At the request of department leadership, we will be revisiting methods of gastric decontamination for today’s pearl. Two methods in particular.
Ipecac-induced emesis and gastric lavage are two procedures that we read about in medical school and in textbooks but never utilize in practice. They are both considered techniques of “gastric emptying” (GE) as opposed to whole bowel irrigation or activated charcoal. Although both were formerly widespread modalities for the management of ingested poisons, support for these techniques has waned over the last twenty years. We’ll take a look at some of the evidence, but first let’s review some terminology.
Gastric lavage (GL) refers to the passage of a large bore orogastric tube followed by repetitive instillation and aspiration of fluid in order to dissolve and retrieve pill fragments or other toxins from within the stomach. Often referred to as “stomach pumping.”
Syrup of ipecac is a once widely used drug to rapidly induced emesis for the management of acute poisoning. Referred to in JAMA as “the treatment of choice in managing acute poisonings” in 1960, it was once a mainstay of prehospital and emergency department protocols. However, it is no longer recommended. Syrup of ipecac is commercially prepared from the roots and rhizomes of the Carapichea ipecacuanha plant.
Tandberg et al. performed a controlled study in 1986 comparing the efficacy of the two. The investigators administered 25 100ug tablets of tagged-Vit B12 to 18 fasting normal subjects. The mean rate of recovery of the ingested tracer with ipecac-induced emesis was only 28%, whereas gastric lavage resulted in retrieval of 45% (paired t-test, P < 0.005). In this study, carefully performed gastric lavage was the more effective method of gastric evacuation.
In 1990, Underhill et al. compared lavage, ipecac, and activated charcoal in Tylenol overdose. Patients aged 16 and over who had ingested 5 gms or more of paracetamol within 4 h of admission were entered into the trial. The mean percentage fall in serum acetaminophen level was 39.3% for gastric lavage and 40.7% for ipecac, with a significant difference between the treatment methods (p = 0.03).
Pond et al. looked at gastric emptying as an adjunct to activated charcoal in 876 emergency department acute poisonings and found no significant difference when either syrup of ipecac or gastric lavage was added to activated charcoal protocols. The authors concluded, in 1995, that “gastric emptying can be omitted from the treatment protocol for adults after acute oral overdose.”
The complications of gastric lavage merit serious consideration. They include aspiration pneumonia, esophageal perforation, laryngospasm, hypoxia, and/or fluid or electrolyte imbalance. For these reasons, contraindications include unprotected airway, caustic ingestion (due to risk of exacerbating any esophageal injury), hydrocarbon ingestion (high aspiration risk), and/or patients at high risk for GI hemorrhage or perforation.
Ultimately, The American Association of Poison Centers (AAPC) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) issued a joint statement discouraging the routine use of gastric lavage in the management of poisoned patients. It is generally acknowledged that in the rare circumstance of a both recent (<1 hr) and lethal ingestion of a drug not adsorbed by charcoal, gastric emptying by means of lavage may be considered. Syrup of ipecac, however, should remain abandoned to the archival record.
