Nausea and vomiting

Nausea and vomiting are common, distressing symptoms, with significant impacts on physical functioning, psychological state, and social interaction. There are numerous causes including gastrointestinal, metabolic, treatment-related, vestibular, cranial, and psychological causes. Vomiting is mediated through pathways involving the nucleus of the solitary tract in the brainstem, with inputs from the gastrointestinal tract, viscera, vestibular system, area postrema, and higher centres. Nausea involves more complex connections between gut and brain. The roles of non-pharmacological strategies and medications (including levomepromazine, olanzapine, haloperidol, metoclopramide, domperidone, hyoscine hydrobromide, serotonin (5-HT3) antagonists, neurokinin antagonists, and others) are discussed. Emerging evidence in palliative care will facilitate optimum treatment.

Unintentional overdose of hyoscine hydrobromide in a young child

A 4-year-old girl presented with confusion, ataxia and hallucinations 3 hours after an accidental overdose of 108 μg per kg of hyoscine hydrobromide (Kwells Kids). She was hypotensive and tachycardic at presentation. Investigations revealed QTc prolongation on ECG. The girl was admitted for observation overnight and was noted to have persistent visual and auditory hallucinations, which resolved without treatment. To our knowledge, this is the first reported case of an overdose of hyoscine hydrobromide at such a young age. Clinicians should be aware that unintentional ingestions in this age group may present with psychiatric manifestations. Hyoscine hydrobromide is easily accessible and available over the counter. It has serious consequences in overdose. Its packaging and appearance are attractive to young children making it susceptible to unintentional ingestions. We argue that its container should be altered to be more childproof.

Closure beyond clozapine: successfully averting rebound symptoms in a patient with schizoaffective disorder and agranulocytosis

Summary ‘Rebound’ or ‘withdrawal’ symptoms are frequently observed after a sudden discontinuation of clozapine. We describe a patient with treatment-resistant schizoaffective disorder who developed agranulocytosis on clozapine but was successfully switched to treatment with olanzapine with no deterioration in her condition. We put forward three possible theories which may have accounted for the lack of rebound symptoms in this patient: the pharmacological profile of olanzapine, the anticholinergic effects of hyoscine hydrobromide, and the possibility that this patient may not be treatment-resistant and so have a reduced risk of rebound psychosis due to displaying a different pathophysiology. Declaration of interest None.