Don’t use outdated treatments —Follow current overdose guidelines

No routine activated charcoal, gastric lavage, or whole bowel irrigation

When an overdose patient comes to your ED, do you automatically provide some type of gastric decontamination? If so, you’re not following current guidelines for those patients.

A surprising number of EDs have not changed their care to reflect these new recommendations, reports Linda Courtemanche, RN, CSPI, director of the New Hampshire Poison Information Center in Lebanon.

Current guidelines clearly state that gastric lavage, activated charcoal, cathartics, and whole bowel irrigation should not be used routinely in the management of poisoned patients, yet this is still being done in many EDs, says Diana Meyer, RN, MSN, CCNS, CCRN, CEN, a clinical nurse specialist for emergency services at Presbyterian Intercommunity Hospital in Whittier, CA. "These new approaches are still an area of controversy in the ED."

In 1997, the Harrisburg, PA-based American Academy of Clinical Toxicology (AACT) and the Birmingham, England-based European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) published five position statements on gastric decontamination, including whole bowel irrigation, gastric lavage, cathartics, ipecac, and activated charcoal.1

Charcoal no longer needed?

Review the position statements to see if your practice is up to date, urges Courtemanche. "These guidelines have a tremendous impact on ED management. In many cases, charcoal or lavage is no longer indicated, just symptomatic and supportive care."

Still, many ED nurses and physicians are unaware about the new approaches recommended by the guidelines, reports Courtemanche. In many EDs, gastric lavage and activated charcoal are still routinely administered to overdose patients she says. (See GI decontamination clinical guideline that includes the practices recommended by the guidelines, inserted in this issue.)

Those practices are outdated, she emphasizes. "The position papers have been written to reflect these changes." (See Sources box for how to obtain copies, p. 79, and Recommended Reading list for other studies on this topic, p. 85.)

You might assume that almost all patients with ingested poisons need some form of decontamination, but that’s no longer the case, says Courtemanche. "Nothing is routine in GI decontamination anymore."

Now, every patient requires a risk/benefit evaluation for doing any form of decontamination if the time frame is greater than one hour from ingestion, Courtemanche says.

"Drugs and products with anticholinergic properties may still need some decontamination beyond the one-hour time frame," she notes. "But that may mean just activated charcoal, without lavage."

Each patient should be evaluated individually, with advice from a regional poison center, to better assess the need to do any gastrointestinal decontamination, says Courtemanche. "Many factors affect this decision, including whether the patient’s stomach is empty, their age and past medical history, the combination of medications or products ingested, and vital signs." (See story on working with poison centers to determine treatment, p. 86.)

According to the position statements, if gastric decontamination is to be used, you should administer activated charcoal, with whole bowel irrigation being used for a few indications, Meyer notes. "Gastric lavage and cathartics were not recommended other than for uncommon situations." (See contraindications for cathartics, p. 80.)

Here are practices recommended by the position statements (see chart for other new approaches, p. 81):

Don’t automatically give activated charcoal.

You shouldn’t administer single-dose activated charcoal to poisoned patients routinely, says Courtemanche. Studies show that the effectiveness of activated charcoal decreases over time, she notes.

Here are the indications for activated charcoal, according to the guidelines:

— Based on volunteer studies, activated charcoal is more likely to produce benefit if you administer it within one hour of poison ingestion.

— Consider the administration of activated charcoal if a patient has ingested a potentially toxic amount of a poison up to one hour following ingestion.

— You might consider activated charcoal more than one hour after ingestion, but there are insufficient data to support or exclude its use.

Don’t automatically lavage patients.

The use of gastric lavage is indicated only for patients with recent, potentially toxic ingestions or patients with significant ingestions and altered level of consciousness, says Weinman.

Despite the guidelines and literature supporting this new approach, many EDs still lavage overdose patients routinely, Meyer reports. The position statement is based on studies which showed no significant difference in outcomes among ED patients who were treated with charcoal, as compared to those who received both gastric lavage and charcoal, she says.

Of all the gastric decontamination methods, gastric lavage is the most likely to have clinically significant complications, Meyer adds.

Intubate patients if there is question of airway compromise.

An unprotected airway could worsen the patient condition during lavage, says Courtemanche. "This is one of the reasons the outcomes of lavaged patients are poor," she says. "If lavage is being instituted and there is any question of airway compromise, then the patient should be intubated prior to this."

This basic principle is ignored too often, Courtemanche stresses. "Consider whether you are actually improving outcomes by lavage or worsening them because of aspiration," she advises.

The following are contraindications for lavage, according to these guidelines:

— patients with the loss of airway protective reflexes (unless intubated), such as in a patient with a depressed state of consciousness;

— patients who have ingested a corrosive substance such as a strong acid or alkali;

— patients who have ingested a hydrocarbon with high aspiration potential;

— patients who are at risk of hemorrhage or gastrointestinal perforation due to pathology, recent surgery, or other medical condition that could be further compromised by the use of gastric lavage.

Stop using syrup of ipecac routinely.

Do not administer syrup of ipecac routinely when caring for poisoned patients, because there is no data showing any benefit to patient outcomes, Courtemanche says. Ipecac also might delay administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation if administered, she adds.

Never give ipecac to patients with a decreased level or impending loss of consciousness, or who have ingested a corrosive substance or hydrocarbon with high aspiration potential, notes Courtemanche.

Ipecac should not be used in the ED setting any longer, with the exception of pediatric iron tablet ingestions, says Courtemanche. "It’s also not used as frequently in the home setting," she notes. "This is a significant change in management."

Don’t use whole bowel irrigation routinely.

There is no research which conclusively shows that whole bowel irrigation improves outcomes," says Courtemanche. According to the guidelines, there are no established indications for whole bowel irrigation. However, the practice may have value in a limited number of toxic ingestions, such as sustained-release or enteric-coated drugs; substantial amounts of iron; substantial amounts of poisons not adsorbed by activated charcoal; or packets of illicit drugs.

Consider decontamination if exposure occurred less than an hour ago.

Most of the time, patients should be lavaged and given activated charcoal if the time frame is under one hour from exposure, says Courtemanche. "If it is longer than that and if the drug or substance has anticholinergic properties, it also may be helpful to lavage," she says. It depends on the drug(s) or substance(s) that were ingested, and the timing, she adds.

About 32% of the ingested drug is removed from the stomach when gastric lavage is performed one hour after drug ingestion, Meyer notes. "The percentage returned diminishes rapidly after the one hour. However, it is rare for a patient to present in a time frame that allows us to be lavaging within one hour."

Reference

1. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position statements: Gut decontamination. J Toxicol-Clin Toxicol 1997; 35:695-792.

For more information on overdose patients in the ED, contact:

Linda A. Courtemanche, RN, CSPI, New Hampshire Poison Information Center, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. Telephone: (603) 650-6318. Fax: (603) 650-8986. E-mail: Linda.A.Courtemanche@Hitchcock.org.

Diana Meyer, RN, MSN, CCNS, CCRN, CEN, Emergency Services, Presbyterian Intercommunity Hospital, 12401 Washington Boulevard, Whittier, CA 90602-1006. Telephone: (562) 698-0811, ext. 7684. Fax: (714) 998-4103. E-mail: meyerrn@socal.rr.com.

Copies of the position statements on gut decontamination can be accessed at the American Academy of Clinical Toxicology Web site: www.clintox.org. Copies of the position statements can also be ordered for $12.50 including shipping and handling. To order copies, contact:

Heather Miller, Executive Director, American Academy of Clinical Toxicology, P.O. Box 8820, Harrisburg, PA 17105-8820. Telephone: (717) 558-7847. Fax: (717) 558-7841. E-mail: hmiller@pamedsoc.org.