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Gastric Decontamination-A View for the Millennium

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Gastric Decontamination-A View for the Millennium 84 Bateman gency situation it may not be medically CRASH Co-ordinating Centre, or by tele- appropriate to delay the start of treatment until phone interview and will not involve any addi- proxy consent can be obtained. Hence, the doc- tional work for collaborating hospitals. J Accid Emerg Med: first published as 10.1136/emj.16.2.84 on 1 March 1999. Downloaded from tor in charge should take responsibility for The CRASH trial aims to be the largest ran- entering such patients, just as they would take domised controlled trial in head injury that has responsibility for choosing other treatments. Of ever been conducted. This will only be possible course, the requirements of the relevant ethics if doctors and nurses world wide can work committee should be adhered to at all times. together to make it a success. Further infor- Numbered drug or placebo packs will be mation about the trial including details about available in each participating emergency taking part can be obtained from the CRASH department. Randomisation involves giving Co-ordinating Centre, Institute of Child brief details to a 24 hour free phone service. Health, 30 Guilford Street, London WC1N The call should last only a minute or two, and 1EH ([email protected]) or by visiting the at the end of it the service will specify to the CRASH web site http://www.crash.ucl.ac.uk. caller which numbered treatment pack to use. 1 Jennett B, Teasdale G. Management ofhead injuries. Philadel- The primary outcome measures are: death phia: FA Davies, 1981. from any cause within two weeks of injury and 2 Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;i:480-4. death or dependence at six months. In-hospital 3 Alderson P, Roberts I. Corticosteroids in acute traumatic deaths, complications, and short term recovery brain injury: systematic review of randomised controlled trials. BMJ 1997;314:1855-9. are to be recorded on a single sided outcome 4 Bracken MB, Shepard MJ, Collins WF, et al. A randomised form which can be completed entirely from the controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. N Engl J Med hospital notes-no extra tests are needed. 1990;322:1405-1 1. Long term recovery will be assessed at six 5 Otani K, Abe H, Kadoya S, et al. Beneficial effect ofmethyl- prednisolone sodium succinate in the treatment of acute months either by a simple postal questionnaire, spinal cord injury (translation ofJapanese). Sekitsui Sekizui sent directly to each trial participant from the J 1994;7:633-47. Gastric decontamination-a view for the millennium D N Bateman Abstract 1990s have been "evidence based medicine" The management of acute poisoning re- in many areas is being and medical practice http://emj.bmj.com/ mains an important part of accident and reassessed in line with this approach. In the emergency (A&E) care. Three gastric management of drug overdoses traditional decontamination procedures have been teaching 20 years ago was that decontamina- widely used: gastric lavage, ipecac, and tion of the stomach was an important part of activated charcoal. Their role has recently management. The approaches used were gas- been reviewed and position statements tric lavage and syrup of ipecac. At the time of developed by working groups of the their introduction these treatments were not American Academy ofClinical Toxicology subjected to formal clinical trial but anecdotal on September 26, 2021 by guest. Protected copyright. and the European Association of Poisons evidence of tablet recovery convinced clini- Centres and Clinical Toxicologists. These cians that they were doing good. The develop- have important implications for A&E, as ment of the orally administered binding agent, they indicate that activated charcoal is activated charcoal, lead to the reconsideration now the agent of choice for most poisons, of the optimal way ofhandling drug overdoses. but that in most situations it is probably In addition formal clinical studies began to be only effective if given within an hour of applied to this area of medical management as overdose. Ipecac is effectively obsolete and clinicians reassessed the evidence for the treat- gastric lavage has a narrow range of indi- ments they had been using. cations, principally for potentially serious The theory behind gastric decontamination amounts of agents not adsorbed by char- seems simple. Toxins in the stomach are very Scottish Poisons coal. Protocols for care of overdose pa- poorly absorbed but once they enter the small Information Bureau, tients should be modified accordingly. bowel the large surface area facilitates passive Royal Infirmary, (7Accid Emerg Med 1999;16:84-86) Edinburgh diffusion and absorption is often rapid, par- Keywords: poisoning; gastric decontamination; acti- ticularly for lipid soluble compounds such as Correspondence to: vated charcol drugs. Therefore removal of a toxin from the Dr D N Bateman, Director, Scottish Poisons Information stomach might decrease the total amount Bureau, Royal Infirmary of absorbed and hence reduce toxicity. Edinburgh NHS Trust, The practice of medicine changes for a variety Gastric lavage involves administering fluid 1 Lauriston Place, Edinburgh of reasons. New treatments are developed and into the stomach via a wide bore tube. This EH3 9YW. their effect is measured against those of older, process is not without hazard. It is associated Accepted 22 October 1998 established regimens. The buzz words of the with transient hypoxia in patients who are Gastric decontamination 85 obtunded, and may result in aspiration.' als has in agreeing policy when there are gaps Furthermore introduction of a large volume of in knowledge. Changing old habits can be fluid into the stomach may actually wash hard, no matter how illogical they are. However J Accid Emerg Med: first published as 10.1136/emj.16.2.84 on 1 March 1999. Downloaded from tablets from the stomach into the small bowel. the recommendations can be summarised as Thus rather than reducing the amount of drug follows. absorbed this process may actually increase the rate of drug absorption, a process associated Ipecac with rapid onset of symptoms. This hypothesis The position statement indicates that ipecac was proposed in the 1970s by Blake and Bram- should not be administered routinely in the ble who observed toxicity after gastric lavage in management of poisoned patients.' The evi- tricyclic poisoning.2 It is important to remem- dence to support this conclusion is that in ber that the toxicity of a drug may not experimental studies the amount of marker necessarily relate to the total quantity ab- removed in volunteers by ipecac is highly vari- sorbed, but more often to the peak plasma able and diminishes if administration of ipecac concentration and especially the speed at is delayed. Studies in both volunteers and poi- which that peak is reached. soned patients given markers with the ipecac Syrup of ipecac works as an emetic by were reviewed. Effects of ipecac, although stimulating the chemoreceptor trigger zone, sometimes statistically significant, are in gen- which lies outside the blood-brain barrier in eral relatively small in clinical terms. The stud- the floor of the fourth ventricle. There is varia- ies of most relevance might be considered tion in individual susceptibility to this agent, those in poisoned patients, but here, use of the and it is therefore not a reliable emetic. To be marker magnesium hydroxide in children active ipecac has itself to be absorbed, hence a showed that it had a poor recovery (28%±7%, delay between administration and vomiting. range 0%-78%).6 When thiamine was admin- Thus after administration of ipecac absorption istered with ipecac on average only 50% of the of the toxin continues to occur in the interval administered dose was recovered.7 Saetta et al, between the administration and its effect. in a UK study, used barium impregnated poly- Delay in vomiting after administration may ethylene pellets given with ipecac in 20 cause uncertainty about whether the appropri- patients.8 Abdominal radiography was per- ate dose has been given. Furthermore nausea formed at a mean of 47.2 minutes after the and vomiting may be important signs of toxic- ingestion of the pellets. In the ipecac group ity from the ingested poison, for example in 39.3% of the pellets had moved into the small iron poisoning, and administration may result bowel compared with 16.3% of those in the in potential confusion in the interpretation of control group. The authors concluded that in clinical signs. some situations ipecac enhances gastric empty- Activated charcoal acts by binding drugs ing facilitating drug absorption, at the same non-specifically. It is not universally effective in time as producing vomiting. that it does not bind ions such as iron or Clinical studies have failed to show benefit of lithium. The charcoal has to come into physical ipecac given alone even when administered less contact with the toxin, and only binds about than 60 minutes after poison ingestion. Al- http://emj.bmj.com/ one tenth of its weight (that is 5 g with the though there are occasional case reports standard 50 g dose). Nevertheless of the three indicating that ipecac produces what appears potential gastric decontamination procedures to be impressive vomiting, there are insufficient available it is the least likely to produce an data to demonstrate any benefit on outcome. adverse response and relatively easy to admin- In this circumstance therefore the UK poisons ister. It has thus gained popularity. For A&E directors are of the view that it should no consultants the question is then which treat- longer be used. Since ipecac may interfere with on September 26, 2021 by guest. Protected copyright. ment to advise for which patient in their A&E the action of other, more effective treatments, department.
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