Author:

FrankLoVecchio

Initial Stabilization/Therapy

• Airway, breathing, and circulation management (ABCs):
  • Secure airway for decreased mental status/inability to protect airway
  • IV access
  • Cardiac monitor
• With altered mental status from overdose:
  • Naloxone
  • Thiamine
  • Dextrose (or Accu-Chek)

ED Treatment/Procedures

• Activated charcoal:
  • General:
    • Prepared by treating heated wood pulp, which creates a large surface area to bind toxins
    • Mainstay of gastric decontamination
    • Effective when contents have reached small intestine
  • Dose:
    • 1-2 g/kg of body weight or an activated charcoal-to-drug ratio of 10:1; often mixed with sorbitol (see below)
    • Oral or nasogastric tube administration
  • Indications:
    • Administer in every toxic ingestion (see below for exceptions)
    • Optimal for toxic ingestions presenting within 1 hr of ingesting a drug that is absorbed by charcoal in a patient with a patent airway
  • Adverse effects:
    • Vomiting and constipation
    • Charcoal aspiration and subsequent charcoal pneumonitis
  • Contraindications:
    • Caustic ingestions
    • Unprotected airway
    • Bowel obstruction or ileus
  • Drugs not effectively bound to charcoal:
    • Metals (borates, bromide, iron, lithium)
    • Alcohols
    • Potassium
    • Potassium cyanide (poorly absorbed)
    • Hydrocarbons
    • Caustics
  • Pediatric considerations:
    • Mix with palatable substance (cola or juice) to facilitate intake or administer via gastric tube
  • Controversies:
    • Rand omized, controlled trials have shown a slightly worse outcome and higher complication rate when asymptomatic patients received charcoal vs. nothing
    • An extremely small minority of patients are likely to benefit from gastric lavage
• Multiple-dose activated charcoal:
  • General:
    • Used in toxic ingestions that are well absorbed by charcoal and undergo enterohepatic circulation
  • Dose:
    • 1 g/kg followed by 0.5 g/kg q2-6h
    • Never use cathartics in conjunction with multiple-dose activated charcoal
  • Indications:
    • Salicylates
    • Theophylline
    • Multiple-dose activated charcoal may decrease area under the curve for drugs such as phenobarbital, phenytoin, and carbamazepine but has not been proven to improve outcome
• Cathartics:
  • General:
    • Used in combination with activated charcoal to prevent constipation and to enhance GI transit time
    • Limited data available to demonstrate any decreased absorption when a cathartic (sorbitol) is added to activated charcoal
    • Cathartics alone are of no proven benefit and should be avoided
    • Never use cathartics in conjunction with multiple-dose activated charcoal
  • Dose:
    • Magnesium citrate: 10% solution: 250 mL (peds: 4 mL/kg)
    • Magnesium sulfate: 15-20 g (peds: 250 mg/kg)
    • Sorbitol: 0.5-1 g/kg to a max 100 g of 70% solution (peds: >1 yr old: 0.5-1 g/kg as a 35% solution to a max. 50 g) PO mixed in the activated charcoal slurry - use only in first dose
  • Adverse effects:
    • Dehydration
    • Hypermagnesemia
    • Diarrhea
    • Abdominal discomfort
  • Contraindications:
    • Pre-existing dehydration
    • Renal disease (cathartics containing magnesium)
    • Avoid in children
  • Controversies:
    • No proven benefit and some cases of harm reported
• Whole-bowel irrigation:
  • General: Cleansing of bowel
  • Indications:
    • Toxins not well absorbed by charcoal, such as toxic iron and lithium ingestions
    • Toxins in sealed containers (body packers) without signs of GI perforation
    • Toxic, sustained-release product ingestions
  • Dose:
    • Polyethylene glycol (Colyte, GoLytely)
    • Solution at 2 L/hr in adults (0.5 L/hr in children) until rectal excretions clear
    • Administer via nasogastric tube with activated charcoal via continuous or bolus method as indicated
  • Adverse effects:
    • Bloating
    • Rectal irritation
    • Frequent bowel movements
  • Contraindications:
    • Mechanical or pharmacologic ileus
    • Bowel obstruction
    • Hypotension
    • Intestinal perforation
    • Unprotected airway
• Orogastric lavage:
  • General:
    • Placement of large-bore tube (32F-36F) in stomach for removal of ingested toxins
    • Effectiveness of orogastric lavage depends on time since ingestion, timing of last meal, and toxin ingested
    • Protected airway is essential prior to any attempts at orogastric lavage
  • Indications:
    • Currently, rarely performed
    • Presentation within 1 hr of taking a potentially lethal ingestion with no known antidote
    • Poisoned intubated patient arriving within ∼1 hr
  • Adverse effects:
    • Intubation of respiratory tree
    • Esophageal or gastric perforation
    • Charcoal aspiration
    • Patient discomfort
  • Contraindications:
    • Large pills (limited by lavage-tube port size) ingestion
    • Caustics (acids and alkali) ingestion
    • Hydrocarbon ingestion
    • Ingestion of agents that rapidly depress mental status
    • Unprotected airway
  • Pediatric considerations:
    • Avoid in children
    • Unlikely to result in any clinically significant pill extraction secondary to smaller-bore orogastric tube (i.e., 18F)
    • Risk of aspiration increased in children
    • Controversies: Several rand omized, controlled trials have documented no benefit when lavage plus activated charcoal is compared with activated charcoal alone
• Ipecac:
  • General:
    • Rarely used
    • Derived from the roots of the plant Cephaelis acuminata
    • Exerts emetic action by direct gastric irritation and centrally mediated chemoreceptive trigger-zone stimulation
    • Delays administration of activated charcoal
    • Offers no advantage over activated charcoal alone when both treatments are potentially effective
  • Dosage:
    • >12 yr: 30 mL
    • 1-12 yr: 15 mL
    • 6 mo-1 yr: 5-10 mL + 15 mL clear fluid
  • Indications:
    • No utility in ED
  • Adverse effects:
    • Vomiting may complicate and worsen clinical presentation
    • Delay to administration of activated charcoal or oral antidotes
  • Contraindications:
    • Caustics (acids and alkali) ingestion
    • Hydrocarbon ingestion
    • Ingestion of agents that rapidly depress mental status
    • Patient actively vomiting

• AlbertsonTE, OwenKP, SutterME, et al. Gastrointestinal decontamination in the acutely poisoned patient . Int J Emerg Med. 2011;4:65.
• HolstegeCP, DobmeierSG, BechtelLK. Critical care toxicology . Emerg Med Clin North Am. 2008;26(3):715-739.
• IsbisterGK, KumarVV. Indications for single-dose activated charcoal administration in acute overdose . Curr Opin Crit Care. 2011;17(4):351-357.

See Also (Topic, Algorithm, Electronic Media Element)

• Poisoning
• Poisoning, Antidotes
• Poisoning, Toxidromes

ICD9

977.9Poisoning by unspecified drug or medicinal substance

ICD10

T65.91XA Toxic effect of unspecified substance, accidental (unintentional), initial encounter

SNOMED

• 75478009 Poisoning (disorder)

• 235453002 selective decontamination of the digestive tract (procedure)