Poisoning:  GI Decontamination
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þ Delayed charcoal after certain ODs?
 - Standard is to give charcoal only within an hour of ingestion.
 - But, if ingested things that slow stomach emptying, does it make sense to
   give delayed doses?
 - Charcoal at 1 hour reduced area under curve by 44%, at 2 hours 22%,
   and at 3 hours, 15%, but only the 1-hour dose changed the maximum serum
   levels.
   [Mullins M. Effect of delayed activated charcoal after acute ingestion of
   acetaminophen and oxycodone. AEM 2004;11(5):531.]

þ Vomiting after charcoal
 - 33% vomiting in control group, 21% if given 8 mg Zofran. [Isenberger K. The
   prophylactic use of ondansetron in toxic ingestions. AEM 2004;11(5):530.]
 - Questions raised: is vomiting good or bad?
 - My take is that if they vomit the charcoal, that's probably OK in most
   settings, one gets a fair number of pill fragments. But with certain ODs
   where vomiting is contraindicated, or risk is low, may be appropriate.

þ Ipecac:
 - good at removing tracer substances, but ? whether it causes a change in
   mortality or morbidity. [Kulig K, Bar-Or D., Cantrill SV, et al.
   Management of acutely poisoned patients without gastric emptying. Ann Emerg
   Med 1985; 14:562.] [Merigan KS, Hedges JR, Pesce A et al.  Prospective
   evaluation of gastric emptying in the self-poisoned patient.  Ann Emerg Med
   1988; 17:402.] [Albertson TE, Derlet J. Foulke GE, et al. Superiority of
   activated charcoal alone compared with ipecac and activated charcaol in the
   treatment of acute toxic ingestions. Ann Emerg MEd 1989; 18:56.]
 - probably inappropriate in ED.  Use NG lavage if needed.  [Kornberg AE,
   Dolgin J. Pediatric ingestions: Charcoal alone versus ipecac and charcoal.
   Ann Emerg Med 1991; 20:648.] [Foulke GE, Albertson TE, Derlet RW. Use of
   ipecac increases emergency department stays and patient complicationi
   rates. Ann Emerg Med 1989; 18:934.]

þ GI Lavage
 - GI lavage is thought to be useless by some.
   [Kulig K. Ann Emerg Med 1985;14:562.]
   [Comstock EG. J Tox-Clin Tox 1982;19:149.]
   [Tenenbeim M. Ann Emerg Med 1987;16:838.]
   [Merigian ?]
   [Comparison of three methods of gut decontamination in tricyclic
   anti-depressant overdose. J Emerg Med 13:203. 1995.]
   51 patients randomly assigned to 1 of 3 groups: 1. charcoal 2. lavage, then
   charcoal 3. charcoal, lavage, charcoal.  No difference in length of
   hospitalization, intubation, EKG changes etc.  But small numbers to decide
   that lavage is useless.

þ Charcoal or Lavage First?
 - "In patients with possibly life-threatening overdoses, I do give charcoal
   prior to and following lavage. I'm not aware of any good literature
   directly comparing charcoal-lavage-charcoal to lavage-charcoal, but am
   aware of literature showing that charcoal is often more effective in
   reducing absorption than lavage (1,2). The second reference demonstrated
   57% versus 38% reduction in ampicillin absorption when charcoal alone was
   compared to lavage alone. In addition, lavage alone has been shown to
   propel drugs into the small intestine, decreasing the opportunity for
   charcoal-binding (3). (This is one of a few reasons why patients undergoing
   lavage should be placed in left lateral recumbent Trendelenburg position.)
   It makes sense then, to give charcoal first, in order to bind any toxins
   which are subsequently propelled out of reach of subsequent charcoal. In
   some EMS systems, activated charcoal is available as prehospital treatment,
   a great idea in nearly any awake patient with a routine overdose, since
   many studies have shown that the earlier charcoal is given, the more
   systemic absorption will be reduced. Finally, when lavage is indicated, it
   also makes sense to give charcoal as an additive method to reduce toxin
   absorption. --James Li, MD, Mount Auburn Hospital, Cambridge, MA
 - (1) [Neuvonen P, et al. Comparison of activated charcoal and ipecac in
   prevention of drug absorption. Eur J Clin Pharmacol 1983;24:557-562.]
   (2) [Tenenbein M, et al. Efficacy of ipecac induced emesis, orogastric
   lavage and activated charcoal for acute drug overdose. Ann Emerg Med
   1987;16:838-841.]
   (3) [Saetta JP, et al. Gastric emptying procedures in the self-poisoned
   patient: are we forcing gastric contents beyond the pylorus? J Roy Soc
   Med 1991;84:274.]