decontamination : who, why, when and how. decontamination when should patient be decontaminated?...

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 Gastric lavage Activated charcoal

• multi dose• with cathartic

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 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.”

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

Gastric lavage

No studies demonstate efficacy even < 60 min.s

Studies exclude serious poisonings

Contraindicated: dodgy airway reflexes corrosives hydrocarbon

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)

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

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

Multi dose activated charcoal

Works by• GI dialysis• drugs with significant enterohepatic circulation

examples:• theophylline• anticonvulsants• salicylates • digoxin

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

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 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

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

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

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 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 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 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

Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None

Would You

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 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 Syrup of Ipecac Gastric lavage Gastric Lavage & AC Gastric lavage & Whole bowel lavage AC Whole Bowel Lavage None