The Importance of Gastrointestinal Decontamination
Robert S. Hoffman, MD
Director, New York City Poison Control Center
Assistant Professor of Clinical Surgery/Emergency Medicine
New York University School of Medicine
Int J Med Toxicol 1999; 2(3):5
These case conferences are supported by a grant from Orphan Medical, Inc.
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See also LETTER TO THE EDITOR - 1999; 2(3): 4
For centuries, common logic and rational thought dictated that the approach to poisoned patients should emphasize efforts at gastrointestinal decontamination. These concepts gave rise to the principles of ipecac-induced emesis, orogastric lavage, and single and multiple-dose activated charcoal. As the "science" of toxicology has developed, however, there has been a trend away from the more aggressive methods of decontamination, and an emphasis on simple techniques such as single-dose activated charcoal. We have all read those few landmark studies, which seem to demonstrate the futility of ipecac-induced emesis in the hospital, the rare indications for orogastric lavage, and even question the utility of activated charcoal in some patients.(1-3)
How then, do we apply the data presented in these studies to the care of our patients? In the case presented above, a patient presented with a seizure four hours after the ingestion of a sustained release bupropion product. He received no decontamination. Recent reviews on all methods of decontamination would probably yield the following information. Since he was four hours after ingestion and had a seizure, ipecac-induced emesis was contraindicated.(4) Similarly, the four-hour period would limit any benefit from orogastric lavage.(5) While a single dose of activated charcoal would be indicated, multiple-dose activated charcoal might not be recommended based on a lack of proven efficacy in this particular ingestion.(6) Whole bowel irrigation might have been supported based on the nature of the preparation, but without specific supporting data.(7) The consulting physicians recommended whole bowel irrigation, and in actuality, no decontamination was ever given. The patient continued to manifest toxicity ten hours later with a second seizure.
It is easy to understand why there is so much confusion – the patient presented here was never studied! It is doubtful if any of the studies or reviews cited above contained any information on patients who overdosed on sustained release bupropion products, much less human volunteer, animal, or basic laboratory data. If such patients were included in these studies, it is certain that their numbers and randomization were insufficient for subgroup analysis. As a result, three important points must be emphasized. First, insufficient data are available to guide decisions on the small, but important, subset of patients with life-threatening ingestions. Second, the failure to find supporting evidence in a small subset of data should not be used as a reason to abandon therapies that are logical, safe, rapid and inexpensive. Finally, and possibly most importantly, there is no evidence to support extension of the data in these studies to new toxins, or old toxins in new formulations.
It is essential to continue investigative efforts, which will help define the appropriateness of various decontamination procedures. From the excellent efforts to date, we have learned that aggressive therapy is not necessary in many patients. However, it should be clear that this minimalist approach to gastrointestinal decontamination is unsuccessful in certain patients. While I probably would have given the above patient at least a single dose, and possibly multiple-dose activated charcoal (to prevent ongoing absorption), whole bowel irrigation does not seem unreasonable, albeit much more time consuming. The safety and efficacy of whole bowel irrigation for patients with altered mental status clearly warrants further study. This is the "art" of medical toxicology. Attempts to over-apply the existing "science" to the "art" might be as harmful as having no science at all. We should all strive to expand the science, while remembering its current limitations as we practice the art.
- Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH: Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985;14:562-7.
- Merigian KS, Woodard M, Hedges JR, Roberts JR, Stuebing R, Rashkin MC: Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990;8:479-83.
- Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW: Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aust 1995;163:345-9.
- Krenzelok EP, McGuigan M, Lheur P:Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35:699-709.
- Vale JA: Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35:711-9.
- Chyka PA, Seger D: Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35:721-41.
- Tenenbein M: Position statement: whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35:753-62.
Int J Med Toxicol 1999; 2(3):5
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