Pediatric emergency medicine trisk 3042 3042

GI Decontamination. The effort to “get the poison out” has long been a mainstay
of the traditional discussion of toxicologic management. However, gastric
emptying measures have fallen out of favor, and the routine use of activated
charcoal as a poison adsorbent has likewise been subjected to increased academic
scrutiny. Unfortunately, young children have been underrepresented in clinical
studies of GI decontamination. It is likely that as further research is conducted,
particularly as directed toward the pediatric population, current dogma regarding
optimal GI decontamination will evolve. For the sections that follow, we review
several appropriate techniques for gastric decontamination, all of which may be
useful under certain circumstances. We then offer an approach to the overall
decision process for specific patients.
Gastric Emptying. The goal of gastric emptying is to rid the stomach of remaining
poison to prevent further systemic absorption. The utility of gastric emptying
diminishes with time and is most effective if done early after ingestion when
unabsorbed drug is still present within the stomach (operationally, within the first
30 minutes to 1 hour). In certain circumstances, such as the delayed gastric
emptying accompanying intoxication with anticholinergic drugs or the presence
of iron tablets in the stomach, benefit may be noted longer after ingestion.
Induced emesis (with syrup of ipecac) was once a favored means of gastric
emptying, but the American Academy of Pediatrics no longer recommends that
syrup of ipecac be used routinely for the poisoned patient in the home or
healthcare facility. This was in response to inconsistent data regarding decreased
drug absorption, no evidence that it changes clinical outcomes, potential for abuse
in vulnerable patients, and the concern that it may delay time to administration of
other more effective therapies.
An alternative to ipecac-induced emesis for emptying the stomach is gastric
lavage. This procedure has very limited indications and is usually reserved for
patients who have ingested a potentially life-threatening amount of poison, in
cases where the procedure can be performed safely very early after ingestion and
charcoal alone is not adequate. To carry out a satisfactory lavage, the patient
should be on his or her left side, head slightly lower than feet, and the largest

orogastric lavage tube that can reasonably be passed should be used (e.g., 24F
orogastric tube for a toddler, 36F orogastric tube for an adolescent). A smaller
caliber nasogastric (NG) tube is sufficient for some liquid toxins, but liquid toxins
are generally rapidly absorbed. Gastric contents should be aspirated initially
before any lavage fluid is introduced. Normal saline aliquots of 50 to 100 mL in
young children and 150 to 200 mL in adolescents can be lavaged repeatedly until