DESCRIPTION

Ipecac is an oral emetic agent.

FORMS AND USES

• Syrup of ipecac is composed of cephaeline and emetine in a 2.5:1 to 1.0:1 ratio.
• Typical doses are 10 cc for an infant 6 to 12 months of age, 15 cc for a child 1 to 5 years of age, and 30 cc for anyone over 5 years of age.
• It is available in 15- and 30-cc containers.

MECHANISM OF ACTION

• Cephaeline stimulates the central vomiting center, and emetine activates sensory receptors in the proximal small intestine.
• Time to vomiting: 88% of patients vomit in less than 30 minutes.
• Mean episodes of vomiting are three; the range is one to eight episodes.
• Duration of vomiting is 23 to 60 minutes.

DRUG AND DISEASE INTERACTIONS

Syrup of ipecac may be absorbed by charcoal, but no effect on time to initiation of vomiting has been demonstrated.

PREGNANCY AND LACTATION

• US FDA Pregnancy Category C. The drug exerts animal teratogenic or embryocidal effects, but there are no controlled studies in women, or no studies are available in either animals or women.
• Ipecac is relatively contraindicated during pregnancy due to potential mechanical effects on the uterus.

Section Outline:

• DESCRIPTION
• FORMS AND USES
• MECHANISM OF ACTION
• DRUG AND DISEASE INTERACTIONS
• PREGNANCY AND LACTATION

ADULT PATIENTS

• Prehospital care. Alert patients in whom health-care evaluation will not occur for an hour or more should be administered ipecac.
• Health-care facility. Gastric lavage should be used instead of ipecac, except for unusual conditions such as the ingestion of toxic plant material or tablets of a size that will not pass through the orogastric lavage tube.

PEDIATRIC PATIENTS

• Prehospital care. Alert patients in whom health-care evaluation will not occur for an hour or more should be administered ipecac.
• Health-care facility. Although gastric lavage is preferred, ipecac should be used within 1 hour of ingestion for patients who are too small to have effective gastric lavage due to orogastric tube size constraints.

Section Outline:

• ADULT PATIENTS
• PEDIATRIC PATIENTS

CONTRAINDICATIONS

• Ingestion of a substance that could cause further injury during emesis, for example, caustic substances or hydrocarbons
• Ingestion of a substance for which the antidote is administered orally (e.g., N-acetylcysteine or activated charcoal), because ipecac may delay administration greatly.
• Children under 6 months of age
• Ingestion of sharp object
• Patients whose ability to protect airway within subsequent 1 hour may deteriorate (e.g., anticipated seizure or coma)
• Ingestion of liquid with rapid absorption (aspiration with nasogastric tube is more rapid)

ADVERSE EFFECTS

• Persistent vomiting is the most common adverse reaction
• Aspiration of vomited substance (e.g., hydrocarbon)
• Vagal-induced bradycardia during emesis
• Esophageal injury, especially Mallory-Weiss tears
• Stomach herniation into chest
• Intracranial hemorrhage
• Pneumomediastinum

Section Outline:

• CONTRAINDICATIONS
• ADVERSE EFFECTS

• Adult dose is 30 ml, administered orally; the dose may be repeated once if vomiting does not occur within 30 minutes.
• Dose for a child 1 to 5 years of age is 15 ml administered orally; the dose may be repeated once if vomiting does not occur within 30 minutes.
• Dose for a child 6 months to 1 year of age is 10 ml, administered orally; the dose may be repeated once if vomiting does not occur within 30 minutes.
• The use of a fluid, like water, to enhance vomiting has not been shown to alter the time to emesis but may increase patient or parent comfort with the procedure because "dry heaves" is considered more uncomfortable than vomiting water.
• Increasing the activity of the patient (e.g., walking) has been recommended to enhance the activity of ipecac; however, the data do not support this belief.
• Giving ipecac with milk products or activated charcoal may delay the onset of vomiting.

Although it has been widely believed that ipecac is never useful in medical practice, this is incorrect: ipecac is of benefit to a patient who is more than an hour distant from a medical facility, when the patient is of small size, or when ingestion of plant material or large pills renders gastric lavage ineffective.

Poisoning by agents primarily affecting the gastrointestinal system: emetics.

RECOMMENDED READING

Bond GR, Requa RK, Normann SA, et al. Influence of time until emesis on the efficacy of decontamination using acetaminophen as a marker in a pediatric population. Ann Emerg Med 1993;22:1403-1407.

Howland MA. Syrup of ipecac. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al., eds. Goldfrank's toxicologic emergencies, 6th ed. Norwalk, CT: Appleton & Lange, 1998.

Author: Richard C. Dart

Reviewer: Katherine M. Hurlbut