Decontamination : Who, why, when and how

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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 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.

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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 lt 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 101 ACtoxin
• Evidence from volunteer studies that absorption
  will be ? if lt 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