Emergency Care/ Injuries and Poisonings

Cervical Spine Injuries

Wound Management
Bites and Stings
Minor Burns
Seizures
Gastrointestinal Decontamination

David Kramer, M.D.

1
 Cervical Spine Injuries
Cervical spine injuries are uncommon in children. They are
 Uncommon in children really not that uncommon in children, but because injuries to the
 Higher fulcrum in children causes most injuries to be upper C-spine in childhood are usually to the upper C-spine, they are
C-spine frequently fatal. So if we were to look at trauma related fatalities
 "Adult" pattern of injury occurs after 8 years of age in young children, we would find quite a number of upper C-
spine injuries. In an emergency department it is quite uncommon
to see a child come in with a C-spine injury without a terribly
morbid series of other injuries. The typical frontal impact in an
automobile accident, where the head comes forward, that fulcrum
being higher in the C-spine causes the injuries to be C1,C2 or C3
in a vast majority of children less than eight years of age. Once
they are over eight, that fulcrum is down around C6. And after
eight years of age, you'll see more of an adult pattern of C-spine
injuries in children.

2
 Evaluation of Cervical Spine Injuries
 Clinical "clearing" of C-spine Injuries
• Normal level of consciousness
• Normal neurological examination
• No neck pain
• No neck tenderness
• No "distracting" injury, such as an abdominal injury
• Full voluntary range of motion
Every child who has had a bump on the head does not need C-
spine x-rays. We frequently will "clear" a C-spine clinically.
However, if there is any question, we'll leave the collar in place
and we will do radiographs. First of all, the child needs a normal
level of consciousness. And people ask, "At what age does a
child really have a normal level of consciousness?" A coopera-
tive four or five-year-old who can tell us that the neck doesn't
hurt is in many cases a child whose neck can be cleared clini-
cally. But again, the younger they are and the less cooperative,
the less likely we are to trust the clinical approach for clearing
the C-spine after a significant head injury. Of course, we want a
normal neurological examination. No neck pain and no neck
tenderness. Any serious injury, any femur fracture or another
very painful injury, can cause endogenous endorphin release and
can cause a child to really be distracted from the neck injury.
And so when a child says there is no neck pain when there is
another very serious painful injury, we don't trust that the
absence of reporting really means that the neck is not injured.
And then once we have gone through these various parameters,
we'll ask a child to fully move the neck voluntarily. If we've met
all of these criteria, then we'll take the C-spine collar off.
The presence of a collar when a child arrives to the Emergency
Department does not obligate one to obtain C-spine films.
Conversely, the fact that a child arrived in the Emergency
Department without a collar doesn't mean it is inappropriate for
you to put one on if you think it is indicated. So we are not
required to continue what are perhaps the mistakes of others. I
would use your own independent judgment to determine whether
or not a collar should be placed or perhaps can be removed
without radiographs.
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Radiographic Evaluation of Cervical
Spine Injuries Radiographs include three views, a lateral and anteroposterior,
from which I get very little information, and then the open-mouth
odontoid view. Recognizing the odontoid is the part of the C-
• Lateral spine most frequently fractured in C-spine injuries in young
• Anteroposterior children, we really want to exclude a fracture of the odontoid in
• Open-mouth odontoid view children with head and neck injuries. If there is any question,
- Flexion/extension views, CT scan, MRI as needed either clinically or from these radiographs, flexion or extension
views are obtained to look for ligamenta injury. CT scan or MRI
can be ordered to better clarify the status of the cervical spine.

The most common reading of a pediatric C-spine that is not

abnormal but may appear a bit abnormal is the
pseudosubluxation C2 on C3. It can also occur on C4. Radio-
graphically, the C2 seems to ride forward on C3, but the poste-
rior elements align. And the more the neck is flexed, the more
exaggerated the C2 on C3 pseudosubluxation will appear. It is
challenging to read C-spine films in children because there is
much more cartilage. Furthermore, even with significant C-spine
fractures, there is more recoil, so when they come to the Emer-
gency Department the fractured fragments may be better aligned
and the neck may be more in place. Children can injure their
spinal cord without a radiographic abnormality. The typical
situation involves a child that has a significant injury and a
transient, either paralysis or paresthesias that are reported, and
then a period where, by clinical examination, they appear to be
okay, or children who have persistent neurologic deficits, and in
cases where there is a suspicion, based on the neurological exam
or based on the specific history, you need to worry about a spinal
cord injury without an obvious fracture. In those cases, a CT
scan, or even better an MRI, are useful.

With C2 on C3 pseudosubluxation, bringing the chin down both

widens the prevertebral soft tissue and causes C2 to ride forward
a bit on C3. If you look at a line between the spinous process of
C1, C2 and C3, you can see there is pretty good alignment,
indicating that it's a pseudosubluxation and not a true
subluxation. This is the ring of C1, C2, and the odontoid, the
normal predental space and the rest of the cervical spine. This is
just another diagram of a C2 on C3 pseudosubluxation that rides
forward a bit and you can see that the line through the posterior
elements lines up. Whereas in this particular patient where there

4

Cervical Spine Injuries Interpretation
of Radiographs
 C2-3 pseudosubluxation increases with neck flexion
 Radiolucent cartilage and greater recoil to normal position
after fracture makes interpretation of pediatric C-spine
radiographs challenging
 Spinal cord injury without radiographic abnormality
is a real subluxation of C2 on C3, you draw a line from here to
here and it misses the cortex of the spinous process of C1. Now,
that is a subtle finding but there is also prevertebral soft tissue
swelling and clinical symptomatology. So if there is any question
about whether the subluxation is a pseudosubluxation or a real
subluxation, look at the clinical examination and leave the collar
in place if there is a persistent concern.
Most severe motor vehicle injuries involve a frontal impact. With
a frontal impact in the forward facing restrained passenger, the
head will fly forward and it will pull C1 forward on C2. The
ligaments that run behind the odontoid can cause pressure and
push anteriorly on the odontoid and cause a type-2 fracture of the
odontoid. And this, far and away, is the most common significant
C-spine injury that we see in children. It is particularly seen in
kids in forward facing car seats where they are adequately
restrained. Furthermore, it is a little bit of a tricky injury because
these children do not impact with the interior of the car and so
they are not necessarily bruised. They are not necessarily
bleeding, and they may look relatively well, but still have an
injury. It usually involves quite a significant deceleration with a
frontal impact.
5
 Management of Cervical Spine Inju-
ries
 Support Airway, Breathing, and Circulation
 Immobilize the cervical spine in all children with suspected
C-spine injury to prevent secondary injury
 Optimal immobilization requires stiff collar and spine board
with shoulder mattress pad or occipital recess
With children who have C-spine injuries, all emergency care
starts with "airway, breathing and circulation". The C-spine
needs to immobilized in all children with suspected C-spine
injury and that includes a stiff collar and immobilization on a
spine board. An occipital recess or shoulder mattress pad is best
for proper alignment. But recognize that even with full immobili-
zation, there is still 10-15º of movement of the cervical spine.
We don't know if that is very significant or not, but certainly if
a C-spine injury has occurred we want to make every effort to
prevent any secondary injury through proper immobilization.
6
 Wound Management--Lacerations
General Principles
 Support Airway, Breathing, Circulation
 Tetanus Prophylaxis
 Neurologic assessment before injecting anesthetic
 Assess tendon function
 Remove foreign material
 Débride devitalized tissue
 Decontaminate with voluminous saline irrigation
 Consider antibiotic prophylaxis for high risk wounds
Wound management. Tetanus prophylaxis needs to be consid-
ered. For lacerations of the hand or other parts of the body, it is
important to do a neurologic assessment and an assessment for
tendon involvement. The neurologic assessment needs to take
place before instilling the lidocaine. Because some degree of
weakness can be the result of the lidocaine infusion and once the
numbing has taken place, our ability to assess the neurologic
function is greatly reduced. You want to remove as much foreign
material from the wound as possible. Débride any devitalized
tissue.
All wounds are contaminated to some degree. Our goal isn't to
sterilize the wound, but it is to reduce the bacterial counts. There
is a clear relationship between bacterial counts in a wound when
it is closed and the likelihood of developing a wound infection.
To reduce bacterial counts, irrigation with large volumes of
saline is the most effective way to cleanse the wound. If the child
has a very small, superficial wounds in a highly vascular area,
one need not use 3 liters of fluid to decontaminate. But for
wounds where the risk is high, either because of location or by
mechanism of injury, using a large volume of saline with
significant pressure will help to decontaminate. Consider
antibiotic prophylaxis for high risk wounds. High risk wounds,
like facial wounds, should be treated because of the risk of
cosmetic problems, even though facial wounds get infected quite
infrequently. And then hand wounds and extremity wounds,
especially highly contaminated hand and extremity wounds.
These get infected at a higher rate than wounds in more vascular
areas.
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 Wound Management of Lacerations
For wound closure, we all live in fear that if we were to use
Wound Closure epinephrine-containing lidocaine in the toes or in the ears, that

 Do not use epinephrine containing anesthetic on fingers, the toes would fall off. People I know who are podiatrists say they

nose, ear routinely use epinephrine-containing solutions in surgery on the

 Débride jagged margins

foot and never have problems with it. I think there is probably not

 Close subcutaneous dead space

much reason to include the epinephrine and I think to be safe I
want you to avoid epinephrine in distribution of end arteries. You
 Undermine if margins are difficult to approximate
want to debride jagged margins because wound closure will better
 Evert wound margins
be affected and cosmetic result will be improved if we are
 Approximate--don't strangulate--with sutures
reapproximating relatively straight margins.

You need to close the subcutaneous dead space. If one only closes
the overlying skin and with continued transudation of fluid and
perhaps persistent bleeding, a collection of fluid or a hematoma
develops below the closed wound. That will be a nidus for a thick
scar which will distort the surface of the skin. And even if the
skin closure is beautiful, if there is some elevation or depression
from the subcutaneous scarring, the cosmetic result from the
wound closure will be inferior. So you want to close subcutaneous
dead space. Sometimes the margins are difficult to reapproximate,
in which case undermining, which is really loosening up the skin
at the wound margin from the subcutaneous tissue so there is
really less tension in the skin, can be a useful technique. And if
possible, we want to put in sutures to try to evert the wound
margins for optimum cosmetic result. We don't want to suture too
tightly. We want to approximate, not strangulate the wound.

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Wound Management of Lacerations --
Special Situations
 Vermillion Border - exact re-approximation is required for
a good cosmetic result. Consider consulting a plastic
surgeon.
 Highly contaminated wounds, and non-facial wounds over
18 hours old, can be decontaminated, dressed, and left
open for 3-5 days for delayed closure.
 Puncture wounds should be cleansed and observed.
Foreign bodies should be removed
 Delayed development of Pseudomonas osteomyelitis is
associated with puncture wounds through sneakers.
Then there are some special situations like wounds that occur at
the Vermillion Border. What we know is that without an exact
reapproximation of the Vermillion Border, there will be a very
visible scar. And even half a millimeter of misalignment is quite
noticeable, especially on the front of a child's face like this. Make
sure that exact margin reapproximates. I would have a low
threshold for consulting a plastic surgeon if you have wounds
through the Vermillion Border. In particular, oblique wounds
through the Vermillion Border are difficult to perfectly
reapproximate.
Highly contaminated wounds and non-facial wounds that are over
18 hours old are at great risk for developing wound infections.
Dressing a wound like that, starting a child on oral antibiotic,
bringing them back at three to five days for a delayed closure of
that wound when it has already declared itself as to whether or not
it will get infected is probably a wise choice. Wounds of the scalp
or of the face get infected so infrequently, probably because of the
higher vascular nature of those tissues, that they can probably be
safely closed without increasing the infection rate even beyond
the 18 hours time. If it is a very contaminated wound, if it's a
wound on a piece of farm machinery, military wounds, other
kinds of highly contaminated wounds, we may be more careful
with our closure. But a fresh, sharp wound, even if there is a
delay, can be safely closed in certain locations.
Puncture wounds should be cleansed externally. Just cleansing the
skin is reasonable, making sure there are no remaining foreign
bodies that need to be removed.
Children who have a puncture wound through a sneaker are at
risk for developing Pseudomonas osteomyelitis. Pseudomonas
osteomyelitis usually comes from the Pseudomonas that resides
within the insole of most sneakers - in that moist, wet environ-
ment. There is probably direct inoculation by the nail which
comes up through the sneaker and then into the bone. We don't
have prophylactic antibiotics to prevent Pseudomonas
osteomyelitis. Ciprofloxacin, if we can use it in the younger child,
may be effective. But this is a rare complication that occurs
weeks later. It is not the same time course that you will see with
a cellulitis from a wound two or three days later presenting with
signs of infection.
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 Bites and Stings--Rabies
 The prevalence of rabies varies geographically. Local
public health authorities should be consulted.
 Bites by Domestic Animals. When the animal can be
observed for 10 days, rabies prophylaxis is generally not
required
 Bites, scratches, and saliva exposures from wild carni-
vores (especially racoon, skunk, fox and bat) require
prophylaxis
 Bites by rodents (rats, mice, squirrels) and lagomorphs
(rabbits) are usually considered no risk
Rabies is a problem we deal with on a regular basis, although I
haven't seen a case of rabies in a child in my lifetime. But rabies
has become endemic in the wild animal population in many parts
of the country. If you are practicing in a part of the country where
rabies is endemic, it is important to recognize the risks that it
poses. Bites by domestic animals that can be observed do not
require rabies prophylaxis. If the animal can be observed for
seven to ten days and the animal does not get sick within that
time frame, then we can be assured that the animal does not have
rabies. Often the public health authorities will take over and make
follow-up phone calls to make sure the animal remains healthy.
Where we really have to worry much more are with bites and even
scratches because often there is saliva on the paws of rabid
animals and it is in the saliva that the rabies virus resides.
Especially wild carnivores like raccoons, skunks, foxes and bats.
They require rabies prophylaxis. Bites by rodents and
lagomorphs, that is rabbits, are usually no risk. So many people
will come in and say my child was bitten by a mouse or by a rat
and, rabies is not a concern in those cases. Mostly wild carnivores
or even sick domestic animals can have rabies.
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 Rabies
 Postexposure Immunization
• Rabies Immune Globulin (RIG) 20 IU/kg. Half in wound
and half IM (separate from human diploid cell vaccine
below)
• Human Diploid Cell Vaccine (HDCV). 1 cc IM (not
gluteal) given on days 1, 3, 7, 14, and 28
Once the decision is made to offer postexposure immunization,
we do both passive immunization and active immunization.
Rabies immune globulin 20 IU/kg is administered half in the
wound and half given intramuscularly. The human diploid cell
vaccine is given intramuscularly, but not in the gluteal region
because some treatment failures have been noted with a gluteal
administration of the human diploid cell vaccine. The rabies virus
is taken up by the nerves and it is transported retrograde to the
brain. So children who have bites on the face by potentially rabid
animals need to be dealt with a little differently because there is
less retrograde transport time when it starts so close to the brain.
In cases like that, immunization should take place even if the
animal can be observed because you would not want to wait the
seven to ten days to determine if the animal is rabid. Retrograde
transport of the virus to the brain for facial wounds may have
already taken place.
Nonpoisonous snakes generally have an oval-shaped head and a
round pupil and most poisonous snakes are in the pit viper family
where they have a triangular head and elliptical pupils. They look
much more evil.
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 Poisonous Snake Bites
 Identify snake if possible.
• Nonpoisonous: These snakes have an oval head and
round pupil
• Pit Vipers: These snakes have a triangular head and
elliptical pupil
• Coral Snake: Black-yellow-red-yellow band pattern.
"red on yellow, kill a fellow"
The coral snake is a poisonous snake with a different kind of
venom that is not a pit viper. If you want to remember, "Red on
yellow, kill a fellow." that will help you identify a coral snake
from some of the others. The water snake has a tendency to bite
but you can see that the head is not triangular and his pupil is
round. The copperhead has a triangular shape and an elliptical
pupil. It is a member of the pit viper family, which is a venomous
or poisonous snake. Some pit viper bites can be potentially lethal,
especially for a child. The milk snake coloring can easily be
mistaken for a coral snake, but the red is not adjacent to the
yellow.
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 Management of Poisonous Snake
Bites
 Support Airway, Breathing, and Circulation.
 Immobilize the extremity below level of the heart.
 Place a wide constriction band proximal to the bite. Avoid
prolonged full vascular occlusion.
 Transport to hospital.
 General wound care
 Laboratory Evaluation: ABG. CBC, CBC, coagulation
profile, type and screen, electrolytes, BUN, creatinine
Management of poisonous snake bites. The typical pit viper bite
is extremely painful, causes inflammation, and local intravascular
coagulation at the site of the bite. In the field we want to manage
"airway, breathing and circulation." We want to minimize the
distribution of the venom. Not all pit viper bites involve the
injection of venom. So there are dry bites where there will be a
bite but there will really be no venom reaction. But we don't want
to take a chance that a venom reaction will develop. We want to
immobilize below the level of the heart. A wide, constricting band
is placed proximal to the bite to minimize the venous return and
the lymphatic return and minimize dissemination of the venom.
Certainly a very tight, localized band can cause a tourniqueting
effect and cause vascular insufficiency and one wants to avoid
that. And rapid transport to a hospital. Venomous snake bites can
cause a necrotic reaction and a lot of swelling of the foot.
Once they reach your office or the Emergency Department, we
need to do general wound care, consider tetanus and all of the
other things. We want to observe and see if there is much of a
venom reaction locally. Laboratory evaluation should include an
ABG, a CBC, a coagulation profile because the local
intravascular coagulation can cause a consumptive coagulopathy
and you can get a prolonged coagulation profile. Type and screen
is recommended. And then for children who have really systemic
effects from the venom, you may want to check electrolytes, BUN
and creatinine.
The decision to give antivenin therapy needs to be approached
with the help of your poison control center. There are some
people who have treated snake bites who feel that more people die
from complications of antivenin therapy than from the snake bite
itself. This is highly allergenic stuff. And for severe snake bites,
the risk-benefit probably favors administering antivenin therapy.
But for every poisonous snake bite, we don't need to give
antivenin therapy and risk those complications. Furthermore, a
test dose is given for those who are candidates to receive the
antivenin therapy and see if there is an allergic type reaction. If a
bite has occurred, but the local reaction does not seem severe
enough to warrant antivenin therapy, one need not give a test dose
of antivenin and one can withhold the antivenin therapy and
observe for four to six hours to see if the local reaction pro-
gresses.
Coral snake bites cause much less local reaction, just some local
13
 redness. But the venom of a coral snake is different and causes a
Spider Bites
more systemic effect. The bite itself is not as painful and causes
cramping, muscle weakness. So there is more of a systemic,
 Brown Recluse neurologic response to the venom of the coral snake than the

• Violin shape on back. more local response to the venom from pit vipers.

• Wound care of local necrosis. Débride if necrosis is

Spiders. There are really two in the United States to be concerned
greater than 2 cm.
about. It is interesting that the brown recluse spider, has a venom
• Consider antibiotic prophylaxis.
that causes local necrosis. In these cases, we really only need to
• Dapsone is contraindicated in children.
provide local wound care and significant debridement if there is
a large area of necrosis that looks greater than 2 cm. Antibiotic
prophylaxis. And although dapsone is used in adults with brown
recluse spider bites, it is not recommended in children because it
is not particularly effective.

This black widow spider a is much more insidious type of bite

because the bite of a black widow spider is painless. Hours later,
a child can develop the more neurologic type symptoms. The
venom causes generalized pain, muscle stiffness and nausea. In
very severe black widow spider bites, in young children in
particular, cardiovascular collapse can occur and there are reports
of fatalities. There is antivenin available if you know it is a black
widow spider bite. For the muscle stiffness, diazepam and
calcium gluconate are recommended.

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 Spider Bites--Black Widow
Minor burns. First aid for minor burns involves preventing any
 Generalized pain, muscle stiffness and nausea occur 1-8 further burning, running the burn under cold water. These are

hours after painless bite things to tell the family when they call you on the telephone about

 Cardiovascular collapse is more likely in children a child with a burn. A burn is a wound and it can be tetanus prone

 Latrodectus antivenin
so you need to consider tetanus prophylaxis. If there are large

 Consider calcium gluconate and diazepam for cramps

bullae that are ruptured, you want to debride that devitalized
tissue. The easiest way to debride most second degree burns is by
rubbing with some sterile gauze. Unruptured bullae should be left
intact. In that case, you essentially have a sterile, biological
dressing at least for a day or two while the burn itself can start to
heal. And so leave unruptured bullae intact.

15
 Minor Burns
We want to dress with an antibiotic cream, again to reduce the
 First Aid burn colonization. We are not going to sterilize the burn but
 Tetanus prophylaxis reduce the numbers of organisms and reduce the likelihood of

 Débride dead tissue, but leave unruptured bullae intact developing infection. We usually use Silvadene cream but

 Dress with antibiotic ointment or cream bacitracin can be used. Parents should change the dressing once

 The parent should change dressing once or twice daily

or twice a day and observe for signs of infection. If the burn is
really greater than 2% or in a cosmetically important area, over
and observe for signs of infection
joints, or anything else about the burn that you are worried about,
 Larger burns (>2%), facial burns, and burns over joints
you may want to have them follow up with a plastic surgeon or a
should be referred to a plastic surgeon
burn specialist. Be particularly aware that burns of the buttocks
 Burns of the buttocks are often a sign of child abuse
are seldom accidental. The toddler toilet-trained who soils himself
may be punished by having his buttocks put under scalding hot
water. If you see burns of the buttocks, you need to be very
suspicious that is an abusive injury.

16
 Seizures - Management
Seizures are relatively common. Simple febrile seizures usually
 Initial management of seizures - stop before we see them although sometimes they start in our

• ABC-Dextrose waiting room so we do have occasion to observe them. Families

• Antipyretics if febrile think the child is dying and even physicians who have seen lots
of seizures get very nervous when the child is seizing in front of
• Anticonvulsants
us. If the child is having a seizure, but is adequately oxygenated
1. seizures > 10 minutes
and has adequate glucose, there is no reason to take drastic
2. seizures associated with significant oxygen
measures that can cause complications. We can observe that
desaturation
seizure for a brief period of time. We want to try to maintain an
3. Diazepam, 0.2 mg/kg/dose or
airway. Make sure breathing and circulation are okay. Check the
4. Lorazepam, 0.1 mg/kg/dose IV, slowly. Repeat in dextrose. If it is a febrile seizure, antipyretics can function as
5 minutes if seizure activity continues. anticonvulsants.
5. Diazepam, 0.5 mg/kg/dose, rectally if vascular
access is unavailable Anticonvulsants. Most kids who have seized at home and arrived
at the Emergency Department have been seizing for more than 10
minutes. If they start seizing in our waiting room, we will watch
them for a bit. Seizures associated with significant desaturation
should be treated immediately with anticonvulsants. Diazepam or
Lorazepam are our first anticonvulsants of choice. Diazepam may
have a slightly faster onset, Lorazepam has a longer duration of
action. It is not just the total dose of benzodiazepine that is given
that is associated with apnea, but the rapidity with which it is
infused. So we infuse these things slowly. When a child is having
seizure, oxygen and dextrose and the benzodiazepine is given
slowly. Rectal Diazepam is very useful for kids with seizure
disorders for parents to administer at home or in cases where
vascular access is difficult. One or 2 cm past the anal verge, 0.5
mg/kg has a relatively rapid onset and can be used.

17
 Gastrointestinal Decontamination--
Emesis GI decontamination. Ipecac is first aid in the home, followed with
some fluid. Vomiting almost always occurs with ipecac, but if it
doesn't, one need not remove ipecac from the stomach. In
 Ipecac is first aid in the home children with anorexia nervosa who chronically abuse ipecac, a
- Infants 10 mL cardiomyopathy was demonstrated. But a single dose of ipecac
- Children 15 mL for a toddler who has ingested something is not going to have any
- Adolescents 30 mL cardiac toxicity even if the child doesn't vomit.

 Follow ipecac with 8 oz fluid

 If vomiting does not occur (rare), ipecac does not need to
be removed from the stomach

18
 GI Decontamination--Gastric Lavage
Gastric lavage. If you want to get large pill fragments, one needs
 Large-bore orogastric tube necessary to retrieve pill to use a large-bore orogastric tube. Often, intubation is necessary

fragments to use a tube large enough to get pill fragments. The left side

 Left side down to delay gastric emptying down will delay gastric emptying and that is the way proper

 Use isotonic fluid until clear

gastric lavage is conducted. Isotonic fluid is given until it is clear.

 Rarely more effective than charcoal alone

It is rarely more effective than charcoal alone and so most of us
use very little lavage and will give charcoal. Occasionally there
will be a child who refuses to drink the charcoal and if we are
putting an NG-tube down to administer charcoal, we may do a
little bit of lavage but it is not usually more effective than the
charcoal alone.

19
GI Decontamination--Activated Char-
coal
 Nonspecific binding of most poisons
 Activated charcoal alone is as effective as gastric empty-
ing (lavage or emesis) followed by charcoal in most
situations
 Give 1 g/kg po/ng with cathartic
 Repeated doses of charcoal increase clearance for drugs
that undergo enterohepatic recirculation and those that
can be dialyzed across the GI mucosa
 Repeated doses of charcoal should not include cathartic
Charcoal binds most large molecules nonspecifically. We usually
give 1 gm/kg either p.o. or ng. The first dose should be with a
cathartic, sorbitol. And there is an unfortunate problem of
children vomiting the charcoal. Some of the charcoal usually
stays down, but removing the tube may prevent some of the
vomiting. Repeated doses of charcoal increase the clearance for
drugs that undergo enterohepatic recirculation. So drugs are
absorbed, re-excreted in the bile, they have a second pass through
the gut where the charcoal can bind them. Other drugs can be
dialyzed across the GI mucosa by creating a column of charcoal
from the stomach to the anus. So in certain cases, repetitive doses
of charcoal can be given. We don't want to give a cathartic with
every dose of charcoal because of problems with diarrhea.
Phenobarbital is a molecule that is not highly protein bound that
is being dialyzed across the gut mucosa. So repetitive dose
activated charcoal for many drugs is very useful.
20
 GI Decontamination -- Whole Bowel
Irrigation
 Drugs not bound by charcoal (lithium, iron, alcohols) and
slow release preparations can be removed by whole bowel
irrigation with polyethylene glycol solutions
 Toddlers 500 cc/hr po/ng
 Adolescents 1 liter/hr po/ng
For drugs like iron, or for lithium, or some of the alcohols, which
tend to be small molecules that don't bind to charcoal or for the
slow release preparations which can agglutinate in the gut, we can
flush them through the absorptive portion of the gut by using
whole bowel irrigation, 500 cc/hour for toddlers and that almost
always needs to be given Ng. Some older kids will drink a
liter/hour but most of them need to get the fluid ng. Golytely, a
balanced electrolyte solution, can be given in huge volumes
without there being fluid and electrolyte shifts of any signifi-
cance. Paint chips in the gut can be removed by whole bowel
irrigation. Whole bowel irrigation is another very effective
technique for gastrointestinal decontamination particularly when
charcoal is ineffective.
21