Gastrointestinal Decontamination

Fundamentally, decontamination seeks to prevent drug absorption - some techniques may also enhance elimination.

The decision to decontaminate is in essence a risk/benefit assessment. When the risk of decontamination is very low such as washing after a dermal exposure of a toxic compound there is relatively little controversy. This is not the case with Gastrointestinal Decontamination, which is one of the most hotly debated areas in clinical toxicology. Decisions include whether to do it at all and if so which type of decontamination should be used. The potential choices are described below. You should be aware that for a number of the choices there is significant technical variation in clinical practice and therefore in the literature. For example gastric lavage has been described with various sizes of tubes, various amounts and types of lavage fluid. You could also consider the potential cost of these procedures which can be measured in both consumables and staff time.

In general any potential benefit from gastrointestinal decontamination is very reduced once 2 hours from the ingestion has elapsed.

The risk of the procedure increases markedly as the patients GSC (level of consciousness) decreases.

• Do nothing

or

• Induce emesis (most commonly ipecac initiated)
• Perform gastric lavage and/or whole bowel irrigation
• Administer activated charcoal
• Other binding resins
• Cathartics

• Risk of the decontamination procedure varies between the procedures and is also dependent upon the patient’s clinical status in particular their ability to protect their airway

• Evidence for clinical benefit is scant and mostly theoretical, extrapolating from intermediate outcomes such as the demonstration of reduced absorption.
• Important variables that are likely to affect efficacy are:
  • Time from ingestion
  • Tablet formulation
  • Drug chemistry
  • Intestinal motility

1. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicology. Position statement: Ipecac syrup. Clinical Toxicology . (fulltext)
2. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicology. Position statement: Gastric lavage. Clinical Toxicology .(fulltext)
3. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicology. Position statement: Single-dose activated charcoal. Clinical Toxicology .(fulltext) also Multiple dose charcoal
4. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicology. Position statement: Whole bowel irrigation. Clinical Toxicology (fulltext)
5. For a commentary on all of these papers see The revised position papers on gastric decontamination Buckley & Eddleston
6. Isbister GK, Dawson AH, Whyte IM. Feasibility of prehospital treatment with activated charcoal: Who could we treat, who should we treat? Emerg Med J 2003;20:375-378. (fulltext)
7. Eddleston M, Juszczak E, Buckley NA, Senarathna L, Mohamed F, Dissanayake W,Hittarage A, Azher S, Jeganathan K, Jayamanne S, Sheriff MR, Warrell DA; Ox-Col Poisoning Study collaborators. Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial. Lancet. 2008 Feb 16;371(9612):579-87. (fulltext)
8. de Silva HA, Fonseka MM, Pathmeswaran A, Alahakone DG, Ratnatilake GA, Gunatilake SB, Ranasinha CD, Lalloo DG, Aronson JK, de Silva HJ. Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial. Lancet. 2003 Jun 7;361(9373):1935-8 (fulltext)
9. Gastrointestinal Decontamination from the New York Poison centre