Gastric lavage: Difference between revisions

Revision as of 04:25, 17 July 2011

Background

Of limited/infrequent utility
Almost never used in conscious and cooperative patients should be minimal (< 5% of presentations)
restricted to poisonings where benefits over oral Activated Charcoal are likely

Indications

Life-threatening poisoning (or history is not available) and unconscious presentation
Life-threatening poisoning and presentation within 1 hour
Life-threatening poisoning with drug with anticholinergic effects and presentation within 4 hours
Ingestions of sustained release preparation of significantly toxic drug
Large salicylate poisonings presenting within 12 hours
Iron or lithium poisoning

Contraindications

Absolute

Corrosive ingestions or oesophageal disease

Technique

Protect airway (endotracheal intubation) if patient is stuporous or comatose
Lie patient on their left side
Insert a large bore double lumen orogastric tube
Aspirate stomach contents
Use a small cycle lavage of 50-100 mL (and then aspirate)
Lavage is rarely indicated beyond 5 minutes, unless tablets are still actively being returned

It is no longer recommended to have a completely clear return before ceasing gastric lavage.

Complications

Increase gastric delivery of tablets into the small bowel
Aspiration of gastric contents (3% of patients)
Esophageal Rupture (rare)
Profound bradycardia, cardiac arrest, and asystole may be precipitated by lavage in poisonings with propranolol, calcium channel blockers and other drugs affecting cardiac conduction
1. Atropine should be used to block the increased vagal tone associated with the procedure in these situations

Source

Vale JA. Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35(7):711-9

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-if greater than 2 hrs or toxin already in intestine, gastric decontam not helpful
+#Of limited/infrequent utility
+#Almost never used in conscious and cooperative patients should be minimal (< 5% of presentations)
+#restricted to poisonings where benefits over oral [[Activated Charcoal]] are likely
--    helpful however if delayed emptying or decreased intest motility
+==Indications==
+# Life-threatening poisoning (or history is not available) and unconscious presentation
+# Life-threatening poisoning and presentation within 1 hour
+# Life-threatening poisoning with drug with anticholinergic effects and presentation within 4 hours
+# Ingestions of sustained release preparation of significantly toxic drug
+# Large salicylate poisonings presenting within 12 hours
+# Iron or lithium poisoning
--    always use charcoal asap unless agent/ quantity not toxic, agent not absorbed to charcoal, or delay so long absorption is complete
+==Contraindications==
+===Absolute===
+# Corrosive ingestions or oesophageal disease
--    gastric emptying before charcoal- higher risk of aspiration, intubation, icu- not routinely recommended
+==Technique==
+# Protect airway (endotracheal intubation) if patient is stuporous or comatose
+# Lie patient on their left side
+# Insert a large bore double lumen orogastric tube
+# Aspirate stomach contents
+# Use a small cycle lavage of 50-100 mL (and then aspirate)
+# Lavage is rarely indicated beyond 5 minutes, unless tablets are still actively being returned
--    gastric emptying helpful if symptomatic within 1 hr, symptomatic with agents that slow gi motility, sustained release meds or massive/ life threatening amount
+It is no longer recommended to have a completely clear return before ceasing gastric lavage.
+==Complications==
+# Increase gastric delivery of tablets into the small bowel
+# Aspiration of gastric contents (3% of patients)
+# [[Esophageal Rupture]] (rare)
+# Profound bradycardia, cardiac arrest, and asystole may be precipitated by lavage in poisonings with propranolol, calcium channel blockers and other drugs affecting cardiac conduction
+##Atropine should be used to block the increased vagal tone associated with the procedure in these situations
-==Does GI Decont Change Pt Outcome?==
+==See Also==
+[[Activated Charcoal]]
--    effect only if used early- no effect if late
--    however, no prospective trial has proven charcoal or ipecac- only suggests it
--    also, gi decont benefit never disproved either
-==Risks==
+==Source==
-#  aspiration- by cns depression, loss of gag reflex, spont or induced emesis, manipulation of airway or gi tract
+Vale JA. Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35(7):711-9
-#ipecac assoc with asp if used incorrectly-
-##charcoal usually not assoc with asp- but can be
-##charcoal asp worse than gastric content asp because causes granulomatous reaction, tissue reaction to sorbitol or povidone, increased lung microvascular permeability
-##risk of gastric lavage include unnecessary intubation
-##intubation for airway protection/ aspiration not 100% protective
-#lavage can also damage throat, esoph, stomach
-==Which Pt Not Need GI Decon?==
--    most preschool pts do not need decont
--    no need for decon if nontoxic dose or substance or drug taken so long ago already absorbed.
--    Gi decon reasonable if all pt and all symptomatic pt unless full absorption already occurred- risks of single dose low.
--    However- if low risk pt and uncooperative- may not be worth trauma/ risk to staff or pt
-==Benefit of GI Emptying Before Charcoal?==
--    no- especially not if present late, are asymptomatic.
--    Gastric emptying will not add benefit to charcoal
--    Benefit of charcoal not even proven but is considered state of the art to give unless full absorption already occurred
-==Will Some Pts Benefit From Aggressive GI Decon?==
--    charcoal not useful for iron, lithium alcohol, caustics, hydrocarbons
--    even with sustained release meds, if most of drug has moved beyond stomach, lavage will only hold up charcoal
--    if pt given ipecac and vomits long time before ED presentation- probably don't need additional charcoal for pediatric pts
-ED physician needs to evaluate each ingestions individually and design treatment plan.  If substance poorly aborbed to charcoal- try gastric lavage unless have prolonged delay.  Usually charcoal alone is best choice.  If late presenting pt and asymptomatic- no gi decon needed.  If ealy and symptomatic- personal choice to do gastric lavage followed by charcoal or just charcoal- examine relative risk.
-==See Also==
-[[Charcoal]]
 [[Category:Procedures]]
 [[Category:Tox]]