CME Review Article
Gastrointestinal Decontamination of the Poisoned Patient
Spencer Greene, MD, Cindy Harris, MD, and Jonathan Singer, MD
Abstract: Gastrointestinal decontamination has been a historically
accepted modality in the emergency management of oral intoxicants.
Theoretically, gastric and whole-bowel emptying procedures hinder
absorption, remove toxic substances, prevent clinical deterioration,
and hasten recovery. This article presents a current overview of
gastrointestinal decontamination. It challenges the accepted precepts
of gut decontamination and assesses the utility of syrup of ipecac-
induced emesis, orogastric lavage, single-doseYactivated charcoal,
cathartics, and whole-bowel irrigation.
Key Words: poisoning, gastrointestinal decontamination
TARGET AUDIENCE
This CME activity is intended for health care workers
who care for children seeking treatment of potentially toxic
ingestions. The information is of use to emergency physi-
cians, pediatricians, intensivists, family practitioners, emer-
gency nurses, pharmacists, and specialists in poison
information.
LEARNING OBJECTIVES
After completion of this article, the reader should be
able to:
1. Explain the role of gastrointestinal decontamination (GID)
in the management of the poisoned patient.
2. Identify the various methods of GID and how each is
performed.
3. Appraise situations in which GID may be beneficial.
E xposure to potentially toxic substances is a common
problem, particularly among the pediatric population, and
these patients are frequently encountered in the emergency
department (ED). Of the 2,424,180 human exposures re-
ported to the American Association of Poison Control Cen-
ters (AAPCC) in 2005, 64.5% occurred in patients younger
Assistant Professor (Greene), Resident (Harris), Professor (Singer), Depart-
ment of Emergency Medicine, Wright State University Boonshoft School
of Medicine, Dayton, OH.
The authors have disclosed that they have no significant relationship with or
financial interests in any commercial companies that pertain to this
educational activity.
All staff in a position to control the content of this CME activity have dis-
closed that they have no financial relationships with, or financial interests
in, any commercial companies pertaining to this educational activity.
Lippincott CME Institute, Inc. has identified and resolved all faculty and
staff conflicts of interest regarding this educational activity.
Address correspondence and reprint requests to Jonathan I. Singer, MD,
Wright State University, Department of Emergency Medicine, 3525
Southern Blvd, Dayton, Ohio 45429. E-mail: jonathan.singer@wright.edu.
Copyright * 2008 by Lippincott Williams & Wilkins
ISSN: 0749-5161/08/2403-0176
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than 20 years. In fact, 50.9% affected children younger than
5 years, and 45.3% of exposures were in children younger than
3 years. The most common route of entry was ingestion, which
accounted for 76.7% of all encounters and 69.9% of fatal toxic
exposure.1
An ingested substance may have local toxicity or
systemic impacts. Systemic effects from an intoxicant require
absorption into the bloodstream and distribution to various
organ systems. It has long been a toxicological precept that
preventing the absorption of a poison from the gastro-
intestinal (GI) tract would limit systemic toxicity. The
reduced absorption concept has led to several interventional
methods, including gastric emptying (GE), administration of
an adsorbent, or promoting catharsis. Collectively, these
techniques have been and continue to be known as gastro-
intestinal decontamination (GID). Gastrointestinal decon-
tamination has become Broutine[ in the management of
potentially poisoned patients in the ED.
In the past decade, GID as a routine has been called
into question. Individual authors have raised questions on
both the safety and efficacy of GID and have offered
strategies for GID.2Y7
As an example, Bailey8 proposed the Bgastrointestinal
decontamination triangle.[8 He suggested that 3 relevant
questions should be asked when confronted with a patient
who has ingested a toxic substance. First, is the ingestion
likely to cause significant effects? If the answer is no, GID is
not considered. If the answer is yes, then second, is GID
likely to affect outcome? The answer to this depends on the
nature of the poison, how long ago it was ingested, if
coingestants were present, and the overall health of the
patient. If GID is unlikely to affect outcome regardless of the
reason, it should not be performed. Third, given the toxic
substance ingested and the patient_s status, could GID be
harmful? If the answer to this question is yes, Bailey
suggested the relative risks and benefits of performing or
withholding GID should be weighed.
Toxicological societies have provided recommendations
as to when and how GID should be performed in the ED. In
1997, the 2 largest organizations of academic toxicologists, the
American Academy of Clinical Toxicology (AACT) and the
European Association of Poisons Centres and Clinical Tox-
icologists (EAPCCT), jointly published several position
papers describing the potential indications, contraindications,
and adverse reactions of each method of GID.9Y13 These
societies based their recommendations on animal studies,
volunteer human studies, individual case reports, and con-
trolled clinical trials. In contrast to common belief, they
concluded that no method of GID should be performed
routinely in the management of the poisoned patient.
Pediatric Emergency Care  Volume 24, Number 3, March 2008
Pediatric Emergency Care  Volume 24, Number 3, March 2008
Gastrointestinal decontamination, however, bathed in
controversy, continues to be practiced in most EDs. It is likely
that GID will ultimately be abandoned by practitioners for
ingested substances that are of low potential for toxicity but
continued for ingested substances that have highly toxic
potentials. Below, the reader is taken through the topics of
GE, activated charcoal (AC), and cathartics. The reader is
challenged to analyze their own utilization of GID. The
authors provide a historical perspective on GID and describe
the techniques, trials, adverse impacts, indications, and contra-
indications to the various techniques. Lastly, the authors
provide a summary of the AACT or the EAPCCT position
papers and terminally include their personal clinical insights.
GASTRIC EMPTYING
Gastric emptying involves the removal of toxic
substances from the stomach. This is accomplished mechan-
ically via gastric lavage or chemically. Chemical methods
that have been used and abandoned include sodium chloride,
copper sulfate, hydrogen peroxide, and apomorphine. The
use of syrup of ipecac by the emergency physician has waned
but remains in our armamentarium as an emetic.
Syrup of Ipecac
Background
Ipecac contains a mixture of alkaloids derived from the
plants Cephalis acuminata and/or Cephalis ipecacuanha.
These substances, particularly emetine and cephaeline,
promote emesis through stimulation of gastric mucosal
sensory receptors, which subsequently activates the vomiting
center in the brain, and by direct stimulation of the chemo-
receptor trigger zone in the brain. Extracts from C.
ipecacuanha had long been used by natives of South
America to treat a variety of GI maladies, including amebic
dysentery.9 Once researchers were able to isolate the
pharmacologically active substances, ipecac was on its way
to replacing less effective and more dangerous methods for
inducing emesis. Traditional syrup of ipecac became avail-
able without prescription in 1966, and because its popularity
increased, parents and day-care workers were encouraged to
have this medication readily available for the unforeseen
pediatric toxic ingestion. In 1983, the use of ipecac was
advised by poison control centers in 13.4% of reported
exposures. However, because research raised questions of
both safety and efficacy, poison specialists were less likely to
recommend ipecac, and by 2003, its use was advised in only
0.4% of toxic exposures.14 Nevertheless, the AAPCC reports
its use in 3027 cases in 2005.1 Even in the early 1980s,
however, questions regarding ipecac_s safety and efficacy
had emerged, and clinicians such as Dershewitz and Nieder-
man15 identified ipecac as more of a hazard than a
therapeutic intervention.
Technique
Recommended doses were 5 to 10 mL for 6- to 12-
month-olds, 15 mL for ages 1 to 12 years, and 30 mL for
adolescents. The medication is followed by 120 to 240 mL of
clear liquids. When possible, the patient is encouraged to
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GI Decontamination of the Poisoned Patient
ambulate, because movement is purported, but not docu-
mented, to increase its emetic quality. The mean time to emesis
in pediatric studies ranged from 14 to 37 minutes, with most
reporting values close to 20 minutes.16 Near the time of onset,
the parent is advised to maintain their child upright with the
head and the thorax flexed forward. Patients usually
experience 2 or 3 episodes of vomiting, although some
patients may require an additional dose to induce emesis.
Emesis ceases within 1 hour for most children, but emesis
may persist for more than 1 hour in 13% to 17% of patients.17
Studies
Data have long been available on the efficacy of ipecac
to induce emesis. Older and more recent studies have
confirmed that the efficacy of ipecac is highly variable. The
mean recovery of gastric contents is generally less than 50%.
The recovery is related to the time since ingestion. The
amount recovered falls off rapidly as further time elapses.
Vasquez et al18 administered technetium Tc 99m 1 mCi
human serum albumin-sucralfate followed by ipecac at 5, 30,
and 60 minutes after ingestion. An average of 83% (range,
71%Y97%) of the marker was removed from the GI tract in
the 5-minute group and 44% (range, 10%Y65%) in the 60-
minute group.18 A more inconsistent effect was observed
when Tandberg et al19 administered 30 mL of ipecac along
with 1 L of water 10 minutes after ingestion of 2500 2g of
cyanocobalamin and recovered a mean of only 28.4% (range,
6%Y70%). The maximal removal in pediatric studies seems
to be 9% to 38% of an ingested substance when ipecac is
provided more than 30 minutes after ingestion.20
Studies designed to evaluate the outcomes of patients
given ipecac have failed to demonstrate superiority of ipecac
to no gastric decontamination or alternate gastric decontami-
nation methods. As examples, in the context of pediatric
acetaminophen poisoning, ipecac-induced emesis did not
alter hospital admission rates, complication rates, length of
stay in the ED, or hospital admission lengths of stay.21,22
Kulig et al,23 in a study of all patients who presented to the
ED with an initial diagnosis of oral drug overdose, compared
the use of ipecac and 30 to 50 g of AC mixed with 20 g (or
250 mg/kg in pediatric patients) of magnesium sulfate to the
use of AC and magnesium sulfate without any form of GE
and found no significant difference in either improvement or
deterioration. There was, however, a trend toward improve-
ment in the charcoal-only group and a smaller trend toward
deterioration in the ipecac-charcoal group. In a similar study
by Merigian et al24 of all patients who presented to the ED
with reported self-poisoning, asymptomatic patients were
treated with 50 g of charcoal on even days and with no GID
on odd days, whereas symptomatic patients were treated with
only charcoal on odd days and with GE plus charcoal on
even days. Gastric emptying consisted of ipecac for alert
patients and gastric lavage for obtunded patients. Similar
percentages (58%) of patients treated with and without GE
were admitted to the hospital. The data for lavage and ipecac
were pooled, so no direct evaluation of ipecac could be made,
but the patients in the GE group had an intensive care unit
(ICU) admission rate twice that of the charcoal-only patients,
and the rate of mechanical ventilation was nearly 4 times as
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Greene et al
high in the GE group. Pond et al25 also compared GE patients
to patients for whom no GE was performed with patients
aged 13 to 82 years. On even-numbered days, patients re-
ceived only 50 g of AC with 200 mL of 70% sorbitol,
whereas on odd-numbered days in addition to charcoal,
patients underwent GE via 30 to 50 mL of ipecac if alert and
cooperative or via gastric lavage if obtunded. After treatment
effect was adjusted for patient severity, there was no
significant difference in the percentage of patients who
deteriorated or improved between GE and non-GE groups.
The clinical studies by Kulig et al,23 Merigian et al,24
and Pond et al25 all had limitations that the reader must
acknowledge before applying the results to clinical practice.
In general, these were nondifferentiated patients, with many
of the ingestions likely nontoxic. One would not expect to
observe a clinical improvement after GE compared with a
control group if the ingestion does not produce toxicity.
Furthermore, treatment allocation was not blinded in the
studies, and in the Kulig study, the end point was subjective.
The study of Merigian et al24 also did not distinguish patients
who received ipecac from those who underwent gastric
lavage. Finally, it is unclear what percentage of patients
enrolled in the studies by Kulig et al23 and Merigian et al24
underwent GID within 1 hour of ingestion, when decontami-
nation is expected to have its greatest effect.
Indications
There are no absolute indications for the use of ipecac
in the ED.
Contraindications
Ipecac is contraindicated in patients with compromised
or potentially compromised airway reflexes for whom no
definitive airway, that is, endotracheal intubation, is estab-
lished. Ipecac should be avoided after ingestion of substances
with high aspiration potential, such as hydrocarbons. Ipecac
is contraindicated after ingestion of substances with high
corrosive potential, that is, iron, acids, and alkalis. Ipecac is
not suggested for retained esophageal corrosive batteries.
Relative contraindications include the anticipated use of an
oral antidote or the utilization of whole-bowel irrigation
(WBI), as well as patients with medical conditions that could
be significantly exacerbated by forceful vomiting, that is,
intracranial hypertension and anticoagulant use.
Complications
Ipecac administration leads to protracted vomiting
more than 1 hour in 13% to 17% of patients, sedation in
10% to 21%, and diarrhea in 5% to 26%. Reports of other
complications are rare and include esophageal tears, gastric
rupture, electrolyte imbalance, pneumomediastinum, retro-
pneumoperitoneum, and asystole.26
Position Papers
Successive position statements of the AACT and the
EAPCCT in 1997 and 2004 suggested that ipecac should not
be administered routinely in the management of poisoned
patients. There is no evidence from clinical studies that
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
ipecac improves outcomes, and its use may reduce the
effectiveness of AC, WBI, and oral antidotes. They felt there
were insufficient data to support or to exclude its admin-
istration soon after ingestion.9,27
Authors_ Recommendations
Within the ED, ipecac has no utility. Within the
prehospital setting, ipecac may have a role. The 2003
American Academy of Pediatrics position statement on
poison treatment in the home states ipecac should no longer
be used routinely and advises parents to dispose of ipecac
they may have at home, which is a departure from the 1989
statement that recommended that parents maintain a 1-oz
bottle of ipecac available for use on the advice of a physician
or poison specialist.28 We, however, concur with conclusions
of the AAPCC position statement on out-of-hospital ipecac
use.29 Prehospital administration would be warranted only
when the following requirements are satisfied: (1) there is no
contraindication to use of ipecac; (2) there is substantial risk
of serious toxicity to the victim; (3) there is no alternative
therapy available or effective means to decrease GI absorp-
tion; (4) there will be a delay of more than 60 minutes before
the patient arrives at the ED, and ipecac can be administered
within 30 minutes of the ingestion; and (5) the use of ipecac
will not adversely affect more definitive treatment that might
be provided at the hospital. Most pediatric ingestions will not
satisfy these criteria, and ipecac should not be used routinely.
However, if ipecac can be given within 30 minutes of an
ingestion with the potential for significant toxicity, such as
colchicine, calcium-channel antagonists, or digoxin, and if
the patient is in a remote location, ipecac may be helpful.
Gastric Lavage
Background
The use of either a nasogastric or an orogastric tube to
remove poisons via suction, with or without concomitant
lavage, dates back several hundred years. Secondus first used
a tubular stomach pump in 1769 to deliver neutralizing
agents for the treatment of Bbloat[ in sheep and cattle.30 In
1805, Physick reportedly used hollow tubes to lavage 2
infants who had overdosed on laudanum.31 Also, in the early
1800s, Dupuytren lavaged a patient_s stomach with warm
water with the intention of removing poison, and finally, in
1822, Jukes and Bush independently reported the use of a
new procedure called gastric lavage to remove toxic
ingestants, which Jukes demonstrated on himself after an
opium ingestion.31 Shortly thereafter, lavage became, as
Proudfoot32 described, Bone of the very pillars of manage-
ment of poisonings by ingestion.[
Technique
Endotracheal intubation should precede lavage in
patients who are obtunded or who lack a gag reflex.
Intravenous access should be obtained, and the patient should
be placed on a cardiac monitor and a pulse oximeter. Place
the patient in a left lateral decubitus position. For the patient
who is not intubated, place the head down approximately 20
degrees to minimize the potential for aspiration. Nasogastric
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
tubes are not recommended for attempted retrieval of pills or
pill fragments but may be useful for the removal of liquid
medication immediately after ingestion. For pills, an orogastric
tube large enough to accommodate particulate matter should
be used. Size 36F to 40F catheters are recommended, although
tubes with a diameter of at least 24F may be used for small
children.33,34 It has previously been suggested that extra
holes be created near the tip of the orogastric tube, but there
are no data to support this recommendation, and creating
sharp edges at the tip of the tube could increase the risk of
damage to the GI tract. The position should be confirmed
either by auscultation of air insufflation over the stomach or
by pH testing of aspirated material. Aspiration should be
performed before actual lavage. If the poison may potentially
contaminate hospital personnel, ensure that gastric aspirate
remains isolated in a self-contained suction unit. Lavage is
performed using small volumes of liquid. In children, 10 mL/
kg of warm, normal saline should be used. In adolescents,
aliquots should be instilled of 200 to 300 mL of either water
or normal saline. A total of 1 to 2 L should be used in a child
and 2 to 4 L in an adolescent. Repositioning and abdominal
massage may be performed as necessary to improve flow
through the gastric tube. The procedure should be carried out
until the fluid returned is clear. Activated charcoal, if used,
may be instilled. At the completion of lavage, pinch the tube
to prevent drippage from the distal component of the tube.
This decreases the likelihood of aspiration.
Studies
Animal and human studies have been performed on
orogastric lavage. The procedure has been analyzed as a
single method of pill or liquid retrieval, compared with syrup
of ipecac or compared with charcoal alone. There are
differences in percent of recovery among the studies. It is
appropriate to conclude that recovery is variable and not
likely to be superior to ipecac. Like ipecac, recovery with
lavage has a variation depending on the time of attempted
retrieval after ingestion. Christophersen et al35 administered a
subtoxic dose of acetaminophen to 12 adult volunteers and
found that gastric lavage performed 1 hour after ingestion
reduced absorption by 48.2%. Tenenbein et al36 lavaged 10
fasting volunteers 1 hour after they ingested 5 g of ampicillin
and observed a reduction in absorption of 32% compared
with controls. Orogastric tubes may be inadequate for pill
removal. In an endoscopic evaluation of patients treated with
ipecac or gastric lavage, Saetta and Quinton37 found that of
17 patients who were randomized to undergo lavage, 15 were
subsequently found to have solid material including tablets in
their stomachs. Watson et al38 found a recovery rate of up to
20% of pills after gastric lavage for cyclic antidepressants.
Lapatto-Reiniluoto et al39 found that gastric lavage used for a
mixed, subtoxic ingestion in patients aged 19 to 40 years
produced no statistically significant reduction in absorption
compared with treatment with AC. This is consistent with the
study of Kulig et al23 that noted gastric lavage offered no
improvement over AC alone.
There are limited data to suggest that outcome is
favorably impacted by orogastric lavage. The study of Kulig
et al23 showed a subgroup of patients who did seem to benefit
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GI Decontamination of the Poisoned Patient
from lavage who presented to the ED obtunded within 1 hour
of ingestion. This is a surprising finding considering that the
rationale for all GID, including gastric lavage, is to prevent
absorption of the toxic substance. Symptomatic patients must
have absorbed the poison, so GID should have no effect at
that point. Furthermore, the converse was not noted; people
who did not undergo gastric lavage did not have higher rates
of clinical deterioration. Subsequent studies have failed to
demonstrate improved outcomes after gastric lavage. In the
study of Merigian et al,24 comparing GE to AC alone in the
treatment of symptomatic patients, there were no statistically
significant differences in mean length of stay in the ED, mean
length of time intubated, or mean length of stay in the ICU.
Pond et al25 found no differences in improvement or
deterioration in patients who underwent GE compared with
patients who received AC only.
As mentioned in the discussion on ipecac, these clinical
studies are not without limitations. Treatment allocation was
neither randomized nor blinded, and analysis was performed
on all patients who presented after an oral overdose who did
not meet exclusion criteria. In addition, it is unclear if
endotracheal intubation, one of the end points of the
Merigian study, was secondary to complications from GE
or done prophylactically before gastric lavage. Nonetheless,
when considering the available data, no appreciable benefit
from gastric lavage is noted.
Indications
There are no absolute indications for the use of gastric
lavage. One situation in which it is of theoretical benefit is
recently after ingestion of a very toxic substance. Ideally, this
is performed within 30 minutes of ingestion and certainly
within 1 hour. An additional theoretical indication is a severe
poisoning not amenable to charcoal.
Contraindications
Like syrup of ipecac, gastric lavage is contraindicated
in patients with compromised or potentially compromised
airway reflexes for whom no definitive airway, that is,
endotracheal intubation, is established. Lavage should be
avoided after ingestion of substances with high aspiration
potential, such as hydrocarbons. Gastric lavage is contra-
indicated after ingestion of substances with high corrosive
potential, that is, iron, acids, and alkalis, and in patients at
risk for hemorrhage or GI perforation due to underlying
pathology or recent surgery. Gastric lavage is relatively
contraindicated after ingestions of pills known to be larger
than the aperture of the orogastric tube.
Complications
Adverse effects from gastric lavage are estimated to
occur in 3% of cases.40 Aspiration has been found to occur in
alert patients as well as in those who were intubated before
performing lavage. An increased incidence of laryngospasm
and subsequent hypoxia may occur, particularly in conscious
patients.41 Death has occurred from unrecognized endotra-
cheal placement of the lavage tube. Mechanical injury to the
oropharyngeal, esophageal, and gastric mucosa can occur.
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Greene et al
These events are seen in patients without predisposing
conditions.42 Esophageal spasm has been reported. Hypo-
thermia can be sustained if cold fluids are used for lavage.
Hyponatremia and water intoxication have been reported in
children who have been lavaged with water. The theoretical
complication of gastric lavage propelling ingested toxins
beyond the pylorus has been mentioned in a number of articles
and texts, but a systematic review by Eddleston et al43 found
no evidence this actually occurs.
Position Papers
In 1997, the societies questioned the propriety of GE.
The statement suggested that gastric lavage should not be
used routinely in the management of poisoned patients.11 In
2004, the position statement took a firmer stand against
gastric lavage. It stated that gastric lavage should not be used
routinely, if ever, in the management of poisoned patients
and that results of clinical outcome studies in overdose
patients are weighed heavily on the side of showing a lack of
beneficial effects. They also noted that the procedure is
associated with serious risks.44 Despite this recommendation,
the AAPCC reports that 12,255 patients underwent gastric
lavage in 2005.1
Authors_ Recommendations
The authors believe that orogastric lavage should not
be used. The therapy has not proven to be clinically useful
and procedural risks are significant.
ACTIVATED CHARCOAL
Chemistry
Charcoal is an insoluble powder created from the
pyrolysis of a variety of organic materials, including peat,
wood, and coconut shell. The powder is then oxidized by one
or more gases, such as steam, oxygen, carbon dioxide,
phosphoric acid, sulfuric acid, or zinc chloride, at temper-
atures between 500-C and 900-C. This Bactivation[ increases
its adsorptive surface area to at least 950 m2/g, and many of
the commercially available compounds have surface areas of
950 to 2000 m2/g. A superactivated charcoal with a surface
area of 3150 m2/g has been shown to have increased
adsorptive capacity and better palatability, but it is not
currently available.33,34,45Y47
Background
The most commonly used method of GID today is
single-doseYactivated charcoal (SDAC). Data from the
AAPCC indicate 119,096 cases of SDAC administration in
2005.1 The aim of SDAC is to avert toxicity by adsorbing the
poison within the GI tract, thereby preventing systemic
absorption. Hippocrates reportedly used charcoal to treat a
variety of ailments, but the study of charcoal_s adsorptive
capacity was first documented in the mid-18th century. In
1829, the first case report of the use of charcoal in the
management of a poisoned patient was published, and 2 years
later, the French pharmacist, Touery, demonstrated the
effectiveness of charcoal by ingesting 15 g along with a
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
lethal amount of strychnine. His benign clinical course
convinced his contemporaries of the efficacy of charcoal.47
In 1846, Garrod performed the first animal studies demon-
strating the effectiveness of charcoal and presented his
findings before the Medical Society of London. By the
middle of the 19th century, charcoal was in use as an
antidote, and in 1963, after Holt and Holz referred to AC as
the most valuable agent in treating acute poisonings, its use
became widespread.47
Technique
There is no known optimal dose for AC. Charcoal
binding is saturable, so as surface area increases, the binding
capacity improves. Studies have evaluated various charcoal-
toxin ratios, and a commonly cited goal is a ratio of 10:1,
based on a study by Olkkola48 of charcoal binding of para-
aminosalicylate. Many authorities recommend 1 g/kg in
children up to 100 kg to achieve this desired ratio. Others
suggest 10 to 25 g for infants, 25 to 50 g for children 1 to 12
years, and 25 to 100 g for adolescents.34,46 Activated
charcoal is available as a tablet, as a bulk powder (1 tbsp
approximates 5 g), and as a premixed solution. If using
tablets or powder, a slurry should be prepared. Despite the
gritty texture, children will typically drink a charcoal-water
slurry that is administered. Palatability of the charcoal
solution may be improved without loss of efficacy by
addition of small amounts of cola, chocolate syrup, or cherry
syrup.49Y51 Premixed preparations of charcoal as a suspension
in 70% sorbitol enhance the palatability, although the
associated increase in vomiting may reduce efficacy. The
premixtures are contained in a compressible bottle that easily
attaches to a nasogastric tube, which can be used if the child
does not accept the oral offering. Thorough container
agitation and rinsing are necessary to ensure the patient has
received sufficient AC.52
Studies
Charcoal shares efficacy and time-sensitive features of
ipecac and orogastric lavage. There is great variability in the
effectiveness of AC to reduce absorption. The ability of AC
to adsorb poison from the GI tract is greatest when charcoal
is given as soon as possible after the ingestion. There is a
definite trend of decreased efficacy over time. Volunteer
studies by Christophersen et al35 demonstrate a mean
reduction in the absorption of subtoxic doses of acetamino-
phen of 66% when AC was administered 1 hour after
ingestion, whereas the reduction in absorption associated
with AC given 2 hours after ingestion was 22.7%. Yeates and
Thomas53 observed similar results after treating healthy
volunteers with subtoxic acetaminophen ingestions. Absorp-
tion was reduced by 56%, 22%, and 8% when AC was
administered after 1, 2, or 4 hours, respectively.53 A similar
study was conducted by Green et al.54 In a randomized 4-
limb crossover study involving adults aged 22 to 31 years,
the participants ingested acetaminophen and then received 50
g of AC at 1, 2, and 3 hours after ingestion. The decrease in
bioavailability in the 1-hour group was 30.3%, whereas the
other 2 groups failed to achieve clinical or statistical
significance.54 Lapatto-Reiniluoto et al39 treated healthy
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
volunteers who simultaneously ingested ibuprofen, citalo-
pram, and diazepam with 25 g of AC 30 minutes after taking
the pills and noted a reduction in diazepam absorption of
27%, a reduction in ibuprofen absorption of 30%, and a
reduction in the absorption of citalopram of 51%. The AACT
or the EAPCCT position statement describes 122 volunteer
comparisons involving 46 drugs evaluating the effect of 0.5
to 100 g of charcoal from 0 to 360 minutes and found that the
mean percent reduction in absorption from time 0 to 60
minutes was 67.3% (range, 5.7%Y100%). At 60 minutes, the
mean was 38.14% (range, 5.7%Y77.9%).46 When the 48
volunteer comparisons involving 26 drugs, in which at least
50 g of AC was used, the mean percent reduction in
absorption was 71.71% from 0 to 60 minutes (range,
12.9%Y100%), and when AC was given at 60 minutes, the
mean reduction was 40.07% (range, 12.9%Y77.9%). In the
studies using at least 50 g of AC, when charcoal was
administered 120 minutes after ingestion, the mean reduction
in absorption fell to 16.5% (range, 7.7%Y22.0%).
There are few studies assessing the clinical impact of
AC. In a 1990 study by Merigian et al24 assessing the efficacy
of GE in overdose patients, asymptomatic patients were
treated with either AC or no GID. There were no significant
differences in admission rates, ICU admission rates, or
adverse outcomes. In 2002, Merigian and Blaho55 conducted
the first prospective, controlled trial of SDAC in the self-
poisoned patient. Over a 24-month period, 1479 patients aged
22 to 82 years were entered in the study. Patients underwent
no GE procedures. On even-numbered days, patients were
treated with 50 g of AC, whereas on odd-numbered days, no
GID was performed. Patients were observed for a minimum of
4 hours in the ED. There were no significant differences in the
rates of deterioration, length of hospital stay, or complications.
However, a significantly higher percentage of patients treated
with AC vomited compared with the group that underwent no
GID (23% vs 13%). In addition, a significantly greater
proportion of ICU patients (55.6%) who received AC were
intubated than those of ICU patients (22.6%) who did not
receive AC, although it is unclear if these intubations were
performed prophylactically before administration of AC or if
the patients_ clinical condition warranted it.
Several investigators have criticized the design of the
Merigian and Blaho study, particularly because the odd-even
enrollment scheme precluded true randomization, the control
(n = 1080) and treatment (n = 399) groups had such disparate
numbers, and because several highly toxic ingestions were
excluded.56 A more recent randomized clinical trial by Cooper
et al57 also compared AC to no GID in 327 patients aged 16
years and older who presented to the ED within 12 hours after
a deliberate oral ingestion. Patients were randomized to 50 g
of AC or no AC. Outcomes measured included length of stay
until medically fit for discharge, vomiting, mortality, and ICU
admission. There was no significant difference between the
AC and no AC group in any of the outcomes.
Indications
There are no absolute indications for the administration
of AC. Studies have demonstrated a higher likelihood of
preventing absorption if given soon after the ingestion, and
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GI Decontamination of the Poisoned Patient
many toxicologists use 1 hour as the time frame in which to
consider its use. A delay of more than 1 hour is not a
contraindication to the use of AC, but studies have suggested
that the reduction of absorption decreases to values of
questionable clinical significance.
Contraindications
The use of AC requires a functional and an intact GI
tract. Its use is contraindicated in patients with a dysfunctional
GI tract, such as in the setting of a bowel obstruction. Charcoal
is also contraindicated in patients who are predisposed to GI
perforation or hemorrhage because of either underlying
medical conditions or secondary to the nature of the ingestion,
that is, corrosives. Charcoal should also be avoided after
ingestion of a corrosive because it may impede subsequent
endoscopy. Charcoal is contraindicated in patients who lack an
intact or a protected airway, particularly if the ingestion is
likely to produce central nervous system depression. Charcoal
is also contraindicated in ingestions with high aspiration
potential, such as hydrocarbons. Finally, AC should not be
administered after ingestions of substances that are not
adsorbed by AC. Most substances are adsorbed by AC, but
those that are not include highly ionic salts and elements, such
as iron and lithium, and polar molecules, such as ethanol.
Complications
Adverse events produced by a single dose of AC with
or without sorbitol include gagging and vomiting. Charcoal
alone is associated with a 15% incidence of vomiting. The
incidence of vomiting is greater when AC is administered
with sorbitol, with estimates in the 16% to 56% range.58
Osterhoudt et al59 noted a 20.4% incidence of vomiting in
pediatric patients receiving AC in the ED. Prior vomiting and
insertion of a nasogastric tube, but not sorbitol content or fast
administration rates, were associated with an increased risk.
Other adverse events after charcoal administration are less
common but more significant, including death. Seger47 has
reported several cases in which patients treated with AC after
an oral overdose were determined to have died not from the
ingestion but solely due to the charcoal. A 16-month-old
child believed to have ingested amitriptyline underwent
nasogastric lavage followed by administration of a char-
coalYmagnesium citrate slurry. She aspirated, became asys-
tolic, and could not be resuscitated. Her postmortem
examination revealed no evidence of tricyclics, and charcoal
aspiration was listed as the cause of death. There are other
deaths reported in the AAPCC Toxic Exposure Surveillance
System data in which charcoal was suspected but not proved
to be responsible for fatalities. Many complications from AC
are due to the route by which charcoal is given in addition to
the intrinsic properties of charcoal. When AC is used in
conjunction with gastric lavage, the complications of esoph-
ageal or gastric perforation, aspiration, laryngospasm and
subsequent hypoxia, and dysrhythmias are possible. Even
when no lavage is performed, the presence of an orogastric or
nasogastric tube increases the risk. Furthermore, when
charcoal is aspirated, it causes extensive lung damage beyond
that which results from aspiration of gastric contents. Arnold
181
Greene et al
et al60 demonstrated that charcoal increases pulmonary
microvascular permeability and produces arterial blood gas
derangements not observed in simple cases of gastric
aspiration. Activated charcoal may obscure the view of the
oropharynx, rendering endoscopy and orotracheal intubation
difficult. Activated charcoal may reduce the effectiveness of
orally administered antidotes. Constipation is generally
observed with multiple doses of AC but has been reported
after SDAC.61 Pharmacobezoar formation and bowel obstruc-
tion are recognized complications only of repeated charcoal
use. There has been a single case report of bowel perforation
associated with a single dose of AC without sorbitol.62
Position Papers
In 1997, ACCT or EAPCCT published its first position
statement on SDAC, and the 2005 revision reflected no
significant change in their policy. They recommended that
SDAC should not be administered routinely in the manage-
ment of poisoned patients. Based on volunteer studies, they
suggested that the administration of AC may be considered if
a patient has ingested a potentially toxic amount of a poison
(which is known to be adsorbed to charcoal) up to 1 hour
previously. Although volunteer studies demonstrated that the
reduction of drug absorption decreases to values of ques-
tionable clinical importance when charcoal is administered at
times more than 1 hour, the potential for benefit after 1 hour
could not be excluded. They concluded there was no
evidence that the administration of AC improved clinical
outcome. They further cautioned that, unless a patient had an
intact or a protected airway, the administration of charcoal
was contraindicated.46
Authors_ Recommendations
Many physicians feel compelled to attempt some form
of GID when a poisoned patient presents to their ED,63 and
parents of poisoned toddlers often share this expectation. The
2 prospective trials cited previously failed to demonstrate a
benefit from AC, but it is certainly possible that this was due
to the Bshotgun[ approach of AC use. It is possible that AC
imparts a benefit when administered to patients with
significantly toxic ingestions. We believe that AC should
not be used routinely in the management of the poisoned
patient but may be administered when all of the following
criteria are satisfied: (1) the ingestion is potentially toxic; (2)
there are no contraindications to the use of AC; (3) the
substance(s) ingested is bound by charcoal; (4) the toxic
substance is likely to be in the GI tract at time of charcoal
administration; (5) the patient is either intubated before
charcoal administration or expected to maintain a protected
airway throughout the course of the therapy; (6) the GI tract
is anatomically and functionally intact; and (7) there is no
safer or more effective alternative therapy.
CATHARTICS
Background
The theoretical goals of cathartic administration in
ingestion are to increase motility of the poison through the GI
182
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
tract and therefore decrease its absorption. A variety of
pharmaceuticals that had been used and abandoned include
neostigmine, erythromycin, and metoclopramide. Several
osmotic agents that increased colonic fluid leading to
diarrhea and enhanced bowel evacuation were used. Magne-
sium citrate (4 mL/kg of 10% solution) and magnesium
sulfate and sodium sulfate granules, each at a dose of 250
mg/kg, have fallen out of use. Sorbitol remains as the only
cathartic used.
Technique
Rarely is sorbitol used as monotherapy in GID. The
recommended dose is 1 to 2 mL/kg of a 70% solution for
adolescents. For children, the standard 70% solution is
diluted to 35% with water, and 4.3 mL/kg is provided. More
often, sorbitol is used with charcoal. The charcoal-sorbitol
slurry is administered by mouth or via nasogastric or
orogastric tube.
Studies
Several volunteer studies have evaluated the effects of
cathartic agents as the sole method of eliminating a poison.
There seems to be no reduction in absorption of a toxic
substance after administration of magnesium sulfate, sodium
sulfate, or sorbitol.64Y66 Volunteer studies evaluating the
effect of sorbitol when mixed with AC have yielded
conflicting data. Goldberg et al67 found a reduction in the
absorption of theophylline after a dose of sorbitol mixed with
AC compared with AC alone, whereas al-Shareef et al68
found no significant difference in theophylline absorption.
No clinical studies have been published that indicate
cathartics with or without AC improve the outcome of
poisoned patients.
Indications
The stated indications for sorbitol are to improve the
palatability of AC as well as to prevent the constipation that
theoretically charcoal may produce. As sorbitol can shorten
the GI transit time, it may be of utility for drugs that decrease
GI motility, such as antihistamines, hypnotic sedatives,
opioids, phenothiazines, and tricyclic antidepressants.
Contraindications
Cathartics alone, or in combination with AC, are
contraindicated in patients with ileus, intestinal obstruction,
or recent abdominal trauma or surgery. Cathartics are also
contraindicated in patients with compromised or potentially
compromised airway reflexes for whom no definitive airway,
that is, endotracheal intubation, is established. Cathartics
should be avoided after ingestion of substances with high
aspiration potential, such as hydrocarbons. Cathartics are
contraindicated in patients with volume depletion or known
electrolyte imbalance and should be avoided in ingestants
that produce diarrhea.
Complications
Complications of a single-dose cathartic, with or
without charcoal, are few. They include nausea, abdominal
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
cramps, and vomiting. Repeated use, which is contraindi-
cated, may produce presyncope, dehydration, and electrolyte
abnormalities, including fatal hypernatremia in children.
Position Papers
The initial and revised position statements suggested
that a cathartic alone had no role in the management of the
poisoned patient. They stated that if a cathartic was used, it
should be limited to a single dose to minimize adverse effects
of the cathartic.12,69 The use of a cathartic in combination
with AC as a routine was not endorsed.
Authors_ Recommendations
The authors concur that cathartics have no role as
monotherapy in GID. In circumstances where AC may be
appropriate, we believe that a single dose of sorbitol added to
the AC is acceptable, so long as no contraindications exist.
We also caution providers that sorbitol may result in
significant vomiting.
WHOLE-BOWEL IRRIGATION
Background
Polyethylene glycol electrolyte solution (PEG-ES) is
used as a bowel-cleansing solution before surgery and
colonoscopy. The solution was designed to prevent fluid or
electrolyte changes across the GI epithelium. In 1982, WBI
solutions were proposed as a method of GID. The postulate
was increasing the transit of the toxic material beyond the
area of the proximal small bowel, where most substances are
absorbed. In 2005, its use was reported by the AAPCC 2809
times.1
Technique
The process involves the administration of a large
amount of fluid in a short time frame. The solution is
administered orally but is often declined even by relatively
cooperative patients. Polyethylene glycol electrolyte solution,
if refused orally, can be given by nasogastric tube, although
this increases the potential for aspiration. The recommended
dosing schedule is 500 mL/h for children 9 months to 6 years,
1000 mL/h for children 6 to 12 years, and 1500 to 2000 mL/h
for adolescents. To minimize the chance of complications, it is
best to start WBI at a lower rate and slowly advance to the
desired dose. The patient is placed upright, sitting on a
commode, and the solution is continued until rectal effluent
is clear. If pills had initially been noted on plain abdominal
radiographs, repeat films should no longer exhibit tablet
visibility. Alternatively, some authorities recommend con-
trasted abdominal imaging to confirm bowel evacuation.
Studies
There are no reported controlled clinical trials evaluat-
ing the efficacy of WBI. However, there are case reports
involving patients with ingestions in which WBI seemed to
be effective. Volunteer studies using subtoxic ingestions or
inert markers have had mixed results. Tenenbein et al70
observed a 67% reduction in absorption of ampicillin after
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GI Decontamination of the Poisoned Patient
initiation of WBI. A similar effect was noted by Smith et al71
using sustained-release lithium. Ly et al72 measured the
absorption of delayed-release acetaminophen as well as the
progression of a radiopaque marker on abdominal radio-
graphs in a crossover study involving adults and found that
WBI accelerated the transit of the Sitzmarks polyvinyl
chloride markers but did not significantly reduce the
absorption of the acetaminophen. The study has been
criticized, however, because the markers do not share
physical characteristics of most ingested pills and because
delayed-release acetaminophen is absorbed much faster than
typical sustained-release products.73,74 Successful use of
WBI has also been reported after accidental ingestion of a
clonidine patch by a 6-year-old child.75
Indications
Although there are no absolute indications for WBI, its
use should be considered in several circumstances. Whole-
bowel irrigation has its greatest potential benefit for
substances that are slowly absorbed from the GI tract. Whole-
bowel irrigation should be considered for potentially toxic
ingestions of sustained-release or enteric-coated drugs, and it
is arguably the only option for GID in patients presenting
more than 2 hours after ingestion, when the amount of poison
adsorbed by AC is insignificant. Whole-bowel irrigation
remains a theoretical option for ingested transdermal patches
and latex packets of cocaine and other drugs of abuse. Whole-
bowel irrigation would be of utility for potential toxic
ingestions of iron, lead, arsenic, and zinc.
Contraindications
Whole-bowel irrigation is contraindicated in patients
with impaired airway reflexes or intractable vomiting. It
should be avoided in patients with ileus or mechanical bowel
obstruction and in patients with GI hemorrhage or perfo-
ration. Whole-bowel irrigation is relatively contraindicated in
debilitated patients and patients with an underlying medical
condition that can be further compromised.
Complications
Adverse effects from PEG-ES include taste perversion,
nausea, and vomiting. Vomiting may then limit the oral route
and may require placement of a nasogastric tube. With
placement of the nasogastric tube, possible complications
include aspiration, GI tract injury, and laryngospasm with
subsequent hypoxia. Bloating and abdominal cramping are
occasionally seen with PEG-ES use. Polyethylene glycol
electrolyte solution is not associated with systemic abnormal-
ities. In fact, in a report of inadvertent intravenous infusion of
nearly 400 mL of PEG-ES, the 4-year-old patient developed
no acidosis, renal failure, or other complications.76 Poly-
ethylene glycol electrolyte solution, if given with AC, may
decrease the efficacy of the AC and the subsequent specific
oral antidotes.
Position Papers
Whole-bowel irrigation was not recommended rou-
tinely in the management of the poisoned patient in either the
183
Greene et al
1997 or the 2004 position papers.13,77 The 2004 statement
acknowledges that some volunteer studies have shown
substantial decreases in the bioavailability of ingested drugs
but that no controlled clinical trials have been performed, and
there is no conclusive evidence that WBI improves the
outcome of the poisoned patient. It is suggested that WBI
should be considered for potentially toxic ingestions of
sustained-release or enteric-coated drugs, particularly for
those patients who presented beyond 2 hours after ingestion,
and for ingestions of iron and packets of illicit drugs.77
Authors_ Recommendations
Whole-bowel irrigation offers no benefit after ingestion
of substances that are rapidly absorbed. After potentially
toxic ingestions of drugs that are likely to remain in the GI
tract, the use of WBI should be considered. The GI tract must
remain functional, and the airway must be protected during
the course of WBI. When PEG-ES is not tolerated orally, the
smallest possible nasogastric tube should be used, which will
provide the necessary volume of PEG-ES.
Of the 5 methods described in this article, we believe
that only AC and WBI can be of clinical benefit, and only in
certain circumstances. Deciding which modality to use
depends on the nature of the substance and the time that
has elapsed since ingestion. For ingestions that present to the
ED after a delay of 1 hour or more, AC is unlikely to be
beneficial, but WBI may be useful if the substance is
expected to be in the GI tract. For ingestions that occurred
FIGURE 1. Gastrointestinal decontamination decision tree.
184
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
within 60 minutes of ED arrival, WBI is probably preferable
to AC if the ingestant is a sustained-release product, a latex
packet, a transdermal patch, or a substance that is not
adsorbed by charcoal but is also not absorbed from the GI
tract rapidly. For other ingestions that present within 60
minutes, AC is the GID modality of choice so long as the
previously identified criteria for its use have been satisfied
(Fig. 1).
CONCLUSION
Although pediatric ingestions are common, they rarely
result in significant morbidity or mortality. Every patient who
presents to the ED after an ingestion should be assessed
thoroughly. Monitoring and supportive caring continue as
mainstays in the management of toxic ingestions in the ED.
Gastrointestinal decontamination, long a touted benefit of
toxicological care, has been questioned. Many learned
individuals have questioned whether GID has benefits in
the practice of toxicological care.78 The decision to perform
one or more methods of GID, however, should be made only
after careful analysis of the potential toxicity of the ingested
substance(s) and the potential risks and benefits of whichever
modalities of GID are being considered. Most ingestions can
be managed safely and effectively without any GID.
Emergency physicians should abandon the practice of
reflexively performing GID. Finally, whenever questions
arise, consultation with a toxicologist is recommended.
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
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63. Jacobsen P, Ebbehoj NE. Risk assessment by physicians and by the
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64. Sorensen PN, Lindkaer-Jensen S, Dijk A, et al. The effect of magnesium
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activated charcoal on serum theophylline concentrations after slow-
release theophylline. Clin Pharmacol Ther. 1987;41:108Y111.
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Pediatric Emergency Care  Volume 24, Number 3, March 2008
68. al-Shareef AH, Buss DC, Allen EM, et al. The effects of charcoal and
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73. Tenenbein M. Effect of whole bowel irrigation on delayed-release
acetaminophen and gut transit time. Ann Emerg Med. 2004;44:668Y669.
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75. Horowitz R, Mazor SS, Aks SE, et al. Accidental clonidine patch
ingestion in a child (case report). Am J Ther. 2005;12:272Y274.
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Pediatric Emergency Care  Volume 24, Number 3, March 2008 GI Decontamination of the Poisoned Patient

CME EXAM
Instructions for the Pediatric Emergency Care CME Program Examination

To earn CME credit, you must read the designated article and complete the examination below, answering at least 80%
of the questions correctly. Mail a photocopy of the completed answer sheet to the Lippincott CME Institute Inc., 770 Township
Line Road, Suite 300, Yardley, PA 19067. Only the first answer form will be considered for credit and must be received by
Lippincott CME Institute, Inc. by May 15, 2008. Answer sheets will be graded and certificates will be mailed to each
participant within six to eight weeks after LCMEI, Inc. receipt. The answers for this examination will appear in the June 2008
issue of Pediatric Emergency Care.
Credits
Lippincott Continuing Medical Education Institute, Inc. designates this educational activity for a maximum of 1 AMA
PRA category 1 Credit TM. Physicians should only claim credit commensurate with the extent of their participation in the
activity.
Accreditation
Lippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.

CME EXAMINATION
March 2008
Please mark your answers on the ANSWER SHEET.
Gastrointestinal Decontamination of the Poisoned Patient, Greene et al

1. Routine GI decontamination is an imperative modality in c. fifty well-wrapped packages each containing 50 mg of

management of which of the following circumstances? cocaine swallowed 2 hours ago
a. unwitnessed, but suspected ingestion d. fifty 325-mg ferrous sulfate tablets ingested 80 minutes
b. witnessed ingestion of a nontoxic substance ago
c. witnessed ingestion of a toxic substance 4. In which of the following situations may the use of AC be
d. none of the above considered?
2. Which of the following interventions would be most a. patient who is not intubated and who lacks a gag
appropriate after ingestion of five 200-mg ibuprofen tablets reflex
by a toddler weighing 15 kg that occurred 45 minutes b. isolated ingestion of a corrosive substance
before ED arrival? c. mixed ingestion that involves acetaminophen
a. gastric lavage using normal saline 10 mL/kg d. recent gastrointestinal surgery that predisposes the
b. activated charcoal 15 g PO patient to GI perforation
c. whole-bowel irrigation at 500 mL/h until rectal effluent 5. Which of the following is not a documented complication
is clear of gastric lavage?
d. no GI decontamination a. aspiration pneumonia
3. For which of the following ingestions would WBI be least b. esophageal perforation
helpful? c. electrolyte imbalance
a. thirty 250-mg Depakote ER tablets ingested 1 hour ago d. propulsion of toxic substance beyond the pyloric
b. thirty 0.2-mg clonidine tablets ingested 1 hour ago sphincter

* 2008 Lippincott Williams & Wilkins 187

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Greene et al Pediatric Emergency Care  Volume 24, Number 3, March 2008

ANSWER SHEET FOR THE PEDIATRIC EMERGENCY CARE

CME PROGRAM EXAM
March 2008
Please answer the questions on page 187 by filling in the appropriate circles on the answer sheet below. Please mark the
one best answer and fill in the circle until the letter is no longer visible. To process your exam, you must also provide the
following information:
Name (please print): ______________________________________________________________________________________
Street Address ___________________________________________________________________________________________
City/State/Zip ___________________________________________________________________________________________
Daytime Phone __________________________________________________________________________________________
Specialty _______________________________________________________________________________________________
1. A B C D
2. A B C D
3. A B C D
4. A B C D
5. A B C D
Your evaluation will help us assess whether this CME activity is congruent with LCMEI’s CME mission statement and will assist us
in future planning of CME activities. Please respond to the following questions:
1. Did the content of this CME activity meet the stated learning objectives?
[ ] Yes [ ] No
2. On a scale of 1 to 5, with 5 being the highest, how do you rank the overall quality of this educational activity?
[]5 []4 []3 []2 []1
3. Was the activity’s format (ie, print, live, electronic, Internet, etc.) an appropriate educational method for conveying the activity’s
content?
[ ] Yes [ ] No
4. Did this CME activity increase your knowledge/competence in the activity’s topic area? If No, please explain why not.
[ ] Yes [ ] No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5. As a result of participating in this CME activity, will you be changing your practice behavior in a manner that improves your
patient care? Please explain your answer.
[ ] Yes [ ] No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
6. Did you perceive any evidence of bias for or against any commercial products? If yes, please explain.
[ ] Yes [ ] No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
7. How long did it take you to complete this CME activity?
__________hour(s) __________minutes
8. Please state one or two topics that you would like to see addressed in future issues.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
[ ] YES! I am interested in receiving future CME programs from Lippincott CME Institute! (Please place a check mark in the box)

Mail by May 15, 2008 to

Lippincott CME Institute, Inc.
770 Township Line Road, Suite 300
Yardley, PA 19067

188 * 2008 Lippincott Williams & Wilkins

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Pediatric Emergency Care  Volume 24, Number 3, March 2008 GI Decontamination of the Poisoned Patient

CME EXAM ANSWERS

Answers for the Pediatric Emergency Care CME Program Exam

Below you will find the answers to the examination covering the review article in the December 2007 issue. All participants
whose examinations were postmarked by February 15, 2008 and who achieved a score of 80% or greater will receive a certificate
from Lippincott CME Institute, Inc.

EXAM ANSWERS
December 2007
1. D
2. C
3. E
4. A
5. D

* 2008 Lippincott Williams & Wilkins 189

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