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Emetics in Accidental Poisoning
EMETI~
IN ACCmENTAL POISONING
WILLIAM CURTIS ADAMS, M.D.
T he clinical use of emetics has been subject to much controversy. Some of the controversy results from the inherent danger of these drugs and some from their inappropriate use. When used, an emetic must be chosen for its rapidity of action, effectiveness, safety and availability. Their most common use is to rid the stomach of unwanted and often dangerous substances. A common abuse is to use an impotent, slow-acting emetic in circumstances demanding prompt results. More than five years' experience in poison control work has emphasized the importance of immediate removal of accidentally ingested substances which are potentially harmful to a patient. A common-sense approach to the problem has been developed as a result of these experiences. The greatest number of inquiries directed to the private physician about accidental poisoning come to him by telephone. Practical first aid is important. With few exceptions, this means giving instructions about making a patient vomit. Emetics obtainable only at a drug store can be of little value then. It is easier to induce vomiting if the stomach is full rather than empty. Water is the most readily available and safest substance with which to dilute the poison and fill the stomach. One cannot proceed beyond directing the following steps: (1) the use of water as a diluent, (2) insertion of a bite block between the teeth, (3) positioning the patient in a head-down position, (4) using a finger in the back of the throat to stimulate gagging. If available, WITHOUT DELAY, mustard water (1 to 2 teaspoonfuls of powdered mustard per glass of warm water) or a warm hypertonic salt solution (1 tablespoonful of table salt in glass of warm water) may be given in quantities sufficient to help stimulate vomiting by local irritation in the stomach. When used in this manner, these substances must merely replace step number 1 above and cannot be considered a substitute for steps 2, 3 and 4. The tremendous variability of the human gag reflex has far too often prompted dependence upon emetic preparations alone. Syrup of 351
35 2
EMETICS IN ACCIDENTAL POISONING
ipecac is slow-acting (30 to 60 minutes). It is mentioned only to discourage its use in accidental poison ingestion. In physician's offices or in the hospital emergency room, copper sulfate (0.25 to 0.5 gm. per 100 cc.) or zinc sulfate (1 to 2 gm. per 200 cc. of water) can be used. However, it would probably be a mistake to take the time to mix those solutions rather than simply taking the immediate measure of diluting by giving large amounts of water. Apomorphine, although undeniably the most potent emetic, creates such a severe central nervous system depression that its use is generally considered contraindicated. The recent introduction of numerous pharmacologically active antiemetics has created a special problem. Attempts at creating emesis with emetics in patients who have taken the various antiemetic substances can generally be considered a waste of time. These patients should have their stomachs washed out as Soon as possible. The relative effectiveness of lavage versus emesis in emptying a stomach is still a debated question about which much opinion is expressed and little fact is known. The emergency at the other end of the telephone leaves little time for questioning in most cases. Even here, however, certain definite contraindications to emesis do exist: ( 1) as suggested above, after ingestion of an antiemetic; (2) for unconscious or convulsing patients; (3) for those who have ingested corrosive substances; (4) for those patients who have ingested liquid petroleum products or similar hydrocarbons; gastric lavage is here preferred. 323 E. Chestnut St. Louisville 2, Ky.
IN ACCmENTAL POISONING
WILLIAM CURTIS ADAMS, M.D.
T he clinical use of emetics has been subject to much controversy. Some of the controversy results from the inherent danger of these drugs and some from their inappropriate use. When used, an emetic must be chosen for its rapidity of action, effectiveness, safety and availability. Their most common use is to rid the stomach of unwanted and often dangerous substances. A common abuse is to use an impotent, slow-acting emetic in circumstances demanding prompt results. More than five years' experience in poison control work has emphasized the importance of immediate removal of accidentally ingested substances which are potentially harmful to a patient. A common-sense approach to the problem has been developed as a result of these experiences. The greatest number of inquiries directed to the private physician about accidental poisoning come to him by telephone. Practical first aid is important. With few exceptions, this means giving instructions about making a patient vomit. Emetics obtainable only at a drug store can be of little value then. It is easier to induce vomiting if the stomach is full rather than empty. Water is the most readily available and safest substance with which to dilute the poison and fill the stomach. One cannot proceed beyond directing the following steps: (1) the use of water as a diluent, (2) insertion of a bite block between the teeth, (3) positioning the patient in a head-down position, (4) using a finger in the back of the throat to stimulate gagging. If available, WITHOUT DELAY, mustard water (1 to 2 teaspoonfuls of powdered mustard per glass of warm water) or a warm hypertonic salt solution (1 tablespoonful of table salt in glass of warm water) may be given in quantities sufficient to help stimulate vomiting by local irritation in the stomach. When used in this manner, these substances must merely replace step number 1 above and cannot be considered a substitute for steps 2, 3 and 4. The tremendous variability of the human gag reflex has far too often prompted dependence upon emetic preparations alone. Syrup of 351
35 2
EMETICS IN ACCIDENTAL POISONING
ipecac is slow-acting (30 to 60 minutes). It is mentioned only to discourage its use in accidental poison ingestion. In physician's offices or in the hospital emergency room, copper sulfate (0.25 to 0.5 gm. per 100 cc.) or zinc sulfate (1 to 2 gm. per 200 cc. of water) can be used. However, it would probably be a mistake to take the time to mix those solutions rather than simply taking the immediate measure of diluting by giving large amounts of water. Apomorphine, although undeniably the most potent emetic, creates such a severe central nervous system depression that its use is generally considered contraindicated. The recent introduction of numerous pharmacologically active antiemetics has created a special problem. Attempts at creating emesis with emetics in patients who have taken the various antiemetic substances can generally be considered a waste of time. These patients should have their stomachs washed out as Soon as possible. The relative effectiveness of lavage versus emesis in emptying a stomach is still a debated question about which much opinion is expressed and little fact is known. The emergency at the other end of the telephone leaves little time for questioning in most cases. Even here, however, certain definite contraindications to emesis do exist: ( 1) as suggested above, after ingestion of an antiemetic; (2) for unconscious or convulsing patients; (3) for those who have ingested corrosive substances; (4) for those patients who have ingested liquid petroleum products or similar hydrocarbons; gastric lavage is here preferred. 323 E. Chestnut St. Louisville 2, Ky.