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Decontamination : Who, why, when and how
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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
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Decontamination
Syrup of Ipecac Gastric lavage Activated charcoal
• multi dose• with cathartic
Whole bowel irrigation
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Where is the Evidence ?Based on Animal studies Volunteer studies clinical studies
Difficulty due to serious ingestions excluded conflicting results
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Where is the EvidencePosition 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.”
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Syrup of Ipecac
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
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Gastric lavage
No studies demonstate efficacy even < 60 min.s
Studies exclude serious poisonings
Contraindicated: dodgy airway reflexes corrosives hydrocarbon
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Gastric lavage 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)
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Activated charcoal Will adsorb many toxins in GI tract BUT:
• Alcohols• Li+, Fe 2+ (probably all alkali metals)
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
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Activated charcoal
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
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Multi dose activated charcoal
Works by• GI dialysis• drugs with significant enterohepatic circulation
examples:• theophylline• anticonvulsants• salicylates • digoxin
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Multi dose activated charcoal
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
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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
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Whole bowel irrigation 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
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A 50 kg female presents having ingested 6 g of paracetamol 5 hours previously
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Would You
Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 70 kg male presents having ingested 14 g paracetamol 3 hours before
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Would You
Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 70 kg male presents having ingested 14 g paracetamol 1 hour before
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Would You
Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 45 kg female presents having ingested 2 g of a tricyclic antidepressant 1 hour before
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Would You Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 50 kg male presents unconscious having ingested an unknown amount of a tricyclic antidepressant at an unknown time
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Would You Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 67 kg male presents having ingested 800 mg of a tricyclic antidepressant 6 hours before. He is well.
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Would You Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 80 kg male presents having ingested 100 mg of diazepam 4 hours before
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Would You
Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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Would You
Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 65 kg female presents having ingested 3.5 g of Verapamil SR 4 hours before.
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Would You Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None
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A 45 kg female presents having ingested 2 g elemental iron 4 hours before. Tablets are noted on her plain AXR
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Would You Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None