GENERAL APPROACH TO THE POISONED PATIENT - rEMERGs

DECONTAMINATIONGENERAL Definition‣ Decontamination is the prevention of absorption into the bloodstream Factors to consider‣ Is this a dangerous toxin?‣ Is there likely to be further absorption?‣ How long from the time of ingestion?‣ Is there an effective antidote?‣ Has the clinical course excluded the posibility of toxicity? Gastric Emptying‣ Most studies show that minimal drug is in stomach after 2-4 hours‣‣Vomiting‣‣‣‣‣Time in stomach varies with drugDrugs that SLOW gastric emptying and increase the possible time forgastric empyting to be effective­ Anticholinergics­ Opiates­ Sedative/hypnotics­ Gastric concretions: ASA, iron, phenobarbitalSelf induced vomiting and ipecac are never indicatedUnlikely to removed significant amount of toxinRisk of aspirationIpecac hinds administration of charcoalRisk of MWTs, esophageal ruptureGASTRIC LAVAGE Technique of Gastric Lavage‣ Large gastric tube (36 french)‣ Left lateral position‣ Tap water or saline‣ 300 cc in, clamp, drain by gravity‣ Continue until clear; follow lavage with activated charcoal Potential Complications‣ Injury to pharynx‣ Esophageal tears‣ Gastric perforation‣ Aspiration Evidence Behind and Controversies‣ Shown to decrease drug absorption in volunteers‣ Only (limited) clinical benefit has been shown if done LESS than one hour‣ Has been trends toward clinical improvements in serious overdoses‣ Some people advocate never using gastric lavage, BUT!!‣ ACEP policy statement: little to indicate value; selective use only‣ Study limitations­ Small sample sizes thus not powered to exclude clinicallyimportant differences