NAUSEA MANAGEMENT
Assessment: Conceptualize Underlying Causes: 13 "M's" of Emesis Above Neck 1. Masses 2. Meningeal Irritation 3. Migraine / other headaches 4. Movement Below Neck 5. Motility 6. Mucositis 7. Mechanical obstruction 8. Myocardial infarction 9. Maternity Systemic 10. Mentation 11. Medications 12. Microbes 13. Metabolic
Treatment 1. Treat underlying cause 2. Treat experience of nausea
Conceptualize likely neurotransmitters. Dopamine antagonists are first choice. Titrate to effect using t Cmax . Add medications from different classes. Do not overlap mechanisms of action.
Causes Above Neck Treat Underlying Cause
Causes Below Neck Treat Underlying Cause
Treat Nausea
Treat Nausea CTZ: 1. DA antagonist 2. H 1 antagonist
5. Motility
If due to medications: • or stop responsible medications • motility with prokinetic medication • opioid inhibition of bowel function with methylnaltrexone If due to gastroparesis, e.g., Diabetes: • motility with prokinetic medication
1. Masses
CTZ: 1. Dexamethasone 2. DA antagonist 3. H 1 antagonist CTZ: 1. Dexamethasone 2. DA antagonist 3. H 1 antagonist CTZ: 1. DA antagonist 2. H 1 antagonist CTZ: 1. DA antagonist 2. H 1 antagonist
• Dexamethasone to inflammation / edema • If tumor, treat to mass effect • If fluid collection, drain fluid • Dexamethasone to inflammation / edema • If tumor, treat to mass effect
2. Meningeal Irritation
CTZ: 1. DA antagonist 2. H 1 antagonist
3. Migraine or other headaches 4. Movement, vestibular stimulation
• Treat headache to pain, associated symptoms
CTZ: Chemo Trigger Zone Adapted from Emanuel LL et al. EPEC-Oncology, 2005. Open Access at www.P ALL M ED .us. Wood G et al. JAMA 2007. PMID: 17848654.
• motion • Treat inner ear infections • or stop offending medications
16 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024
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