Toxic Ingestion — Decontamination — Clinical Pathway: Emergency Department, ICU and Inpatient

Toxic Ingestion Clinical Pathway — Emergency Department, ICU and Inpatient

Decontamination

Most children do not require any GI decontamination.

  • GI decontamination is most effective early in an exposure
  • Ipecac is no longer recommended for any toxic ingestion
  • Consult Poison Control Center to determine suitability and timing of decontamination

Topical Decontamination

  • Indications
    • Residual substances on skin and eyes
  • Example Substances
    • Laundry detergent packets, household cleaners, caustics
  • Mechanism
    • Removes substance in contact with skin, restores surface pH towards normal
    • Copious eye irrigation
  • Administration
    • Copious irrigation with water sufficient in most cases
  • Comments
    • Risk of aspiration if irrigating near the mouth

Activated Charcoal

  • Indication
    • Many ingested pharmaceuticals and miscellaneous substances
    • Especially if nonpolar, water-soluble, organic, and molecular weight ~100-1000
  • Example Substances
    • Digoxin
    • Salicylates
    • Phenothiazines
  • Mechanism
    • Decreases GI absorption by adsorption of substance to activated charcoal surface
  • Administration
    • Often single dose, though multiple doses may be recommended by Poison Control Center
    • Give PO or NG
    • Typical dose 1 g/kg, max 50 g
  • Comments
    • Not recommended/effective for certain substances
      • Alcohols
      • Volatile
      • Hydrocarbons
      • Metals
      • Caustics
    • Most effective if given within 1 hour of ingestion
    • Consider intubation for administration given aspiration and emesis risk

Whole Bowel Irrigation

  • Indications
    • Substances not adsorbed by activated charcoal
    • Delayed/extended-release formulations of highly toxic drugs
      • Calcium channel blockers
      • Beta blockers
      • Bupropion
      • Lithium
    • Body packer/body packer syndrome
  • Example Substances
    • Iron, lithium, lead
    • Many pharmaceutical drugs
    • Bupropion, verapamil, metoprolol, lithium
    • Ingested packets of cocaine, opioids
  • Mechanism
    • Eliminates substance from GI tract prior to absorption
  • Administration
    • High volume/rate administration of polyethylene glycol balanced electrolyte solution
    • Give PO or NG until rectal effluent clear
  • Comments
    • Not routinely used or recommended in children
    • Aspiration and emesis risk with administration
    • Requires intact peristalsis

Gastric Lavage

  • Indications
    • Rarely used
    • Consider early in presentation for life-threatening dose of high toxicity substance
  • Example Substances
    • Colchicine
    • Calcium channel blocker
    • Beta blocker
    • Bupropion
  • Mechanism
    • Removes drug from stomach before gastric emptying
  • Administration
  • Comments
    • Aspiration, emesis risk
    • Risk of trauma to esophagus and stomach including potential perforation