- Email: [email protected]
Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose
ORIGINAL CONTRIBUTION ipecac, effect of; lavage, activated charcoal, effect of
Efficacy of Ipecac-Induced Emesis, Orogastric Lavage, and Activated Charcoal for Acute Drug Overdose The efficacy of ipecac-induced emesis, large-bore orogastric lavage, and activated charcoal as gastrointestinal decontamination procedures after acute drug overdose is unknown. Using an ampicillin overdose model, these three procedures were compared with one another and to a control ingestion in ten human volunteers. Serial serum ampicillin levels were used to compute the areas under the concentration vs time curves (AUC) for each study. The reductions of ampicillin absorption compared to control were as follows: orogastric lavage 32% (NS), ipecac-induced emesis 38% (P < .01), and activated charcoal 57% (P < .01). This model examines each intervention in a mutually exclusive fashion. It supports activated charcoal administration as the primary gastrointestinal decontamination procedure after acute drug overdose. [Tenenbein M, Cohen S, Sitar DS: Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Ann Emerg Med August 1987;16:838-841.] INTRODUCTION Ipecac-induced emesis and gastric lavage as therapy for acute poisoning "have a venerable history extending back into the mists of medical mythology."1 These two interventions with activated charcoal administration are routinely advocated for the treatment of the acutely poisoned patient.Z, 3 Because a review of the literature revealed no single controlled human study comparing the relative efficacies of these three procedures, we undertook this study to make these comparisons. MATERIALS A N D M E T H O D S One female and nine male volunteers, ages 21 to 28 years, made up the study group. Inclusion criteria were good health, absence of recent or intercurrent medications that could alter ampicillin serum levels or their determination, and lack of penicillin allergy. The research protocol was approved by the University of Manitoba Faculty Committee on the Use of Human Subjects in Research, and informed consent was obtained from each participant. The study consisted of a randomized four-limbed crossover design with each limb being at least one week apart. On each of the four occasions, after an eight-hour fast, the volunteer ingested 5.0 g (20 x 250 mg) of ampicillin capsules with 250 mL of water. Fasting was continued for the first six hours, after which juice and a light snack were permitted. Blood for ampicillin level was collected at zero, one, two, three, four, six, and 12 hours. Samples were spun, and the serum separated and immediately frozen. Ampicillin assays were performed within two weeks of specimen collection. One ingestion served as a control. One hour after the other three ingestions the volunteers submitted to one of the three study interventions. Each volunteer was subjected to all three interventions in a mutually exclusive fashion and served as his own control. Gastric lavage was performed using a 34-gauge orogastric tube. During larage the volunteer was maintained on his left side, three-quarters prone with the stretcher placed so that the head was lower than the feet. Two hundred milliliters of tepid tapwater per cycle was used until the returns were clear or a minimum of 2.0 L was used. The dose of the activated charcoal slurry (Instachar ®) was 50 g with 30 g of 16:8 August 1987
Annals of Emergency Medicine
Milton Tene0bein, MD, FRCPC*t!Stuart Cohen, MD, FRCPC* Daniel S Sitar, PhD1Winnipeg, Manitoba, Canada From the Department of Pediatrics* and Clinical Pharmacology Section,I- University of Manitoba, and the Manitoba Poison Control Centre,¢ Winnipeg, Manitoba, Canada. Received for publication January t3, 1986. Revision received June 27, 1986. Accepted for publication July 21, 1986. Presented at the American Association of Clinical Toxicology Annual Scientific Meeting, Kansas City, Missouri, August 1985. Research supported by the Children's Hospital of Winnipeg Research Foundation. Address for reprints: Dr Milton Tenenbein, Children's Hospital, 840 Sherbrook Street, Winnipeg, Manitoba, Canada R3A 1S1.
838/21
ACUTE DRUG OVERDOSE Tenenbein, Cohen & Sitar
magnesium sulfate. The dose of syrup of ipecac was 30 mL with 250 mL of tapwater. This was repeated in 20 minutes if vomiting did not occur. Serum ampicillin levels were measured in quadruplicate by standard biologic assay. The sensitivity of the assay was /> 1.5 mg/L. The averages of the four determinations were used to calculate the area under the serum concentration vs time curve (AUC) using the trapezoidal rule. 4 The percentage of unabsorbed ampicillin was calculated from the following equation: AUC c - A U C Ix 100% = AUCc % unabsorbed ampicillin where AUC~ is the mean AUC for the control group and AUG I is the mean AUC for each of the intervention groups. Statistical analysis was performed by analysis of variance, and Duncan's Multiple Range Test was used to determine significant differences between the groups. RESULTS All ten volunteers completed the protocol. All vomited after syrup of ipecac administration, with an average time of 16 minutes (range, five to 37 minutes) (one volunteer required a second dose of syrup of ipecac). One subject vomited shortly after charcoal a d m i n i s t r a t i o n ; however, his data were included. Most of the subjects vomited small amounts during the passage of the orogastric tube. No complications were noted with any of the procedures. The serum concentration vs time curves are shown (Figure). The AUG for each group and the percentage of ampicillin not absorbed is shown (Table 1). Orogastric lavage, ipecac-induced emesis, and activated charcoal/ magnesium sulfate prevented the absorption of 32%, 38%, and 57% of the ampicillin. Statistical comparisons between groups are shown (Table 2). Only ipecac and charcoal were significantly different from the control group. Charcoal was significantly different from gastric lavage. All other comparisons lacked statistical signifiC3nce.
DISCUSSION Although large-bore orogastric lavage, ipecac-induced emesis, and activated charcoal plus cathartic are 22/839
TABLE l. Efficacy of gastrointestinal decontamination procedures one hour
after an oral dose of 5.0 g ampicillin
Treatment Group
AUC (~g/hr/mL) Mean _ SE
% Not Absorbed
Control
50.2 + 10.7
Gastric lavage
34.2 _+ 4.3
32
Ipecac-induced emesis
30.9 ___ 7.3
38
Charcoal/cathartic
21.8 _+ 2.4
57
acceptable as routine therapies for the prevention of absorption of acutely ingested toxins,Z, 3 there is no h u m a n controlled study comparing the relative efficacies of these procedures. Similarly, there is no published study concerning large-bore orogastric lavage. Several authors have questioned the efficacy of the two gastric emptying procedures,S-U and some have suggested that activated charcoal plus cathartic without either of these two procedures is appropriate therapy for drug overdose. 10-1s The cathartic is not thought to enhance prevention of absorption16, ~7 but to prevent constipation. 18 Ampicillin was chosen as the marker substance because its low toxicity a l l o w s a d m i n i s t r a t i o n of l a r g e a m o u n t s . D r u g s t a k e n in l a r g e amounts are likely to be less completely absorbed over time when compared to drugs taken in therapeutic amounts. This has been described in salicylate overdoseJ 9 Thus, gastrointestinal decontamination procedures may be more efficacious when an ingestion of a large quantity of a drug is studied. The term "toxicokinetics" rather than pharmacokinetics can be used to emphasize this difference. Our data support the c o n c e p t of toxicokinetics. Ampicillin was found in six of the ten control studies at six hours after overdose. This is longer than after a routine therapeutic dose of this drug. 2o AUC was chosen as the measure of the effectiveness of the interventions. It is used f r e q u e n t l y in p h a r m a cological and toxicological studies as an indicator of total drug absorption.lO,16,17 Because it reflects bioavailability, AUC is more appropriate than peak serum level, which is dependent on rate of absorption. This experimental design may even tend to favor the interventions under Annals of Emergency Medicine
0
TABLE 2. Comparisons between
treatment groups
Groups
P
Ipecac vs control
< .01
Charcoal vs control
< .01
Gastric lavage vs control
NS
Charcoal vs gastric lavage
< .05
Charcoal vs ipecac
NS
Gastric lavage vs ipecac
NS
study (particularly gastric lavage) as being efficacious when compared to the clinical situation because of the timing of the interventions and the technique of gastric lavage. All interventions were initiated 60 minutes after ampicillin ingestion. The mean time of presentation after ingestion is 68 minutes for young children 21 and 3.3 h o u r s for older c h i l d r e n and adults, is In order to maximize the efficacy of gastric lavage the methodol'ogy of Burke was followed. ~2 Large-bore orogastric tubes were used and strict attention was paid to the subjects' position and to the volume of lavage per cycle. Attention to these details is uncommon in the clinical situation because they are rarely addressed in routine references and because of less than optimal patient cooperation. Orogastric lavage was the least efficacious procedure. Considering these three interventions, it is the most labor intensive, is associated with more complications, and is least favored by the recipient (according to this group of volunteers); its use for 16:8 August 1987
20~
k
CONTROL
B:
SYRUP OFIPECAC
107~ 54-
for her patience with manuscript preparation.
3-
t
2-
E 1 _z 0.8 ,--J -J_ <
20-
I
2
REFERENCES
7
i
C:
OROGASTRIC LAVAGE
D:
ACTIVATED CHARCOAL
1075432-
1 0.8 TIME (hr)
acute drug overdose s h o u l d be strongly questioned. C o m p l i c a t i o n s of gastric lavage h a v e b e e n e s t i m a t e d to occur at a rate of 3% and i n c l u d e aspiration p n e u m o n i t i s , e s o p h a g e a l perforation, and cardiac a r r e s t A 3 C o m p l i c a t i o n s of a p p r o p r i a t e s y r u p of ipecac a d m i n i s t r a t i o n are l i m i t e d to a few i s o l a t e d c a s e r e p o r t s . 24-28 O n l y one case report of a c o m p l i c a t i o n f r o m activated charcoal administration could be found. 29 T h i s i n v o l v e d t h e administration of an overly t h i c k solution of charcoal to a v e r y y o u n g child (8 months) f o l l o w i n g syrup of ipecacinduced emesis. She promptly v o m i t e d and had a s e v e r e a s p i r a t i o n pneumonia. A l t h o u g h t h e 57% vs 3 8 % reduction of a m p i c i l l i n a b s o r p t i o n f a v o r s a c t i v a t e d c h a r c o a l o v e r s y r u p of ipecac, this was n o t s t a t i s t i c a l l y significant. However, r e c e n t studies h a v e 16:8 August 1987
F I G U R E . L o g a r i t h m of s e r u m a m picillin concentration versus time curves for the ten volunteers w h o ingested 5.0-g doses of ampicillin. Panel A, a m p i c i l l i n control; Panel B, amp i c i l l i n a n d i p e c a c ; P a n e l C, a m picillin and orogastric lavage; Panel D, ampicillin and activated charcoal/ c a t h a r t i c . D a t a are p r e s e n t e d as m e a n s +_ SE.
d e m o n s t r a t e d s u p e r i o r i t y of c h a r c o a l o v e r ipecac,13,15 and t h e a d m i n i s t r a t i o n of a c t i v a t e d c h a r c o a l is delayed by p r e t r e a t m e n t w i t h s y r u p of ipecac. is T h e r e is e v i d e n c e t h a t t h e cons e c u t i v e u s e of i p e c a c a n d c h a r c o a l m a y be less efficacious t h a n charcoal alone. 13 Also, activated charcoal m a y f u r t h e r benefit t h e p o i s o n e d p a t i e n t by increasing t h e e x c r e t i o n of p r e v i o u s l y absorbed t o x i n f r o m t h e I b l o o d s t r e a m by t h e process of "gastrointestinal dialysis. "18
CONCLUSION Activated charcoal administration w i t h o u t a gastric e m p t y i n g procedure m a y v e r y w e l l be t h e o n l y indicated gastrointestinal d e c o n t a m i n a t i o n procedure for t h e h o s p i t a l m a n a g e m e n t of a c u t e drug overdose. The authors are grateful to Arva Kalynuk Annals of Emergency Medicine
1. Reid DHS: Treatment of the poisoned child. Arch 1)is Child 1970;45:428-433. 2. Easom JE, Lovejoy FH Jr: Efficacy and safety of gastrointestinal decontamination in the treatment of oral poisoning. Pediatr Clin North Am 1979;26:827-836. 3. Cupit GC, Temple AR: Gastrointestinal decontamination in the management of the poisoned patient. Emerg Med Clin N Am 1984; 2:15-28. 4. Gibaldi M: Biopharmaceutics and Clinical Pharmacokinetics. Philadelphia, Lea & Febiger, 1984, p 315-316. 5. Rumack BH, Rosen P: Emesis: Safe and effective? Ann Emerg Med 1981;10:55I. 6. Comstock EG, Faulkner TP, Boisaubin EV, et al: Studies on the efficacy of gastric lavage as practiced in a large metropolitan hospital. Clin Toxico11981; 18:581-597. 7. Locket S: Emergency situations: Overdose. Br J Hosp Med 1978;19:204-219. 8. Corby DG, Decker WJ, Moran MJ, et ah Clinical comparison of pharmacologic emetics in children. Pediatr 1968;42:361-364. 9. Tenenbein M: Inefficacy of gastric emptying procedures. J Emerg Med 1985;3:133-136. 10. Neuvonen PJ, Vartianinen M, Tokola O: Comparison of activated charcoal and ipecac syrup in prevention of drug absorption. Eur J Clin Pharmacol 1983;24:557-562. 11. Fane LR, Combs HE Decker WJ: Physical parameters in gastric lavage. Clin Toxicol 1971;4:389-395. 12. Chin L: Induced emesis - - A questionable procedure for the treatment of acute poisoning. Am J Hosp Pharm 1972;29:877-879. 13. Curtis RA, Barone J, Giacona N: Efficacy of ipecac and activated charcoal/cathartic: Prevention of salicylate absorption in a simulated overdose. Arch Intern Med 1984;144:48-52. 14. Spyker DA: Activated charcoal reborn: Progress in poison management. Arch Intern Med 1985; 145:43-44. 15. Kulig K, Bar-Or D, Cantrill SV, et al: Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985; 14:562-567. 16. Van De Graaff WB, Thompson WL, Sunshine I, et ah Adsorbent and cathartic inhibition of enteral drug absorption. J Pharmacol Exp Ther 1982;221:656-663. 17. Sketris IS, Mowry JB, Czajka PA, et ah Saline catharsis: Effect on aspirin bioavailability 840/23
ACUTE DRUG OVERDOSE Tenenbein, Cohen & Sitar
in combination with activated charcoal. ] Clin Pharmacol 1982;22:59-64. 18. Levy G: Gastrointestinal clearance of drugs with activated charcoal. N Engl J Med 1982; 307:676-678. 19. Levy G, Tsuchiya T: Effect of activated charcoal on aspirin absorption in man. Clil~ Pharmacol Ther 1972;13:317-322. 20. Jusko WG, Lewis GP, Schmidtt GW: Ampicillin and hetacillin pharmacokinetics in normal and anephric subjects. Clin Pharmacol Ther 1973;14:90-99. 21. Robertson WO: Syrup of ipecac - - a slow or a fast emetic. A m r Dis Child 1962; 103:136-139.
24/841
22. Burke M: Gastric lavage and emesis in the treatment of ingested poisons: A review and a clinical study of lavage in ten adults. Resuscitation 1972;1:91-105. 23. Matthew H, Mackintosh TF, Tompsett SL, et al: Gastric aspiration and lavage in acute poisoning. Br Med J 1966;1:1333-1337.
26. Wolowdiuk OJ, McMicken DB, O'Brien P: Pneumomediastinum and retropneumoperitoneum: An unusual complication of syrup-ofipecac-induced emesis. Ann Emerg Med 1984; 13:1148-1151. 27. Klein-Schwartz W, Gorman RL, Oderda GM, et al: Ipecac use in the elderly: The unanswered question. Ann Emerg Med 1984;13: 1152-1154.
24. Tandberg D, Liechty EJ, Fishbein D: Mallory-Weiss syndrome: An unusual complication of ipecac-induced emesis. Ann Emerg Med 1981;10:521-523.
28. Robertson WO: Syrup of ipecac associated fatality: A case report. Vet H u m a n Toxicol 1979;21:87-89.
25. Timberlake GA: Ipecac as a cause of the Mallory-Weiss syndrome. South Med J 1984;77: 804-805.
29. Pollack MM, Dunbar BS, Holbrook PR, et al: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981;10:528-529.
Annals of Emergency Medicine
16:8 August 1987
Efficacy of Ipecac-Induced Emesis, Orogastric Lavage, and Activated Charcoal for Acute Drug Overdose The efficacy of ipecac-induced emesis, large-bore orogastric lavage, and activated charcoal as gastrointestinal decontamination procedures after acute drug overdose is unknown. Using an ampicillin overdose model, these three procedures were compared with one another and to a control ingestion in ten human volunteers. Serial serum ampicillin levels were used to compute the areas under the concentration vs time curves (AUC) for each study. The reductions of ampicillin absorption compared to control were as follows: orogastric lavage 32% (NS), ipecac-induced emesis 38% (P < .01), and activated charcoal 57% (P < .01). This model examines each intervention in a mutually exclusive fashion. It supports activated charcoal administration as the primary gastrointestinal decontamination procedure after acute drug overdose. [Tenenbein M, Cohen S, Sitar DS: Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Ann Emerg Med August 1987;16:838-841.] INTRODUCTION Ipecac-induced emesis and gastric lavage as therapy for acute poisoning "have a venerable history extending back into the mists of medical mythology."1 These two interventions with activated charcoal administration are routinely advocated for the treatment of the acutely poisoned patient.Z, 3 Because a review of the literature revealed no single controlled human study comparing the relative efficacies of these three procedures, we undertook this study to make these comparisons. MATERIALS A N D M E T H O D S One female and nine male volunteers, ages 21 to 28 years, made up the study group. Inclusion criteria were good health, absence of recent or intercurrent medications that could alter ampicillin serum levels or their determination, and lack of penicillin allergy. The research protocol was approved by the University of Manitoba Faculty Committee on the Use of Human Subjects in Research, and informed consent was obtained from each participant. The study consisted of a randomized four-limbed crossover design with each limb being at least one week apart. On each of the four occasions, after an eight-hour fast, the volunteer ingested 5.0 g (20 x 250 mg) of ampicillin capsules with 250 mL of water. Fasting was continued for the first six hours, after which juice and a light snack were permitted. Blood for ampicillin level was collected at zero, one, two, three, four, six, and 12 hours. Samples were spun, and the serum separated and immediately frozen. Ampicillin assays were performed within two weeks of specimen collection. One ingestion served as a control. One hour after the other three ingestions the volunteers submitted to one of the three study interventions. Each volunteer was subjected to all three interventions in a mutually exclusive fashion and served as his own control. Gastric lavage was performed using a 34-gauge orogastric tube. During larage the volunteer was maintained on his left side, three-quarters prone with the stretcher placed so that the head was lower than the feet. Two hundred milliliters of tepid tapwater per cycle was used until the returns were clear or a minimum of 2.0 L was used. The dose of the activated charcoal slurry (Instachar ®) was 50 g with 30 g of 16:8 August 1987
Annals of Emergency Medicine
Milton Tene0bein, MD, FRCPC*t!Stuart Cohen, MD, FRCPC* Daniel S Sitar, PhD1Winnipeg, Manitoba, Canada From the Department of Pediatrics* and Clinical Pharmacology Section,I- University of Manitoba, and the Manitoba Poison Control Centre,¢ Winnipeg, Manitoba, Canada. Received for publication January t3, 1986. Revision received June 27, 1986. Accepted for publication July 21, 1986. Presented at the American Association of Clinical Toxicology Annual Scientific Meeting, Kansas City, Missouri, August 1985. Research supported by the Children's Hospital of Winnipeg Research Foundation. Address for reprints: Dr Milton Tenenbein, Children's Hospital, 840 Sherbrook Street, Winnipeg, Manitoba, Canada R3A 1S1.
838/21
ACUTE DRUG OVERDOSE Tenenbein, Cohen & Sitar
magnesium sulfate. The dose of syrup of ipecac was 30 mL with 250 mL of tapwater. This was repeated in 20 minutes if vomiting did not occur. Serum ampicillin levels were measured in quadruplicate by standard biologic assay. The sensitivity of the assay was /> 1.5 mg/L. The averages of the four determinations were used to calculate the area under the serum concentration vs time curve (AUC) using the trapezoidal rule. 4 The percentage of unabsorbed ampicillin was calculated from the following equation: AUC c - A U C Ix 100% = AUCc % unabsorbed ampicillin where AUC~ is the mean AUC for the control group and AUG I is the mean AUC for each of the intervention groups. Statistical analysis was performed by analysis of variance, and Duncan's Multiple Range Test was used to determine significant differences between the groups. RESULTS All ten volunteers completed the protocol. All vomited after syrup of ipecac administration, with an average time of 16 minutes (range, five to 37 minutes) (one volunteer required a second dose of syrup of ipecac). One subject vomited shortly after charcoal a d m i n i s t r a t i o n ; however, his data were included. Most of the subjects vomited small amounts during the passage of the orogastric tube. No complications were noted with any of the procedures. The serum concentration vs time curves are shown (Figure). The AUG for each group and the percentage of ampicillin not absorbed is shown (Table 1). Orogastric lavage, ipecac-induced emesis, and activated charcoal/ magnesium sulfate prevented the absorption of 32%, 38%, and 57% of the ampicillin. Statistical comparisons between groups are shown (Table 2). Only ipecac and charcoal were significantly different from the control group. Charcoal was significantly different from gastric lavage. All other comparisons lacked statistical signifiC3nce.
DISCUSSION Although large-bore orogastric lavage, ipecac-induced emesis, and activated charcoal plus cathartic are 22/839
TABLE l. Efficacy of gastrointestinal decontamination procedures one hour
after an oral dose of 5.0 g ampicillin
Treatment Group
AUC (~g/hr/mL) Mean _ SE
% Not Absorbed
Control
50.2 + 10.7
Gastric lavage
34.2 _+ 4.3
32
Ipecac-induced emesis
30.9 ___ 7.3
38
Charcoal/cathartic
21.8 _+ 2.4
57
acceptable as routine therapies for the prevention of absorption of acutely ingested toxins,Z, 3 there is no h u m a n controlled study comparing the relative efficacies of these procedures. Similarly, there is no published study concerning large-bore orogastric lavage. Several authors have questioned the efficacy of the two gastric emptying procedures,S-U and some have suggested that activated charcoal plus cathartic without either of these two procedures is appropriate therapy for drug overdose. 10-1s The cathartic is not thought to enhance prevention of absorption16, ~7 but to prevent constipation. 18 Ampicillin was chosen as the marker substance because its low toxicity a l l o w s a d m i n i s t r a t i o n of l a r g e a m o u n t s . D r u g s t a k e n in l a r g e amounts are likely to be less completely absorbed over time when compared to drugs taken in therapeutic amounts. This has been described in salicylate overdoseJ 9 Thus, gastrointestinal decontamination procedures may be more efficacious when an ingestion of a large quantity of a drug is studied. The term "toxicokinetics" rather than pharmacokinetics can be used to emphasize this difference. Our data support the c o n c e p t of toxicokinetics. Ampicillin was found in six of the ten control studies at six hours after overdose. This is longer than after a routine therapeutic dose of this drug. 2o AUC was chosen as the measure of the effectiveness of the interventions. It is used f r e q u e n t l y in p h a r m a cological and toxicological studies as an indicator of total drug absorption.lO,16,17 Because it reflects bioavailability, AUC is more appropriate than peak serum level, which is dependent on rate of absorption. This experimental design may even tend to favor the interventions under Annals of Emergency Medicine
0
TABLE 2. Comparisons between
treatment groups
Groups
P
Ipecac vs control
< .01
Charcoal vs control
< .01
Gastric lavage vs control
NS
Charcoal vs gastric lavage
< .05
Charcoal vs ipecac
NS
Gastric lavage vs ipecac
NS
study (particularly gastric lavage) as being efficacious when compared to the clinical situation because of the timing of the interventions and the technique of gastric lavage. All interventions were initiated 60 minutes after ampicillin ingestion. The mean time of presentation after ingestion is 68 minutes for young children 21 and 3.3 h o u r s for older c h i l d r e n and adults, is In order to maximize the efficacy of gastric lavage the methodol'ogy of Burke was followed. ~2 Large-bore orogastric tubes were used and strict attention was paid to the subjects' position and to the volume of lavage per cycle. Attention to these details is uncommon in the clinical situation because they are rarely addressed in routine references and because of less than optimal patient cooperation. Orogastric lavage was the least efficacious procedure. Considering these three interventions, it is the most labor intensive, is associated with more complications, and is least favored by the recipient (according to this group of volunteers); its use for 16:8 August 1987
20~
k
CONTROL
B:
SYRUP OFIPECAC
107~ 54-
for her patience with manuscript preparation.
3-
t
2-
E 1 _z 0.8 ,--J -J_ <
20-
I
2
REFERENCES
7
i
C:
OROGASTRIC LAVAGE
D:
ACTIVATED CHARCOAL
1075432-
1 0.8 TIME (hr)
acute drug overdose s h o u l d be strongly questioned. C o m p l i c a t i o n s of gastric lavage h a v e b e e n e s t i m a t e d to occur at a rate of 3% and i n c l u d e aspiration p n e u m o n i t i s , e s o p h a g e a l perforation, and cardiac a r r e s t A 3 C o m p l i c a t i o n s of a p p r o p r i a t e s y r u p of ipecac a d m i n i s t r a t i o n are l i m i t e d to a few i s o l a t e d c a s e r e p o r t s . 24-28 O n l y one case report of a c o m p l i c a t i o n f r o m activated charcoal administration could be found. 29 T h i s i n v o l v e d t h e administration of an overly t h i c k solution of charcoal to a v e r y y o u n g child (8 months) f o l l o w i n g syrup of ipecacinduced emesis. She promptly v o m i t e d and had a s e v e r e a s p i r a t i o n pneumonia. A l t h o u g h t h e 57% vs 3 8 % reduction of a m p i c i l l i n a b s o r p t i o n f a v o r s a c t i v a t e d c h a r c o a l o v e r s y r u p of ipecac, this was n o t s t a t i s t i c a l l y significant. However, r e c e n t studies h a v e 16:8 August 1987
F I G U R E . L o g a r i t h m of s e r u m a m picillin concentration versus time curves for the ten volunteers w h o ingested 5.0-g doses of ampicillin. Panel A, a m p i c i l l i n control; Panel B, amp i c i l l i n a n d i p e c a c ; P a n e l C, a m picillin and orogastric lavage; Panel D, ampicillin and activated charcoal/ c a t h a r t i c . D a t a are p r e s e n t e d as m e a n s +_ SE.
d e m o n s t r a t e d s u p e r i o r i t y of c h a r c o a l o v e r ipecac,13,15 and t h e a d m i n i s t r a t i o n of a c t i v a t e d c h a r c o a l is delayed by p r e t r e a t m e n t w i t h s y r u p of ipecac. is T h e r e is e v i d e n c e t h a t t h e cons e c u t i v e u s e of i p e c a c a n d c h a r c o a l m a y be less efficacious t h a n charcoal alone. 13 Also, activated charcoal m a y f u r t h e r benefit t h e p o i s o n e d p a t i e n t by increasing t h e e x c r e t i o n of p r e v i o u s l y absorbed t o x i n f r o m t h e I b l o o d s t r e a m by t h e process of "gastrointestinal dialysis. "18
CONCLUSION Activated charcoal administration w i t h o u t a gastric e m p t y i n g procedure m a y v e r y w e l l be t h e o n l y indicated gastrointestinal d e c o n t a m i n a t i o n procedure for t h e h o s p i t a l m a n a g e m e n t of a c u t e drug overdose. The authors are grateful to Arva Kalynuk Annals of Emergency Medicine
1. Reid DHS: Treatment of the poisoned child. Arch 1)is Child 1970;45:428-433. 2. Easom JE, Lovejoy FH Jr: Efficacy and safety of gastrointestinal decontamination in the treatment of oral poisoning. Pediatr Clin North Am 1979;26:827-836. 3. Cupit GC, Temple AR: Gastrointestinal decontamination in the management of the poisoned patient. Emerg Med Clin N Am 1984; 2:15-28. 4. Gibaldi M: Biopharmaceutics and Clinical Pharmacokinetics. Philadelphia, Lea & Febiger, 1984, p 315-316. 5. Rumack BH, Rosen P: Emesis: Safe and effective? Ann Emerg Med 1981;10:55I. 6. Comstock EG, Faulkner TP, Boisaubin EV, et al: Studies on the efficacy of gastric lavage as practiced in a large metropolitan hospital. Clin Toxico11981; 18:581-597. 7. Locket S: Emergency situations: Overdose. Br J Hosp Med 1978;19:204-219. 8. Corby DG, Decker WJ, Moran MJ, et ah Clinical comparison of pharmacologic emetics in children. Pediatr 1968;42:361-364. 9. Tenenbein M: Inefficacy of gastric emptying procedures. J Emerg Med 1985;3:133-136. 10. Neuvonen PJ, Vartianinen M, Tokola O: Comparison of activated charcoal and ipecac syrup in prevention of drug absorption. Eur J Clin Pharmacol 1983;24:557-562. 11. Fane LR, Combs HE Decker WJ: Physical parameters in gastric lavage. Clin Toxicol 1971;4:389-395. 12. Chin L: Induced emesis - - A questionable procedure for the treatment of acute poisoning. Am J Hosp Pharm 1972;29:877-879. 13. Curtis RA, Barone J, Giacona N: Efficacy of ipecac and activated charcoal/cathartic: Prevention of salicylate absorption in a simulated overdose. Arch Intern Med 1984;144:48-52. 14. Spyker DA: Activated charcoal reborn: Progress in poison management. Arch Intern Med 1985; 145:43-44. 15. Kulig K, Bar-Or D, Cantrill SV, et al: Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985; 14:562-567. 16. Van De Graaff WB, Thompson WL, Sunshine I, et ah Adsorbent and cathartic inhibition of enteral drug absorption. J Pharmacol Exp Ther 1982;221:656-663. 17. Sketris IS, Mowry JB, Czajka PA, et ah Saline catharsis: Effect on aspirin bioavailability 840/23
ACUTE DRUG OVERDOSE Tenenbein, Cohen & Sitar
in combination with activated charcoal. ] Clin Pharmacol 1982;22:59-64. 18. Levy G: Gastrointestinal clearance of drugs with activated charcoal. N Engl J Med 1982; 307:676-678. 19. Levy G, Tsuchiya T: Effect of activated charcoal on aspirin absorption in man. Clil~ Pharmacol Ther 1972;13:317-322. 20. Jusko WG, Lewis GP, Schmidtt GW: Ampicillin and hetacillin pharmacokinetics in normal and anephric subjects. Clin Pharmacol Ther 1973;14:90-99. 21. Robertson WO: Syrup of ipecac - - a slow or a fast emetic. A m r Dis Child 1962; 103:136-139.
24/841
22. Burke M: Gastric lavage and emesis in the treatment of ingested poisons: A review and a clinical study of lavage in ten adults. Resuscitation 1972;1:91-105. 23. Matthew H, Mackintosh TF, Tompsett SL, et al: Gastric aspiration and lavage in acute poisoning. Br Med J 1966;1:1333-1337.
26. Wolowdiuk OJ, McMicken DB, O'Brien P: Pneumomediastinum and retropneumoperitoneum: An unusual complication of syrup-ofipecac-induced emesis. Ann Emerg Med 1984; 13:1148-1151. 27. Klein-Schwartz W, Gorman RL, Oderda GM, et al: Ipecac use in the elderly: The unanswered question. Ann Emerg Med 1984;13: 1152-1154.
24. Tandberg D, Liechty EJ, Fishbein D: Mallory-Weiss syndrome: An unusual complication of ipecac-induced emesis. Ann Emerg Med 1981;10:521-523.
28. Robertson WO: Syrup of ipecac associated fatality: A case report. Vet H u m a n Toxicol 1979;21:87-89.
25. Timberlake GA: Ipecac as a cause of the Mallory-Weiss syndrome. South Med J 1984;77: 804-805.
29. Pollack MM, Dunbar BS, Holbrook PR, et al: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981;10:528-529.
Annals of Emergency Medicine
16:8 August 1987