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Gastric Aspiration and Lavage Inacute Poisoning

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Gastric Aspiration and Lavage Inacute Poisoning 28 May 1966 Ampicillin and Pneumonia BtRII 1333 hospital is £5 2s. 8d., which is a little more than a 14-day Christie, G. K. Crompton, T. E. Escott, P. Graham, E. Ruth Gray, course of ampicillin in the dosage used in this trial. W. Gray, J. G. Guy, F. F. Hafez, A. C. Harvey, M. D. Haynes, Joyce M. Hendry, C. Hope, Elinor 0. S. Hope, It would seem, then, that in ampicillin the physician has a Barbara G. Head, Sylvia Jones, A. B. Kay, W. P. U. Kennedy, T. S. Kerr, W. J. H. Br Med J: first published as 10.1136/bmj.1.5499.1333 on 28 May 1966. Downloaded from useful addition to his armamentarium for the treatment of Leckie, D. 0. Lewis, J. Macnamara, T. Middlemass, W. D. Murray, pneumonia. P. L. Pigott, H. Polson, Janet C. Potter, K. D. G. Reid, B. Ritchie, M. Schonell, B. Stack, Sadie D. Walsh, J. B. Wilson, A. Zealley; Summary and to Sisters Black, Boylan, Ferguson, Geekie, Goodwin, Griffiths, McLeod, McSween, Nichol, O'Malley, and Simpson. We are also A controlled trial was carried out to compare the use of grateful to Mr. B. A. Burns, Miss Joy E. Chowdray, Mr. J. A. W. ampicillin with a combination of penicillin and streptomycin Sutherland, Mr. W. J. Webber, and to the many other technicians in the treatment of pneumonia. Seventy-eight patients were of the Wellcome Laboratory, City Hospital, and the Central Micro- allocated to the ampicillin group, in which the regime was biological Laboratories for technical assistance. oral ampicillin 250 mg. six-hourly for 7 or 14 days. Sixty- We are particularly grateful to Miss M. C. Drummond, who seven were allocated to the penicillin/streptomycin group, in acted as co-ordinating secretary of the trial. The work forms which the regime required injections of penicillin 1 mega unit part of a series of investigations supported by the Wellcome Trust, b.d. for 7 or 14 days with streptomycin 1 g. b.d. for the first the Scottish Hospital Endowments Research Trust, the Royal seven days. The treatment groups were comparable, and the Victoria Hospital Tuberculosis Trust, and the Chest and Heart Association. The ampicillin was generously donated by Beecham results of treatment were similar in the two groups. The only T. difference of statistical significance was that a larger proportion Research Laboratories Ltd. through the courtesy of Dr. E. of cases infected with pneumococci alone became afebrile with- Knudsen (Medical Director). in one week when treated with ampicillin than when treated with penicillin and streptomycin. Ampicillin appears to be REFERNCES at least as effective as penicillin and streptomycin even in the Ayliffe, G. A. J., and Pride, N. B. (1962). Brit. med. Y., 2, 1641. comparatively small doses used in this trial. There would Bunn, P., O'Brien, J., Bentley, .D., and Hayman, H. (1962). Antimicrob. appear to be an advantage in domiciliary practice in using a Agents and Chemother., p. 323. Elmes, P. C., King, T. K. C., Langland, J. H. M., Mackay, J. A., drug that can be given by mouth, and if an allowance is made Wallace, W. F. M., Wade, 0. L., and Wilson, T. S. (1965). Brit. for the cost of giving injections there is little difference in med. 7., 2, 904. the expense. General Practitioner Clinical Trials (1963). Practitioner, 191, 356. Grant, I. W. B., Douglas, A. C., and Murray, W. D. (1962). Brit. med. 7., 2, 482. Our thanks are due to the following doctors who played a major Holloway, W. J., Peters, C. D., and Scott, E. G. (1963). Antimicrob. in the conduct of the trial: Drs. S. I. Ahmed, C. Agents and Chemother., p. 314. part day-to-day Howells, C. H., and Tyler, L. E. (1963). Brit. 7. cdin. Pract., 17, 321. Aitken, A. J. Akhtar, Isobel M. E. Anderson, D. Bell, Trafford, J. A. P., Maclaren, D. M., Lillicrap, D. A., Barnes, R. D. S., Kathleen R. M. Brooks, K. A. Buchan, S. Cameron, J. L. Houston, J. C., and Knox, R. (1962). Lancet, 1, 987. Gastric Aspiration and Lavage in Acute Poisoning http://www.bmj.com/ HENRY MATTHEW,* M.B., F.R.C.P.ED.; T. F. MACKINTOSH,* M.B., D.C.H., M.R.C.P.ED. S. L. TOMPSETT,t D.SC., PH.D., F.R.I.C.; JEAN C. CAMERONt A.I.M.L.T. Brit. med.J., 1966, 1, 1333-1337 on 1 October 2021 by guest. Protected copyright. The management of patients who have ingested poison either gastric aspiration and lavage, particularly in respect of accidentally or in attempting suicide presents many problems, barbiturates, which are by far the commonest drugs taken. not the least of which is whether the stomach should be Harstad et al. (1942) demonstrated that even shortly after evacuated. Because of the increasing number of such patients barbiturate had been ingested little could be recovered by (Ministry of Health, 1962), these problems in management gastric aspiration and lavage. This fact, along with their take up much of the time of general practitioners and hospital demonstration that particles of charcoal added to the lavage doctors. fluid could later be found in the pulmonary tissues of patients There is no doubt that in certain types of poisoning gastric who died, led to the abandonment of gastric lavage by Danish aspiration and lavage is positively dangerous; this form of workers (Louw, 1958) and to the use of gastric aspiration therapy therefore has no part to play in the management of alone, without lavage, if it was known that the drug had been poisoning by kerosene and other petroleum distillates (Capel taken within one hour previously (Clemmesen and Nilsson, and Gardner, 1960; Cachia and Fenech, 1964; Baldachin and 1961). However, Wright (1955) found that in three out of Melmed, 1964). It should be undertaken with the greatest of six cases treated within four hours of ingestion appreciable care when corrosive poisons have been swallowed, also in quantities-that is, over 200 mg. of barbiturate-were alcoholics, in the elderly and very young, and in patients who recovered from the gastric washings. In the six patients have undergone gastric surgery. However, the majority of treated more than four hours after ingestion no barbiturate poisoned adults seen in hospital in this country do not fall was recovered. into these limited groups, and, surprisingly, the advice offered Allan (1961), recording his experience with 68 patients, by various authors is contradictory regarding the value of stated that " in most cases of barbiturate overdose, stomach lavage removes only small quantities of ingested barbiturate." * Poisoning Treatment Centre, Royal Infirmary, Edinburgh. He stressed the hazards associated with the procedure, t University Department of Clinical Chemistry, Royal Infirmary, Edinburgh. especially in inexperienced hands, when the patient was semi- D BRITISH 1334 28 May 1966 Acute Poisoning-Matthew et al. MEDICAL JOURNAL conscious. He encountered no complications in conscious not examined, for the following reasons (1) suitable methods patients, and stated that endotracheal intubation in deeply were not available for identification or quantitative determina- unconscious patients "posed no problems." However, he tion; (2) when two or more drugs had been taken it was concluded that "routine lavage of the stomach of patients sometimes possible to analyse only the washings for the more Br Med J: first published as 10.1136/bmj.1.5499.1333 on 28 May 1966. Downloaded from unconscious as a result of barbiturate overdose should be important; and (3) specimens were lost, broken, or inaccur- regarded as potentially dangerous in all cases and of no value ately or wrongly labelled-for this reason analysis was not in most." He did not, however, give any criteria regarding done in 17 of the barbiturate cases (Table I). when the procedure might be of value. TABLE I.-Substances Taken by 259 Patients. (In Some Cases More Understandably, the practitioner is confused by the advice than One Substance had been Ingested) various authorities. Thus Isbell (1963) advocates offered by No. in which gastric lavage only within four hours of ingestion of bar- Total Gastric Contents were Analysed biturate, other authors within eight hours (Graham, 1962; 148 Today's Drugs, 1964), and some almost irrespective of the Barbiturates. 165 Salicylates 25 22 time since ingestion (Deichmann and Gerarde, 1964; David- Libriumn (chlordiazepoxide) 13 11 Largactil (chlorpromazine) 11 6 son, 1964). Clemmesen and Nilsson (1961) and Mark and Tryptizol (amitriptyline) 9 5 aspiration alone, without Amphetamine 7 2 Papper (1964) employ gastric Chloral and Welldorm (dichloralphenazone) 7 5 lavage, and then only if the patient is seen within one hour of Doriden (glutethimide) 6 5 Equanil (meprobamate) 3 3 ingestion of the barbiturate. Epanutin (phenytoin) 3 1 Panadol (paracetamol) 2 2 In view of the paucity of accurate information on this sub- Tofranil (imipramine) 2 2 of Melleril (thioridazine) 1 1 ject and the divergence of opinion regarding the value Arvynol (ethchlorvynol) 1 1 aspiration and lavage in acute poisoning, it was decided Noludar (methyprylone) 1 1 gastric Pethidine 1 1 to carry out a study on poisoned patients admitted to the Acetarsol 1 1 Poisoning Treatment Centre in the Edinburgh Royal Ephedrine 1 1 Infirmary. Miscellaneous Disinfectant (2), varnish (2), DF1 18 (2), ferrous sulphate (2),rPro-Plus (1), trini- trin (1), Pernivit (1), Oblivon (methylpentynol) (1), warfarin (1), alcohol (1), potassium bichromate (1), antacid tablets (1), ergotamine (1), Scheriproct (1), Alophen (1), unknown (1). Method The results obtained in the patients suffering from bar- During five months in 1965 gastric aspiration and lavage biturate or salicylate poisoning are given in detail below; the was carried out on all patients admitted to the Poisoning less common drugs are mentioned briefly in the Discussion.
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