A Suggested Protocol for Nausea & Vomiting
Assess cause - start a vomiting diary.
If vomiting is once a day or more, give anti-emetics parenterally initially.
| Cause | Site | Step 1 | Step 2 (if partial/no response to Step 1) | Step 3 (if partial/no response to Step 2) | If all else fails |
|
DXR + raised intra cranial pressure. Anxiety Vagus-gastro-intestinal or urinary tract distension (including constipation, bowel obstruction). |
Vomiting Centre |
CYCLIZINE 25-50mg tds O/SC/PR |
Add Haloperidol 1.5-5 mg od O/SC |
Intestinal obstruction - add Octreotide 300-600 mg/24 hours |
Either |
|
Chemotherapy Drugs (opiates) Metabolic (calcium, urea) Toxins (including tumour load) |
CTZ |
HALOPERIDOL 1.5mg-5mg od
|
Chemotherapy- substitute Ondansetron
Opiate induced- add Metoclopramide |
Anxiety/Chemotherapy
- add Lorazepam |
Dexamethasone 8mg od
Levomepromazine 12.5mg od |
|
Drugs Outflow obstruction Squashed stomach (hepatomegaly, large tumour mass) |
Gastric Stasis |
METOCLOPRAMIDE 30-60mg O or S/C (10-20mg three times daily) or DOMPERIDONE 30-60mg PR 8 hourly |
|
Nasogastric tube |
|
At each step:
- Re-assess cause
- Stop all anti-emetics that are not working
- Avoid combinations of more than two anti-emetics if possible
- Re-assess carefully and see if simpler and more specific treatment is possible
© Palliative care nausea and vomiting pack 1 Dr Eileen Palmer 2008