist and a potent central antiemetic, is ineffective in preventing motion sickness Kohl, Domperidone Motilium is an antiemetic that does not cross the blood-brain barrier and thus has less side effects.
There is a possible role for new antiemetics which are a 5-HT 3 antagonists ondansetron: Kytril used in treating the nausea associated with chemotherapy and post-operative nausea and vomiting. The high cost of these agents presently limits their usefulness in the treatment of vertigo, but they are reasonable agents to try in situations where the more usual agents are ineffective or contraindicated.
These agents do not appear to be helpful in preventing motion sickness Stott et al, In theory, these agents might be less effective for vestibular elicited emesis than agents with other pharmacologic actions. Calcium channel blockers are the most promising agents in this group. More detail about these drugs can be found here. Calcium channel blockers, such as flunarizine and cinnarizine , are popular antivertiginous agents outside of the U.
Rascol et al, Some calcium channel blockers, such as verapamil, have quite strong constipating effects, which may be helpful in managing diarrhea caused by vestibular imbalance. This use of verapamil for vertigo has not been studied or approved in the U. A sodium channel blocker, phenytoin Dilantin , has also been recently reported to be protective against motion sickness Knox et al, The author of this review has had no success in limited trials in patients with severe motion sickness unresponsive to the usual agents.
Gabapentin has also been successfully used to suppress certain types of central nystagmus Stahl et al, Since these agents affect GABA, which is important in vertigo, an antivertigo effect is reasonable. Recent agents have been developed for epilepsy which are glutamate antagonists, but at this writing, they have not been tried as treatments of vertigo. Anticonvulsants are also promising agents for treatment of vertigo. No human trials have yet been undertaken.
This agent might be suitable for patients with uncompensated vestibular asymmetries. This is an interesting group that presently appears poised to move from the uncertain role category to the more conventional category. According to Timmerman quoting Laurikainen , H1 receptors do not appear to be important at all in vestibular function and the antivertiginous effects of antihistamines are mediated either through non-H1 receptors or other effects of the drugs. Also, the H1 and H2 effects are rather minor.
H3 is an autoreceptor that modulates H1 and H2 as well as potentially other neurotransmitter systems. Thus, an agent that primarily affected H3, could at this writing, essentially, pharmacologically do anything. The pharmacological literature is confusing as some authors suggest that betahistine is an H3 agonist Kingma, rather than an antagonist Timmerman, Pragmatically, a betahistine dose of 8 mg three times per day is usually prescribed, although greater effect is obtained for doses as high as 32 mg.
The rationale for this use is that betahistine is said to increase circulation to the inner ear Halmagyi, or affect vestibular function in some mysterious way through activity of H3 receptors Kingma et al, ; Timmerman, At this writing, as H2 agonism would be stimulatory, it appears most likely that Serc acts through the H3 receptor. A recent review reported the mechanisms of action to include increasing vestibular blood flow and increasing the production and release of histamine within the brain Lacour, The authors also noted the stumulatory effects on cerebral H1 receptors, which increases alertness.
Serc is not approved as a drug by the FDA in the U. S — it is considered a placebo. Histamine is sometimes prescribed as sublingual drops or subcutaneous injections. It is the authors opinion that sublingual or subcutaneous histamine is a placebo as it is rapidly degraded. This use has not been studied formally.
Sympathomimetics include ephedrine and the amphetamines. They may increase alertness and thereby counterbalance the sedative effects of vestibular suppressants. Sympathomimetics may also increase compensation. However, if used for this purpose, the combination of a vestibular suppressant with a drug targeted to increase compensation seems somewhat illogical. Amphetamines are little used because of their addiction potential. This medication is marketed and largely used in France Rascol et al, It is claimed to exert a rapid antivertiginous effect when administered intravenously in humans and also to act as a vestibular suppressant.
It is not used in the U. Doxepin is a drug that has an H1 antagonist, adrenergic and antocholinergic properties. One small trial found it to be effective in preventing experimental vertigo in the lab. However, it has many side effects and interacts with a number of other medications, limiting its usefulness Zajonc, Fluoxetine Prozac and imipramine have been tested in animal models and found to be effective for the treatment of vertigo, but their effectiveness in humans is unclear Zajonc, This extract is widely used in France, but its efficacy is in question Rascol et al, It has been reported to suppress vertigo and to enhance vestibular compensation in animals.
See here for more information. The acetylcholine ACh receptor has numerous subtypes, and it would seem reasonable that a selective antagonist to the M2 receptor might cause vestibular suppression without many of the untoward side effects of the more general anti-ACh agents. Unfortunately, little research has been pursued in this direction at the present time. Cocculus is advocated for the temporary relief of lightheadedness.
Vertigoheel is also suggested for vertigo. Karkos et al performed a meta-analysis and found four clinical trials showing vertigoheel to be as effective in the treatment of vertigo as betahistine, ginko biloba, and dimenhydrinate.