Pediatric emergency medicine trisk 3045 3045

used by mouth in cooperative patients or by NG tube; the usual recommended
dosing is 500 mL/hr in toddlers and 2 L/hr in adolescents and adults.
GI Decontamination Strategies
It should be apparent that no unique approach to GI decontamination of all
poisoned patients is optimal in every case. Factors to be considered include the
expected degree of toxicity from the drug, the physical nature of the drug, the
current location of the drug within the body, and the presence of contraindications
or alternatives. A risk–benefit decision must be made before the institution of any
decontamination strategy.
Given the considerations discussed above, in the patient for whom GI
decontamination is appropriate, activated charcoal and WBI are the favored
procedures. Ipecac-induced emesis is no longer endorsed as home first aid for
poisoning nor in the ED setting. Gastric lavage still has some role, albeit confined
to patients with recent ingestions of extremely toxic and potentially lethal
substances, especially when those substances do not bind well to charcoal.
Likewise, patients with truly massive overdoses may benefit from lavage when
the charcoal dose given does not achieve the ideal charcoal-to-drug ratio of 10:1
(10 g of charcoal to 1 g of drug).
The correct technique for decontamination, regardless of method, requires that
the ED provider take steps to prevent aspiration and anatomic trauma.
Some of the patients in question would have undergone endotracheal intubation
during the initial life support phase of management, as detailed previously, or
they may be intubated preemptively because of borderline mental status and in
anticipation of their ensuing critical course. Others may be awake, alert, and
cooperative, with normal airway protective reflexes, and thus be given activated
charcoal without prior endotracheal intubation. The combative, agitated patient
poses a dilemma and must be carefully managed on an individual basis.
An attempt to summarize these considerations is diagrammed in Figure 102.1 .
Antidotal Therapy. Commonly used specific antidotes include dextrose, oxygen,
naloxone, and N -acetylcysteine. In addition to the above, the antidotes that
should be available for immediate administration include sodium bicarbonate

(tricyclic
antidepressants),
sodium
nitrite/sodium
thiosulfate
or
hydroxocobalamin (cyanide), atropine and pralidoxime (cholinesterase
inhibitors), ethanol or fomepizole (ethylene glycol and methanol), deferoxamine
(iron),
methylene
blue
(methemoglobinemic
agents),
flumazenil
(benzodiazepines), pyridoxine (INH and Gyromitra mushrooms), digoxin