Decontamination Who why when and how Decontamination When

Decontamination When should patient be decontaminated? risk of morbidity and/or mortality associated with ingestion

Decontamination Syrup of Ipecac w Gastric lavage w Activated charcoal w • multi dose

Where is the Evidence ? Based on w Animal studies w Volunteer studies w

Where is the Evidence Position statements released in 1997 by AACT and EAPCCT “Overall

Syrup of Ipecac Plant extract previously abused by bullimics w needs to be given

Gastric lavage No studies demonstate efficacy even < 60 min. s w Studies exclude

Gastric lavage May increase risk of aspiration w May lead to pharyngeal injury w

Activated charcoal w Will adsorb many toxins in GI tract BUT: • Alcohols •

Activated charcoal Beware the unprotected airway or aspiration risk w dose is 50 g

Multi dose activated charcoal w Works by • GI dialysis • drugs with significant

Multi dose activated charcoal Good, though indirect evidence of effect in digoxin poisoning w

Whole bowel irrigation Used for w SR/EC preparations w when charcoal is ineffective w

Whole bowel irrigation w w w PEG ELS (“go-lytely”) is used does not cause

A 50 kg female presents having ingested 6 g of paracetamol 5 hours previously

Would You w w w w Syrup of Ipecac Gastric lavage Gastric Lavage &

A 70 kg male presents having ingested 14 g paracetamol 3 hours before

A 70 kg male presents having ingested 14 g paracetamol 1 hour before

A 45 kg female presents having ingested 2 g of a tricyclic antidepressant 1

A 50 kg male presents unconscious having ingested an unknown amount of a tricyclic

A 67 kg male presents having ingested 800 mg of a tricyclic antidepressant 6

A 80 kg male presents having ingested 100 mg of diazepam 4 hours before

A 65 kg female presents having ingested 3. 5 g of Verapamil SR 4

A 45 kg female presents having ingested 2 g elemental iron 4 hours before.

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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 Syrup of Ipecac w Gastric lavage w Activated charcoal w • multi dose • with cathartic w Whole bowel irrigation

Where is the Evidence ? Based on w Animal studies w Volunteer studies w clinical studies Difficulty due to w serious ingestions excluded w 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 Plant extract previously abused by bullimics w needs to be given EARLY w induces vomiting by gastric and central mechanism Contraindicated in w unprotected airway w corrosive w very little evidence for or against w possible role in the home for children w

Gastric lavage No studies demonstate efficacy even < 60 min. s w Studies exclude serious poisonings Contraindicated: w dodgy airway reflexes w corrosives w hydrocarbon w

Gastric lavage May increase risk of aspiration w May lead to pharyngeal injury w alleged to increase absorption in some cases w Has lead to significant return of ingestants up to 12 hours post ingestion(salicylates) Indication w Serious life threatening poisoning with well protected airway (level IV evidence) w

Activated charcoal w Will adsorb many toxins in GI tract BUT: • Alcohols • Li+, Fe 2+ (probably all alkali metals) Ratio should be 10: 1 AC: toxin w Evidence from volunteer studies that absorption will be if < 60 min. s w Little to suggest benefits outcome clinically or absorption post 60 min. s DO NOT GIVE ROUTINELY w

Activated charcoal Beware the unprotected airway or aspiration risk w dose is 50 g adult, 1 g/kg in a child Cathartics w Alleged to increase bowel transit time of toxin w Evidence only from animal and volunteer studies w Unlikely to benefit w

Multi dose activated charcoal w Works by • GI dialysis • drugs with significant enterohepatic circulation w examples: • • theophylline anticonvulsants salicylates digoxin

Multi dose activated charcoal Good, though indirect evidence of effect in digoxin poisoning w 50 g q 6 hrly OR by NG infusion if intubated w up to 1 g/kg suggested for serious theophylline poisonings w Justifies “late” instigation of charcoal w

Whole bowel irrigation Used for w SR/EC preparations w when charcoal is ineffective w 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 w w w 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