Download Basic GI Decon.pub - Missouri Poison Center

2012, Volume 2, Issue 1
GI Decontamination (GID): Usually Don’t
“First do no harm.” GID do harm? Sometimes:
--A child who was seen ingesting several tablets of clonidine is brought to an ED 30
minutes post ingestion. On arrival, the alert child is lavaged and given AC per
orogastric tube. As often happens with clonidine, the child becomes very drowsy, then
vomits and aspirates the AC.
--A suicidal teenager arrives in ED stating that she took a handful of acetaminophen
two hours previously. She is lavaged via Ewald tube, and her heart rate drops to 38
(probably because of vagal response to lavage therapy).
Ask: Will GID change anything that needs to be done, or get the patient out of the hospital faster?
All forms of GID have risks to weigh against potential benefits. Based on studies and hard experience, GID is
recommended a lot less frequently now than in the past. Aspiration is a particular concern.
Illustration 1: GI Decontamination Treatments recommended and performed in Missouri emergency departments from 2001-2011
Number of Procedures
Trends in GI Decontamination Recommended and
Performed in MO EDs since 2001
4000
3500
3000
2500
2000
1500
1000
500
0
Charcoal, Single Dose
Charcoal, Multiple Dose
Lavage
01 02 03 04 05 06 07 08 09 10 11
Year Code: 2001-2011
Methods of GI Decontamination:
Syrup of Ipecac: Not recommended in the ED or home setting. There is no evidence that syrup of ipecac improves the
outcome for poisoned patients. In November 2003, the American Academy of Pediatrics issued a statement that ipecac
is no longer recommended in the home as a treatment intervention.
Page 1
Missouri Poison Center
2012, Volume 2, Issue 1
Lavage: Rarely indicated. “Based on experimental and clinical studies, gastric
lavage should not be considered unless a patient has ingested a potentially
life-threatening amount of a poison and the procedure can be undertaken within
30 minutes of ingestion.” “Serious risks of the procedure include hypoxia,
dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and
electrolyte abnormalities, and aspiration pneumonitis.” (American Academy of
Clinical Toxicology, [AACT]/ European Association of Poison Centres and Clinical
Toxicologists, [EAPCCT], Position Paper, J. Toxicol, Clin Toxicol 1997/2004)
♦ Caution: vagal stimulation without ability to counter with beta receptor
activation may lead to profound bradycardia and arrest in beta blocker overdose.
Activated Charcoal (AC): Not routinely indicated in poisonings. Based on volunteer studies, AC may be
considered if it can be administered within 1 hour of poison ingestion. In one study, when certain drugs were taken on
an empty stomach, AC given 5 minutes afterwards reduced the bioavailability of the drugs by 75-98%. When given at
60 min, it was reduced by 10-60%. Respiratory complications of aspirated AC can be serious. Aspiration can be a
real danger, especially when the patient is — or is soon likely to become —CNS depressed. AC is more likely to
cause emesis when given with sorbitol.
Drugs and Toxins
Poorly Adsorbed by
Activated Charcoal:
Acids
Acids
Alkali
Cyanide
Alkali
Cyanide
Ethanol
Ethanol
Ethylene
and other
glycoltoxic
alcohols
Fluoride
Ethylene
Heavy metals
glycol
Hydrocarbons
Fluoride
Inorganic
Heavy metals
salts
Isopropyl
Hydrocarbons
Alcohol
Inorganic
Iron salts
Lithium
Iron
Methanol
Lithium
Potassium
Multiple Dose Activated Charcoal (MDAC): Rarely indicated. Per AACT: “Based on
experimental and clinical studies, MDAC should be considered only if a patient has
ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine,
or theophylline.” (AACT/EAPCCT Position Paper, J. Toxicol, Clin Toxicol 1999) Dose:
25-50 gm in adults or one-half original dose of charcoal every 2-6 hours, usually every 4
hours.
Cathartics: The routine use of a cathartic in combination with AC is not recommended.
Complications include vomiting, abdominal cramping, hypermagnesemia and
hypernatremia. Avoid especially in young children or the very old. Contraindicated with
absent bowel sounds, intestinal obstruction or perforation, recent bowel surgery, volume
depletion by hypotension, significant electrolyte imbalance, or ingestion of a corrosive
substance.
Whole Bowel Irrigation (WBI): May be considered with overdose of iron, some enteric
coated or sustained-release medications, and preparations forming concretions, particularly for those patients presenting greater than two hours after drug ingestion; if the patient
can tolerate the procedure. WBI is contraindicated in patients with bowel obstruction,
perforation, ileus, and patients with hemodynamic instability or compromised, unprotected
airways. WBI may be considered in the case of ingested packets of illicit drugs.
♦ Caution: literature reports catastrophic outcomes from WBI, in certain ingestions where there is hypotension,
bowel hypoperfusion and ileus.
Polyethylene glycol electrolyte solution (i.e. PEG-ELS, Golytely® or Colyte®) given at room temperature, administered
orally or per NG tube.
Dose: Infants: starting 50 mL/hr and slowly increasing rate over two hours to 200 mL/hr.
Children 9 mo —6 yr:
500 mL/hr
Children 6 yr —12 yr:
1000 mL/hr
>12 yr and Adults:
1500-2000 mL/hr
Certainly, GID can have a place in the emergency treatment of poisoned patients, but nothing is routine anymore.
Evidence based statements by the American Academy of Clinical Toxicologists have helped the Missouri Poison
Center change the way we look at GID. Please contact the Missouri Poison Center at 1-800-222-1222 to consult
with a specially trained registered nurse, pharmacist, or physician about the best GID for your poisoned patient.
Page 2
Missouri Poison Center
2012, Volume 2, Issue 1
PoisonSafe Practices
Cut this public education article out of every issue to copy and distribute or post for your clientele!
Do You Know What to Do….If someone gets poisoned?
Information from the Missouri Poison Center
If someone gets ‘poisoned’, call the poison center at 1-800-222-1222. The poison center will take any call about a human
poisoning. But ‘poisoning’ is complicated. It’s a medical term for when your body becomes sick from some substance that
is a toxin or a poison. But almost any substance can be poisonous if taken in the wrong amount, or by the wrong person. You
can be exposed to poisons by eating or drinking them, getting them in your eyes or on your skin, or breathing them in.
Poison centers are for all ages: children, pre-teens, teens, young adults, adults, seniors. It is both for public and health care
providers like your own doctor or nurse. You can call about poisoning at home or work. The call is always free. The call is
always confidential.
When you call the poison center, the nurse or pharmacist will ask you several of the
following questions:
♦ Person’s name and your phone number – this is done to create a medical
record and allows the poison center to follow up by telephone.
♦ Person’s age and weight – many poisons affect children differently than adults.
♦ What happened - Was it inhaled? Swallowed? Did it get on the skin or in the
eyes?
♦ Information from the label – bring the container to the phone with you.
♦ Person’s medical history – this helps to determine the poisoning risk.
♦ What time did it happen?
♦ Does the person have symptoms?
You can trust your call is a private conversation between you and the nurse or pharmacist handling your case. You can trust that
the poison center will help you any time day or night.
First Aid for Poisoning
Has the person collapsed or stopped breathing?
Call 911
Swallowed something poisonous or the wrong medicine or too much medicine?
Call the poison center at 1-800-222-1222
Poison in the eyes?
Rinse eyes with running water for 5 to 10 minutes.
Call the poison center at 1-800-222-1222
Poison on the skin?
Take off any clothing that the poison touched.
Rinse skin with running water for 15 to 20 minutes.
Call the poison center at 1-800-222-1222
Inhaled poison?
Get to fresh air right away.
Call the poison center at 1-800-222-1222
Just in case you need us..….
Program your cell phone with
the nationwide toll free number
to call your
local poison center:
1-800-222-1222.
Make them vomit – Do We, or Don’t We?
--No, never make a person vomit.
--Syrup of Ipecac is no longer used or recommended.
--Salt is not a safe alternative for making a person vomit.
Don’t Guess, Be Sure. If you have a question about a poisoning…..call 1-800-222-1222.
Page 3
Missouri Poison Center
2012, Volume 2, Issue 1
POISONALERT
A quarterly publication of the Missouri Poison Center
Missouri Poison Center Staff
Specialists in Poison Information
Rachel Andrews, RN, SPI; Anne Marie Bailey, RN,
CSPI; Maureen Bredenkoetter, RN, CSPI; Jenny Burt,
RN, CSPI; Linda Campfield, RN, CSPI; Jackie Coffey,
RN, CSPI; Jan Cocayne, RN, CSPI; Sue Dougan, RN,
CSPI; Barbara Eichhorn, RN, CSPI; Shelly Enders,
PharmD, CSPI; Darlene Green, RN, CSPI; Kathy
Hahn, BS Pharm, SPI; Sandra Heffner, RN, CSPI;
Peggy Huebner, RN, CSPI; Peggy Kinamore, RN,
CSPI; Joanne Menendez, RN, CSPI; Julie Moore, RN,
CSPI; Sue Nielsen, RN, CSPI; Carolyn Odom, RN,
CSPI; Amanda Ruback, RN, SPI; Joy Thompson, RN,
CSPI; Rosanna Tochtrop, RN, CSPI; Dianne Wagner,
RN, CSPI; Julie Weber, BS Pharm, CSPI; Janelle Williams, RN, CSPI; Jennifer Williams, PharmD, SPI
*CSPI denotes Certified Specialist in Poison Information
Please send comments and suggestions for future
articles to:
Editors, PoisonAlert
7980 Clayton Road, Suite 200
Saint Louis, MO 63117
Or send e-mail to [email protected]
The Missouri Poison Center website can be found at:
http://www.cardinalglennon.com. Click on Poison
Center under Support Services.
Managing Director
Julie A. Weber, BS Pharm, CSPI
Medical Director
Anthony J. Scalzo, MD
Assistant Medical Director
Rebecca Tominack, MD
Public Education Coordinator
Peggy Kinamore, RN, BSN, CSPI
Administrative Assistant
LaJohnna White
PoisonAlert Editors
Anthony J. Scalzo, MD
Julie A. Weber, BS Pharm, CSPI
PoisonAlert Contributors
Anne Marie Bailey, RN, CSPI
Jenny Burt, RN, CSPI
Shelly Enders, PharmD, CSPI
Peggy Kinamore, RN, CSPI
Carolyn Odom, RN, CSPI
Publisher
LaJohnna White
Page 4
Public Education Materials
Missouri Poison Center is offering a variety of
educational materials FREE of charge including
magnets, stickers, and brochures. For a small fee,
you can order the Toxic Plants Brochure for your
garden club, the Bites and Stings Brochure for
your scout troop, or the Poison Look-Alikes
Brochure for your child care providers and
parents. Please help us teach about poison
prevention and spread the word that the
Missouri Poison Center is open 24/7 and
the call is free and confidential.
Missouri Poison Center