Transcript Gastric lavage

Decontamination : Who, why, when
and how
Decontamination
When should patient be decontaminated?
risk of morbidity and/or mortality associated
with ingestion
What type of decontamination should be
used?
Depends on clinical circumstances and other
treatment options
Decontamination
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Syrup of Ipecac
Gastric lavage
Activated charcoal
• multi dose
• with cathartic
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Whole bowel irrigation
Where is the Evidence ?
Based on
 Animal studies
 Volunteer studies
 clinical studies
Difficulty due to
 serious ingestions excluded
 conflicting results
Where is the Evidence
Position statements released in 1997 by
AACT and EAPCCT
“Overall the mortality from acute poisoning is
less than 1 % and the challenge for
clinicians is to identify promptly those who
are at most risk of developing serious
complications and who might potentially
benefit, therefore, from gastrointestinal
decontamination.”
Syrup of Ipecac
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Plant extract previously abused by bullimics
 needs to be given EARLY
 induces vomiting by gastric and central
mechanism
Contraindicated in
 unprotected airway
 corrosive
 very little evidence for or against
 possible role in the home for children
Gastric lavage
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No studies demonstate efficacy even < 60
min.s
 Studies exclude serious poisonings
Contraindicated:
 dodgy airway reflexes
 corrosives
 hydrocarbon
Gastric lavage
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May increase risk of aspiration
 May lead to pharyngeal injury
 alleged to increase absorption in some cases
 Has lead to significant return of ingestants
up to 12 hours post ingestion(salicylates)
Indication
 Serious life threatening poisoning with
well protected airway
(level IV evidence)
Activated charcoal
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Will adsorb many toxins in GI tract BUT:
• Alcohols
• Li+, Fe 2+ (probably all alkali metals)
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Ratio should be 10:1 AC:toxin
Evidence from volunteer studies that
absorption will be  if < 60 min.s
Little to suggest benefits outcome clinically
or absorption post 60 min.s
DO NOT GIVE ROUTINELY
Activated charcoal
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Beware the unprotected airway or aspiration
risk
 dose is 50g adult, 1g/kg in a child
Cathartics
 Alleged to increase bowel transit time of
toxin
 Evidence only from animal and volunteer
studies
 Unlikely to benefit
Multi dose activated charcoal
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Works by
• GI dialysis
• drugs with significant enterohepatic circulation
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examples:
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theophylline
anticonvulsants
salicylates
digoxin
Multi dose activated charcoal
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Good, though indirect evidence of effect in
digoxin poisoning
50g q 6 hrly OR by NG infusion if intubated
up to 1g/kg suggested for serious
theophylline poisonings
Justifies “late” instigation of charcoal
Whole bowel irrigation
Used for
 SR/EC preparations
 when charcoal is ineffective
 No controlled clinical studies to back up use
physically speeds up transit through GI tract
single dose charcoal given prior to starting
Whole bowel irrigation
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PEG ELS (“go-lytely”) is used  does not
cause significant water/electrolyte
disturbance
frequently causes vomiting, requires NGT
airway must be protected
ileus is CI but has been reversed with
neostigmine
dose is 15-20 mls/kg/hr
endpoint is clear rectal effluent, median
time to achieve this is 6 hours
A 50 kg female presents
having ingested 6 g of
paracetamol 5 hours
previously
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 70 kg male presents
having ingested 14 g
paracetamol 3 hours
before
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 70 kg male presents
having ingested 14 g
paracetamol 1 hour
before
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 45 kg female presents
having ingested 2 g of a
tricyclic antidepressant 1
hour before
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 50 kg male presents
unconscious having
ingested an unknown
amount of a tricyclic
antidepressant at an
unknown time
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 67 kg male presents
having ingested 800 mg of a
tricyclic antidepressant 6
hours before. He is well.
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 80 kg male presents having
ingested 100 mg of diazepam
4 hours before
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 65 kg female presents
having ingested 3.5 g of
Verapamil SR 4 hours before.
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None
A 45 kg female presents
having ingested 2 g
elemental iron 4 hours
before. Tablets are noted
on her plain AXR
Would You
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Syrup of Ipecac
Gastric lavage
Gastric Lavage & AC
Gastric lavage & Whole bowel lavage
AC
Whole Bowel Lavage
None