ToxicologyGut Decontamination

Current Position Statements & Recommendations

Dr.mohamad Shaikhani.

Gut Decontamination

• Ipecac

• Gastric Lavage

• Activated Charcoal

• Whole Bowel Irrigation

Ipecac• Should not be administered routinely in

the poisoned patient

• Drug amount removed highly variable & decreases with time

• Routine administration in the ER should be abandoned

• may delay the administration & effectiveness of charcoal, oral antidotes, & whole bowel irrigation

• Can mask signs of toxicity

• Most useful when ingestion of unknown or potentially toxic amount of substance if patient not close to the ED

• Only beneficial within 60 minutes (solids) , 30 minutes (liquids)

• Contraindications:– Compromised AW reflexes– Drugs potentially causing CNS depression or

seizures (INH, TCA) – Drugs where increased vagal tone not

desirable (digoxin, CCB, BB)– Dydrocarbon ingestion– Ingestion of strong alkali or acid– Medical conditions further compromised by

emesis

• Dose:– 6 to 12 months: 5 to 10 cc (with water)– 1 to 12 years: 15 cc (with water)– 12 years and older: 15 to 30 cc (with water)

Gastric Lavage

• Lavage is rarely recommended anymore

• Differs from gastric aspiration

• At 30 minutes post ingestion < 40% of ingested substance is removed

• Complications– aspiration– laryngospasm hypoxia and hypercapnia– mechanical injury– fluid and electrolyte imbalance– increased amount of toxin placed into small

intestine

• risks considered to outweigh the benefits

Activated Charcoal

• Not routinely administered in poisoned patients but will be used most often

• Greatest benefit within one hour post ingestion

• Administered if ingested potentially toxic amount of poison known to be bound by charcoal

• No data to support or exclude its use after one hour post ingestion

• Recommended dose of 1g/kg

• Don’t need sorbitol

• Contraindiations– unprotected airway– GI tract not intact– acids/alkalis– hydrocarbons– iron– ethanol, isopropyl alcohol– lithium– salts

Multiple Dose Charcoal

• Poisons with long half lives and/or entero-hepatic recirculation– carbamazepine– dapsone– paraquat– phenobarbital– quinine– theophylline

• Do not use charcoal with sorbitol

• dose:– 0.125 g/kg/hr up to 12.5 g/hr

Whole Bowel Irrigation

• Should not be administered routinely in the poisoned patient

• potentially toxic ingestions of SR or EC drugs

• potentially toxic ingestions of:– iron, lead, zinc

• Cocaine body packers/stuffers

• Optimal to start within 4 hours

• GoLytely or other polyethylene glycol electrolyte solution

• use N/G tube --- patients won’t drink enough

• may give A/C prior

• do not give MDC during. MDC after WBI

• Adults:– 1000 cc/hr and increase to 2000cc/hr

• Children ( 9 months and up):– 250 cc/hr and increase to 500 cc/hr

• until rectal effluent is clear

• Contraindications:– bowel perforation/obstruction– GI hemorrhage ileus– unprotected AW– hemodynamic instability– intractable vomiting

Summary• Ipecac

– Rarely used in the ED– Situation specific

• Lavage– Forget about it

• Charcoal– Most effective – Administer within one hour if possible

• WBI– Effective with appropriate poisons