Gastrointestinal Decontamination of The Poisoned Patient - UpToDate

Gastrointestinal decontamination of the poisoned patient - UpToDate 09.07.
2022, 20:02
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Gastrointestinal decontamination of the poisoned

patient
Authors: Robert G Hendrickson, MD, FACMT, FAACT, Shana Kusin, MD
Section Editors: Stephen J Traub, MD, Michele M Burns, MD, MPH
Deputy Editor: Michael Ganetsky, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2022. | This topic last updated: Feb 06, 2022.
INTRODUCTION
Gastrointestinal decontamination refers to the practice of functionally removing an

ingested toxin from the gastrointestinal (GI) tract in order to decrease its absorption or
increase its clearance. Historically, many approaches have been adopted, including gastric
evacuation (forced emesis or gastric lavage), intra-gastric binding (most commonly by
single or multidose activated charcoal), or speeding transit of toxins to decrease total
absorption time (whole bowel irrigation or cathartics). As clinical practice has evolved and
understanding of the efficacy, risks, and benefits of decontamination have grown, many
practices have fallen out of favor.
This topic provides an overview of the approach to gastrointestinal decontamination in

poisoned patients and a review of the evidence supporting the approach described. The
management of intoxication with specific agents and general management of the
poisoned patient, including children, are reviewed separately. (See "General approach to
drug poisoning in adults" and "Initial management of the critically ill adult with an
unknown overdose" and "Approach to the child with occult toxic exposure".)
APPROACH TO GASTROINTESTINAL DECONTAMINATION
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Gastrointestinal decontamination of the poisoned patient - UpToDate 09.07.2022, 20:02
No controlled clinical studies have demonstrated that the "routine" use of gastrointestinal
(GI) decontamination reduces morbidity and mortality in poisoned patients. However,
evidence from human volunteer trials and clinical studies suggest that decontamination
may reduce the absorption of toxins in the GI tract and may be helpful in select
circumstances [1-4].
The decision to perform GI decontamination is based upon the specific poison(s) ingested,
the time from ingestion to presentation, presenting symptoms, and the predicted severity
of poisoning. GI decontamination is most likely to benefit patients who:
● Present for care soon after ingestion (usually within one to two hours)
● Have ingested a poison and amount suspected to cause toxicity
● Do not have clinical factors (eg, obtundation) that make decontamination dangerous
GI decontamination should not be performed if the agent and amount ingested are
clearly nontoxic, if the agent is considered fully absorbed due to delayed presentation, or
if the toxin is not amenable to decontamination.
It is common practice for intentional and potentially toxic ingestions to be treated with
activated charcoal (AC) alone. However, in select scenarios other methods of GI
decontamination may be useful.
METHODS OF DECONTAMINATION
Activated charcoal — Activated charcoal (AC) is a highly adsorbent powder made from
superheated, high surface area, porous particles produced by pyrolysis of organic
material. Its extensive surface area is covered with a carbon-based network that also
includes functional groups (eg, carbonyl, hydroxyl) that adsorb chemicals within minutes
of contact, preventing gastrointestinal absorption and subsequent toxicity. Evidence
supporting the use of AC is discussed separately.
Indications — AC is most likely to benefit patients when administered while toxin

remains in the stomach. Traditionally, this period is thought to be within one hour of
poison ingestion, but the potential for benefit when administered later cannot be
excluded [1,4].
Contraindications — Contraindications to the administration of a single-dose of
activated charcoal (SDAC) include:
● Depressed mental status without airway protection (risk of aspiration)
The decision to intubate a poisoned patient is often complicated, but it should be

made independently of the decision to give AC. In particular, tracheal intubation
should not be performed for the sole purpose of giving AC.
● Late presentation (ie, no toxin is likely to remain in the stomach)
● Increased risk and severity of aspiration associated with AC use (eg, hydrocarbon
ingestion)
● Need for endoscopy (eg, significant caustic ingestion) – AC is likely to impair visibility
during endoscopy
● Toxins poorly adsorbed by AC (eg, metals including iron and lithium, alkali, mineral
acids, alcohols) ( table 1)
● Presence of intestinal obstruction (absolute contraindication) or concern for

decreased peristalsis (relative contraindication)
Dose — The optimal dose of SDAC is not known, but available data show a dose-
response relationship. In vitro studies suggest an AC:toxin ratio of 10:1 to be effective [5].
Alternatively, the following dosing regimen is suggested [1]:
● Children up to one year of age: 10 to 25 g, or 0.5 to 1.0 g/kg

● Children 1 to 12 years of age: 25 to 50 g, or 0.5 to 1.0 g/kg (maximum dose 50 g)
● Adolescents and adults: 25 to 100 g (with 50 g representing the usual adult dose)
Administration — AC is available as a powder that is mixed with water to form a slurry.

The slurry is gritty and poorly palatable, making administration to children particularly
difficult. Flavoring the slurry with juice, chocolate milk, or ice cream may improve
compliance but potentially decreases the adsorptive capacity of AC [6]. AC is also
commercially available as a suspension with thickening agents, such as sorbitol, which
may help improve palatability and additionally act as a cathartic [7,8].
Because sorbitol with AC may cause electrolyte imbalances, it is not recommended in

children. However, if sorbitol-containing AC is the only formulation available, it may be
given but only for one dose.
Complications — The overall rate of AC-associated complications reported in the

literature is low [1]. Gastrointestinal side effects including fullness, abdominal pain,
nausea, vomiting, constipation, and diarrhea have been reported, with higher rates
occurring if AC is used in combination with sorbitol [1]. Treatment with sorbitol-containing
AC should be avoided in children unless there is no alternative, and if that is the case it
must never be used for more than one dose. According to two randomized trials,
aspiration occurs in less than one percent of poisonings and is not increased in patients
who receive AC [9,10]. Aspiration occurred most often when AC was used in conjunction
with gastric emptying techniques that are no longer routinely recommended.
Evidence of efficacy and adverse effects
Activated charcoal: Volunteer data — The majority of data supporting the efficacy
of activated charcoal (AC) come from in vitro and animal data or volunteer trials. An early
study simulating the gastric environment demonstrated that many chemicals adsorb
avidly to AC in a dose dependent fashion, but that certain substances – particularly highly
ionic compounds with low molecular weight, mineral acids, and strong bases – do not
bind well [11]. AC has not been shown to adsorb ethanol, even when administered prior to
ethanol ingestion [12].
A number of volunteer trials support the efficacy of AC when it is administered early after
ingestion, with absorption decreased by up to 95 percent or more when AC is
administered within five minutes [13,14]. When AC is administered one hour after toxin
ingestion, systemic absorption is reduced to the range of 50 to 75 percent, depending
upon the toxin [14-17]. Despite the results of these trials, it is important to remember that
volunteer scenarios may differ markedly from actual poisonings with respect to the timing
of presentation, amount of toxin ingested, and presence of other factors, such as food in
the stomach or drugs that alter GI transit times.
The results of volunteer trials, designed specifically to evaluate the effect of AC when
administered later after ingestion, are less compelling. Two volunteer trials failed to find a
statistically significant reduction in absorption when AC was administered at two, three, or
four hours following ingestion of therapeutic doses of acetaminophen [18,19]. A third trial
demonstrated a small but statistically significant reduction in serum acetaminophen levels
when AC was given three hours after drug ingestion [20]. The subjects in all three
volunteer trials received therapeutic range doses of acetaminophen, so the results are
difficult to extrapolate to larger ingestions that occur in poisoned patients. In a trial where
volunteers were given slightly supratherapeutic doses of rivaroxaban (40 versus 20 mg
maximum recommended dose), AC administered as late as eight hours after ingestion
produced a statistically significant decrease in the concentration-time curve [21]. This
decrease may reflect the particular pharmacokinetics of rivaroxaban but warrants further
study.
Activated charcoal: Clinical trials — Randomized controlled trials of poisoned

patients treated with activated charcoal (AC) have failed to demonstrate a consistent
impact on clinically important outcomes. However, this may in part be due to
methodologic problems in some studies, such as including treatments with AC given
several hours after ingestion and treatment of patients with little or no risk of toxicity.
● A trial of 1479 poisoned patients randomly assigned to receive AC or no

decontamination reported higher rates of emesis and intubation, as well as a small
but statistically significant increase in emergency department length of stay, in
patients treated with AC, but overall no significant differences were noted in the
clinical course or rates of aspiration between groups [22].
● A trial of 71 patients with an overdose of tricyclic antidepressants (TCA) randomly

assigned patients to gastric lavage with or without AC and found no difference in
serum drug concentrations between groups [23]. Of note, most patients presented
late following ingestion.
● A trial of 327 patients, who were randomly assigned to receive AC or no

decontamination, found no difference in length of stay, vomiting, aspiration,
intubation, or mortality between groups [9]. The authors noted that
benzodiazepines, acetaminophen, and selective serotonin reuptake inhibitors (SSRIs)
comprised the majority of toxins, and these drugs would generally not be expected
to cause severe toxicity regardless of whether GI decontamination were performed.
Three observational studies of poisoned patients examined the question of AC efficacy in

late-presenting patients:
● A prospective observational series of patients with toxic acetaminophen

concentrations who presented more than four hours following ingestion found a
lower rate of liver injury among patients given AC in addition to N-acetylcysteine

[24]. For patients given AC between four and eight hours after ingestion, the rate of
liver injury (AST or ALT >1000 IU/L) was 0 versus 12 percent in the group that did not
receive AC. Liver injury rates were also lower for those treated 9 to 12 hours after
ingestion (3 versus 52 percent) and 13 to 16 hours after ingestion (10 versus 45
percent).
● An observational study of 200 patients with massive (>40 g) acetaminophen

ingestion found that patients who received AC up to four hours after ingestion had a
significantly lower "paracetamol ratio" (defined as the ratio of the first
acetaminophen concentration compared with the nomogram cutoff at the time of
measurement) than those who did not receive AC or received it >4 hours after
ingestion (paracetamol ratio 1.4 versus 2.2) [25]. Patients who received AC within
four hours also had a significantly lower risk of hepatotoxicity (odds ratio [OR] 0.12),
which persisted when adjusted for time to acetylcysteine (OR 0.20). Although it was
not a focus of the paper, the presented data suggest that the effect of AC on the
paracetamol ratio was similar when given within two hours versus between two and
four hours.
● A retrospective series described 981 consecutive patients poisoned with

acetaminophen who were treated, prior to receiving N-acetylcysteine, with gastric
lavage and AC, AC alone, or no decontamination [26]. The authors reported that, in
patients presenting within 24 hours with ingestions of 10 g or greater,
administration of AC prior to N-acetylcysteine resulted in a lower risk of liver injury
(defined AST or ALT greater than 1000 IU/L) compared to treatment with N-
acetylcysteine alone (OR 0.36, 95% CI 0.23-0.58) [26]. The authors found that this
effect predominates when patients present within two hours, but may extend to
many who present as long as three hours later.
Activated charcoal: Adverse effects — Aspiration is the concern most often cited
when clinicians choose not to administer activated charcoal (AC). In their joint position
paper on single-use AC, the American Academy of Clinical Toxicology and the European
Association of Poison Centres and Clinical Toxicologists state that charcoal itself is not
responsible for aspiration, but rather administering it improperly (ie, to a patient with an
inadequately protected airway; in association with lavage; or instilling it directly into the
lung via an improperly placed nasogastric tube) [1]. In addition, when aspiration does
occur, poor outcomes cannot clearly be attributed to the charcoal itself rather than the
aspiration of acidic gastric contents.
Given the widespread use of AC, the overall rate of adverse effects, particularly aspiration,
associated with its administration is low. In a randomized clinical trial of self-poisoned
adults, AC was found to increase the risk of vomiting (23 versus 13 percent in controls)
[10], but the rate of aspiration was low in both groups (two patients in each group
developed aspiration pneumonia out of a total of 1479). A second trial of 327 patients
found similar rates of both vomiting (14 and 15 percent, respectively) and aspiration (<1
percent in both groups) in patients treated with AC and those not treated [9].The results of
two observational studies suggest that emesis may occur at a higher rate when sorbitol is
added to AC [27,28].
A retrospective chart review of 4562 overdose patients looking for predictors of aspiration
found that age, male sex, GCS <15, emesis, seizure, tricyclic antidepressant overdose, and
an elapsed time of more than 24 hours between ingestion and presentation were all
predictors of aspiration pneumonia, whereas AC administration itself was not [29].
Another retrospective chart review of patients who received AC after intubation found that
2 out of 50, or 4 percent, developed an infiltrate not present prior to intubation [30];
however, the two cases of aspiration pneumonia could not clearly be attributed to
charcoal administration.
Other less important gastrointestinal side effects have been reported. In a volunteer
study, constipation and abdominal fullness occurred at a rate of 46 percent, nausea at 18
percent, and vomiting at 8 percent [20]. Constipation occurred in 60 percent of subjects in
another volunteer study [14].
Multidose activated charcoal — In some instances, patients may benefit from the
repeated administration of activated charcoal (MDAC). Three distinct mechanisms are
thought to account for such benefit:
● Interruption of enterohepatic recirculation

● Facilitation of transluminal diffusion from the body into the bowel lumen (“gut
dialysis”), followed by excretion
● Reduced absorption of extended or delayed release formulations
Indications — MDAC may be helpful in life-threatening ingestions of the following
medications, but evidence is limited and opinions among toxicologists vary [2]:
● Carbamazepine (see "Carbamazepine poisoning")

● Dapsone
● Phenobarbital
● Quinine
● Theophylline (see "Theophylline poisoning")
● Acetylsalicylic acid (aspirin) (see "Salicylate (aspirin) poisoning in adults")
● Phenytoin (see "Phenytoin poisoning")
Volunteer and animal data suggest that MDAC increases elimination of several toxins (eg,
amitriptyline, digoxin, disopyramide, nadolol, piroxicam), but clinical data are currently
insufficient to support the routine use of MDAC in these exposures [2].
Contraindications — Contraindications to the use of MDAC are similar to those of SDAC,

but also include:
● Presence of intestinal obstruction (absolute) or concern for decreased peristalsis

(relative)
Dose — An optimal dosing regimen for MDAC has not been established. In general, after
the initial dose, AC should be administered at a rate of at least 12.5 g/hour, or the
equivalent, given as divided doses. Examples of acceptable regimens include 50 g
administered every four hours, or 25 g every two hours. A volunteer study found no
difference in effectiveness of larger doses spread out over time compared to smaller,
more frequent doses [31].
Administration — Administration is similar to that of AC, but the concurrent use of a

cathartic, such as sorbitol is not recommended. This is of particular importance with
young children, in whom the development of diarrhea may lead to dangerous fluid shifts
and electrolyte imbalance [2].
Complications — In addition to the complications associated with single-dose AC,

constipation and bowel obstruction have been reported.
Evidence of efficacy and adverse effects — Volunteer trials of MDAC have found
significant decreases in the elimination half-life of several drugs, including phenytoin,
nortriptyline, aminophylline, phenobarbital, carbamazepine, phenylbutazone, digoxin,
and dapsone [14,16,31-35]. However, the results of clinical trials have been mixed:
● A randomized controlled trial of 4629 poisoned patients comparing the routine use
of MDAC to single-dose AC or no intervention found no difference in rates of
intubation, toxin-specific clinical effects, or mortality among groups [36]. The trial
was limited by the prolonged time to treatment for many patients and lower than
expected mortality in the control group.
● In contrast, a randomized controlled trial of 401 patients poisoned with yellow

oleander-poisoned and treated with either MDAC or a single dose of AC found lower
rates of mortality and ICU admission among the MDAC group [37]. This study differs
from the larger trial described above in the narrow scope of toxin studied, shorter
time to treatment, and longer administration of MDAC (along with better adherence
to the regimen).
● Another randomized trial comparing the use of MDAC with no intervention in

patients with phenytoin overdose found a statistically significant decrease in the
time to reach a sub-toxic concentration among those treated, but the study was
limited by small sample size (17 patients) and baseline differences in phenytoin
concentrations between groups [35].
The paucity of data supporting the efficacy of MDAC in actual poisonings and the
availability of better treatments for some of the agents studied (eg, antibody [Fab]
fragments for digoxin overdose) have informed the joint position statement of the
American Academy of Clinical Toxicology and the European Association of Poison Centres
and Clinical Toxicologists, which only supports the use of MDAC in life-threatening
ingestions of carbamazepine, dapsone, phenobarbital, quinine, or theophylline [2].
Complications of MDAC administration are similar to those associated with single-dose AC

and are described separately. (See 'Activated charcoal: Adverse effects' above.)
Additional concerns specific to the repeated administration of AC include the development

of an ileus or obstruction. There are published reports of patients developing a bowel
obstruction requiring surgical intervention and even bowel perforation following repeated
administration of AC [38-40]. However, the large randomized trial described above did not
report any such complications [36].
Whole bowel irrigation — Whole bowel irrigation (WBI) refers to the administration of
osmotically balanced polyethylene glycol electrolyte solution (PEG-ES) to induce liquid
stool and mechanically flush pills, tablets, or drug packets from the GI tract.
Indications — WBI is not routinely recommended, but it may be helpful in the following
settings [3]:
● Potentially toxic ingestions of sustained-release or enteric coated pill formulations

● Significant ingestions of toxins not adsorbed by activated charcoal (eg, iron tablets,
lead-containing foreign bodies)
● Ingestion of illicit drug packets (see "Internal concealment of drugs of abuse (body
packing)")
Contraindications — Contraindications to WBI include:
● Ileus, bowel obstruction, or intestinal perforation

● Clinically significant GI hemorrhage
● Hemodynamic instability (concern for sequestration of bowel and worsening of
shock)
● Intractable emesis
Dose — There are no dose-response studies for WBI, but a consensus recommendation
regarding dosing is as follows [3]:
● Children 9 months to 6 years: 500 mL/hr

● Children 6 to 12 years: 1000 mL/hr
● Adolescents and adults: 1500 to 2000 mL/hr
WBI is continued until the rectal effluent is clear. Radiographic studies may be useful in
some circumstances (eg, iron ingestion, body packing) to confirm the absence of residual
toxin.
Administration — Most patients tolerate poorly the large volume of fluid that must be
taken orally to effectively perform WBI. In many cases, nasogastric tube placement is
necessary for PEG-ES administration.
Complications — There is a paucity of published data regarding complications

associated with WBI. GI complaints including nausea, vomiting, cramping, and bloating
are relatively common [3,41]. Patients with vomiting and an unprotected airway are at risk
of aspiration, but this has not been reported as a direct result of WBI.
Evidence of efficacy and adverse effects — Whole bowel irrigation (WBI) may be useful
for patients who have ingested extended-release or enteric-coated tablets, particularly
when patients present more than two hours after ingestion and therefore are not likely to
benefit from charcoal administration. Volunteer data suggest that WBI is effective in some
cases, but may interfere with activated charcoal (AC) when administered concurrently [15].
As an example, the results of an in vitro study suggest that PEG-ES may increase the
dissolution of non-sustained-release acetaminophen tablets, exacerbating poisoning [42].
One volunteer study examining the effect of WBI on extended release acetaminophen
absorption as well as the transit time of radiopaque markers found that WBI did not
significantly reduce systemic drug absorption but did lead to a clustering of markers in
the right hemicolon in the majority of test subjects [43]. The significance of the latter
finding remains unclear.
One retrospective cohort study of acute-on-chronic lithium exposures found that early
decontamination with sodium polystyrene and WBI was associated with lower Poison
Severity Scores (PSS) (OR 0.21; 0.04-0.99), but was underpowered to detect a difference in
PSS with WBI alone [44].
There is a dearth of high quality evidence supporting the use of WBI, with case series
comprising the majority of studies [3]. In one study, statistical analysis of blood
concentrations of 71 patients poisoned with extended-release venlafaxine found that WBI,
when administered with AC, reduced the total absorbed fraction of drug by 29 percent
[45].
Gastric lavage — Gastric lavage (GL) refers to the passage of a large bore orogastric tube
followed by repetitive instillation and aspiration of small aliquots of fluid in an attempt to
aspirate pill fragments or other toxins from within the stomach. Referred to as “stomach
pumping” by the lay public, this formerly widespread modality has been largely
abandoned due to unclear benefit (particularly when compared with other readily
available and less invasive techniques) and the risk of serious complications.
Indications — The American Association of Poison Centers (AAPC) and the European
Association of Poisons Centres and Clinical Toxicologists (EAPCCT) have issued a joint
statement that gastric lavage should not be employed routinely, if ever, in the
management of poisoned patients [46]. A survey of regional hospitals in the southeast
United States suggested that many institutions are no longer stocking supplies for GL,
and practitioners are performing it less often [47]. However, there are rare cases (eg,
recent and potentially lethal ingestion) where the procedure may be considered after
carefully weighing the well-documented risks against the unclear benefits.
Contraindications — GL is contraindicated in the following cases:
● Unprotected airway
● Caustic ingestion (due to risk of exacerbating any esophageal or gastric injury)
● Hydrocarbon ingestion (due to high aspiration risk)
● Patients at risk of GI hemorrhage or perforation (recent surgery, underlying
anatomic abnormality or pathology, coagulopathy)
Complications — Complications associated with GL are significant and include the

following: aspiration pneumonia, esophageal or gastric perforation, laryngospasm,
hypoxia, dysrhythmia, and fluid or electrolyte imbalance [46]. GL may also propel toxins
that were to be removed past the pylorus, potentially facilitating systemic absorption and
decreasing the effectiveness of activated charcoal [48].
Evidence of efficacy and adverse effects — Gastric lavage (GL), once a mainstay of
emergency decontamination of poisoned patients, has been largely abandoned due to
the effectiveness of activated charcoal (AC).
The results of multiple studies call into question the effectiveness of GL:
● A randomized trial of self-poisoned patients reported that 52 percent of radio

opaque tablets the patients had been asked to swallow immediately prior to GL were
retained in the GI tract, while 33 percent were propelled forward into the small
bowel [48].
● In a study of poisoned patients, endoscopy performed immediately following gastric

emptying revealed that 15 of 17 patients treated with GL (88 percent) had residual
intragastric solid [49].
● A volunteer study found that only 45 percent of ingested cobalt was recovered using
GL [50].
When compared directly to AC or when used in conjunction with AC, GL generally does not
provide added benefit according to the results of volunteer and clinical trials.
Representative studies include the following:
● In a randomized controlled trial of 808 poisoned patients, symptomatic patients

treated with gastric emptying (either ipecac or gastric lavage) had a fourfold increase
in intubation rates and a two-fold increase in the rate of ICU admission compared to
those receiving AC [22]. GL was associated with a significantly increased risk of
aspiration pneumonia.
● An observational study of 981 consecutive patients poisoned with acetaminophen

compared outcomes among those treated with AC, AC plus GL, or no
decontamination, in addition to N-acetylcysteine, and found no additional benefit
from GL beyond that provided by AC alone [26].
● In a volunteer study comparing GL administered with AC versus administration of AC

alone, no statistically significant differences in reduction of systemic absorption of
acetaminophen were noted between the two groups [51].
These results notwithstanding, there is evidence that a small subset of patients presenting
early (within one hour of ingestion) may benefit from GL. In a randomized controlled trial
comparing gastric emptying techniques (syrup of ipecac and GL) with AC, no significant
differences were found between groups with respect to clinical deterioration or
admission. However, subgroup analysis revealed that patients presenting within one hour
of ingestion and treated with GL had a higher rate of clinical improvement than those
receiving AC [52]. A second trial using the same protocol produced similar results, but the
group treated with gastric emptying included more severe overdoses and when the
authors controlled for this difference GL appeared to be of less benefit [53].
Gastric lavage carries significant risks, which, given its questionable clinical benefit,
usually outweigh arguments in favor of its use. In a randomized trial, patients treated with
GL had higher rates of aspiration (9 versus 0 percent) and intubation compared to
controls receiving AC [22]. These findings are consistent with numerous published case
reports [46]. Esophageal and gastric perforation represents another, albeit less common,
risk of GL [46,52].
Endoscopy/surgery — Endoscopic or surgical removal of poisons may be indicated when
a life-threatening toxin has been ingested and cannot be effectively removed by less
invasive means. Examples include lethal amounts of heavy metals or pharmacobezoars
refractory to whole bowel irrigation. Surgical removal is indicated in patients exhibiting
toxicity following ingestion of large cocaine packets ("body packers"). In most cases,
endoscopy is not recommended for the removal of illicit drug packets due to the risk of
packet rupture during extraction attempts [54]. (See "Internal concealment of drugs of
abuse (body packing)".)
Outdated treatments — The following modalities of GI decontamination have been used

in the past but are no longer routinely recommended:
Syrup of Ipecac — Previously a mainstay of prehospital and emergency department

management of toxic ingestions, Syrup of Ipecac (SoI)-facilitated gastric emptying is no
longer recommended by the American Academy of Clinical Toxicology (AACT), the
European Association of Poisons Centres and Clinical Toxicologists (EAPCCT), or the
American Association of Pediatrics (AAP) [55,56]. A review of volunteer and clinical studies
suggests that SoI is less effective at decreasing systemic absorption than activated
charcoal (AC) [13,57], yields unpredictable and inconsistent results [49,58,59], and has an
increased risk of adverse effects including delayed administration of more effective
decontamination measures [27] and higher rates of aspiration [60].
Cathartics — Cathartics (eg, magnesium citrate, magnesium sulfate, sorbitol, mannitol)

are intended to decrease poison absorption by enhancing rectal evacuation of toxins or
the poison-AC complex. The AACT and EAPCCT advise against the use of cathartics as
single agent therapy. The combination of a cathartic and AC (eg, sorbitol and AC) should
be used sparingly in adults, if at all, and should not be used in children. If the only
available formulation of AC contains sorbitol, it may be necessary to give it to a child, but
treatment must be limited to a single dose in such cases [61]. (See 'Activated charcoal'
above.)
Adverse effects associated with cathartic use include increased abdominal pain, nausea,
vomiting, excessive diarrhea, dehydration, and electrolyte abnormalities.
Dilution — Dilution was historically recommended following the ingestion of acidic or

alkaline corrosives to decrease the concentration and, thus, the tissue damage from the
ingestion. This approach is problematic and we recommend that it not be performed.
ADDITIONAL RESOURCES
Regional poison control centers — Regional poison control centers in the United States
are available at all times for consultation on patients with known or suspected poisoning,
and who may be critically ill, require admission, or have clinical pictures that are unclear
(1-800-222-1222). In addition, some hospitals have medical toxicologists available for
bedside consultation. Whenever available, these are invaluable resources to help in the
diagnosis and management of ingestions or overdoses. Contact information for poison
centers around the world is provided separately. (See "Society guideline links: Regional
poison control centers".)
Society guideline links — Links to society and government-sponsored guidelines from

selected countries and regions around the world are provided separately. (See "Society
guideline links: General measures for acute poisoning treatment" and "Society guideline
links: Treatment of acute poisoning caused by specific agents other than drugs of abuse".)
SUMMARY AND RECOMMENDATIONS
The vast majority of adults with toxic ingestions have an uncomplicated course and
recover fully with supportive care. The use of techniques to reduce absorption of poisons
by gastrointestinal (GI) decontamination must be guided by the potential severity of the
poisoning, the time from ingestion, and the potential risk to the patient of the
interventions considered. In addition, the availability of an effective antidote substantially
reduces the importance of decontamination.
While various decontamination procedures can reduce blood concentrations of some

ingested poisons, there are few data demonstrating that use of these procedures reduces
morbidity or mortality. Given these considerations, we suggest the following guidelines
for decontamination:
● A protected airway (ie, patient is alert with intact airway reflexes or is intubated) is
essential prior to initiation of any GI decontamination procedure.
● Patients may benefit from the administration of activated charcoal (AC) in a single
dose of 1 g/kg (maximum dose 50 g), particularly if given within one to two hours of
ingestion.
● AC should be withheld in situations where clinical benefit is not expected, including:
• Nontoxic ingestions
• Patients who present when poison absorption is considered complete
• Poisons not bound by AC ( table 1)
• Patients whose risk of complications (eg, aspiration) is unacceptably high
● A cathartic (eg, 1 g/kg of 70 percent sorbitol) may be administered with the initial
dose of AC. Cathartics should not be used as monotherapy, should be avoided in
children, and repeated doses are not recommended.
● Whole bowel irrigation is reserved for patients who have ingested toxic foreign
bodies (eg, drug packets), sustained release or enteric-coated drugs, or toxic
materials not bound by AC (eg, heavy metals).
● Gastric lavage is not recommended for routine decontamination. Rarely, gastric

lavage may be helpful if the patient has ingested a toxic amount of a poison and the
procedure can be performed within one hour of ingestion. When performed, gastric
lavage should be followed by AC administration, unless the agent ingested is not
adsorbed by AC.
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REFERENCES
1. Chyka PA, Seger D, Krenzelok EP, et al. Position paper: Single-dose activated charcoal.
Clin Toxicol (Phila) 2005; 43:61.
2. Position statement and practice guidelines on the use of multi-dose activated

charcoal in the treatment of acute poisoning. American Academy of Clinical
Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J
Toxicol Clin Toxicol 1999; 37:731.
3. Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: whole bowel
irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol
(Phila) 2015; 53:5.
4. Hoegberg LCG, Shepherd G, Wood DM, et al. Systematic review on the use of
activated charcoal for gastrointestinal decontamination following acute oral
overdose. Clin Toxicol (Phila) 2021; 59:1196.
5. Olkkola KT. Effect of charcoal-drug ratio on antidotal efficacy of oral activated

charcoal in man. Br J Clin Pharmacol 1985; 19:767.
6. West L. Innovative approaches to the administration of activated charcoal in pediatric

toxic ingestions. Pediatr Nurs 1997; 23:616.
7. Gwilt PR, Perrier D. Influence of "thickening" agents on the antidotal efficacy of

activated charcoal. Clin Toxicol 1976; 9:89.
8. Minocha A, Herold DA, Bruns DE, Spyker DA. Effect of activated charcoal in 70%
sorbitol in healthy individuals. J Toxicol Clin Toxicol 1984-1985; 22:529.
9. Cooper GM, Le Couteur DG, Richardson D, Buckley NA. A randomized clinical trial of
activated charcoal for the routine management of oral drug overdose. QJM 2005;
98:655.
10. Merigian KS, Blaho KE. Single-dose oral activated charcoal in the treatment of the
self-poisoned patient: a prospective, randomized, controlled trial. Am J Ther 2002;
9:301.
11. Decker WJ, Combs HF, Corby DG. Adsorption of drugs and poisons by activated
charcoal. Toxicol Appl Pharmacol 1968; 13:454.
12. Minocha A, Herold DA, Barth JT, et al. Activated charcoal in oral ethanol absorption:
lack of effect in humans. J Toxicol Clin Toxicol 1986; 24:225.
13. Neuvonen PJ, Vartiainen M, Tokola O. Comparison of activated charcoal and ipecac
syrup in prevention of drug absorption. Eur J Clin Pharmacol 1983; 24:557.
14. Neuvonen PJ, Elonen E. Effect of activated charcoal on absorption and elimination of
phenobarbitone, carbamazepine and phenylbutazone in man. Eur J Clin Pharmacol
1980; 17:51.
15. Lapatto-Reiniluoto O, Kivistö KT, Neuvonen PJ. Activated charcoal alone and followed
by whole-bowel irrigation in preventing the absorption of sustained-release drugs.
Clin Pharmacol Ther 2001; 70:255.
16. Crome P, Dawling S, Braithwaite RA, et al. Effect of activated charcoal on absorption
of nortriptyline. Lancet 1977; 2:1203.
17. Tenenbein M, Cohen S, Sitar DS. Efficacy of ipecac-induced emesis, orogastric lavage,
and activated charcoal for acute drug overdose. Ann Emerg Med 1987; 16:838.
18. Green R, Grierson R, Sitar DS, Tenenbein M. How long after drug ingestion is
activated charcoal still effective? J Toxicol Clin Toxicol 2001; 39:601.

19. Yeates PJ, Thomas SH. Effectiveness of delayed activated charcoal administration in
simulated paracetamol (acetaminophen) overdose. Br J Clin Pharmacol 2000; 49:11.
20. Sato RL, Wong JJ, Sumida SM, et al. Efficacy of superactivated charcoal administered
late (3 hours) after acetaminophen overdose. Am J Emerg Med 2003; 21:189.
21. Ollier E, Hodin S, Lanoiselée J, et al. Effect of Activated Charcoal on Rivaroxaban

Complex Absorption. Clin Pharmacokinet 2017; 56:793.
22. Merigian KS, Woodard M, Hedges JR, et al. Prospective evaluation of gastric emptying
in the self-poisoned patient. Am J Emerg Med 1990; 8:479.
23. Hultén BA, Adams R, Askenasi R, et al. Activated charcoal in tricyclic antidepressant
poisoning. Hum Toxicol 1988; 7:307.
24. Spiller HA, Winter ML, Klein-Schwartz W, Bangh SA. Efficacy of activated charcoal
administered more than four hours after acetaminophen overdose. J Emerg Med
2006; 30:1.
25. Chiew AL, Isbister GK, Kirby KA, et al. Massive paracetamol overdose: an
observational study of the effect of activated charcoal and increased acetylcysteine
dose (ATOM-2). Clin Toxicol (Phila) 2017; 55:1055.
26. Buckley NA, Whyte IM, O'Connell DL, Dawson AH. Activated charcoal reduces the
need for N-acetylcysteine treatment after acetaminophen (paracetamol) overdose. J
Toxicol Clin Toxicol 1999; 37:753.
27. Kornberg AE, Dolgin J. Pediatric ingestions: charcoal alone versus ipecac and
charcoal. Ann Emerg Med 1991; 20:648.
28. Harchelroad F, Cottington E, Krenzelok EP. Gastrointestinal transit times of a
charcoal/sorbitol slurry in overdose patients. J Toxicol Clin Toxicol 1989; 27:91.
29. Isbister GK, Downes F, Sibbritt D, et al. Aspiration pneumonitis in an overdose
population: frequency, predictors, and outcomes. Crit Care Med 2004; 32:88.
30. Moll J, Kerns W 2nd, Tomaszewski C, Rose R. Incidence of aspiration pneumonia in
intubated patients receiving activated charcoal. J Emerg Med 1999; 17:279.
31. Ilkhanipour K, Yealy DM, Krenzelok EP. The comparative efficacy of various multiple-
dose activated charcoal regimens. Am J Emerg Med 1992; 10:298.
32. Mauro LS, Mauro VF, Brown DL, Somani P. Enhancement of phenytoin elimination by
multiple-dose activated charcoal. Ann Emerg Med 1987; 16:1132.
33. Park GD, Goldberg MJ, Spector R, et al. The effects of activated charcoal on digoxin
and digitoxin clearance. Drug Intell Clin Pharm 1985; 19:937.
34. Neuvonen PJ, Elonen E, Mattila MJ. Oral activated charcoal and dapsone elimination.
Clin Pharmacol Ther 1980; 27:823.
35. Skinner CG, Chang AS, Matthews AS, et al. Randomized controlled study on the use of
multiple-dose activated charcoal in patients with supratherapeutic phenytoin levels.
Clin Toxicol (Phila) 2012; 50:764.
36. Eddleston M, Juszczak E, Buckley NA, et al. Study protocol: a randomised controlled
trial of multiple and single dose activated charcoal for acute self-poisoning. BMC
Emerg Med 2007; 7:2.
37. de Silva HA, Fonseka MM, Pathmeswaran A, et al. Multiple-dose activated charcoal for
treatment of yellow oleander poisoning: a single-blind, randomised, placebo-
controlled trial. Lancet 2003; 361:1935.
38. Atkinson SW, Young Y, Trotter GA. Treatment with activated charcoal complicated by
gastrointestinal obstruction requiring surgery. BMJ 1992; 305:563.
39. Goulbourne KB, Cisek JE. Small-bowel obstruction secondary to activated charcoal
and adhesions. Ann Emerg Med 1994; 24:108.
40. Gomez HF, Brent JA, Munoz DC 4th, et al. Charcoal stercolith with intestinal
perforation in a patient treated for amitriptyline ingestion. J Emerg Med 1994; 12:57.
41. Position paper: whole bowel irrigation. J Toxicol Clin Toxicol 2004; 42:843.
42. Nordt SP, Won KJ, Tomaszweski C, Clark RF. Polyethylene glycol electrolyte lavage
solution increases tablet dissolution of acetaminophen in an in vitro model mimicking
acute poisoning. Am J Emerg Med 2020; 38:325.
43. Ly BT, Schneir AB, Clark RF. Effect of whole bowel irrigation on the pharmacokinetics
of an acetaminophen formulation and progression of radiopaque markers through
the gastrointestinal tract. Ann Emerg Med 2004; 43:189.
44. Bretaudeau Deguigne M, Hamel JF, Boels D, Harry P. Lithium poisoning: the value of
early digestive tract decontamination. Clin Toxicol (Phila) 2013; 51:243.
45. Kumar VV, Oscarsson S, Friberg LE, et al. The effect of decontamination procedures
on the pharmacokinetics of venlafaxine in overdose. Clin Pharmacol Ther 2009;
86:403.
46. Benson BE, Hoppu K, Troutman WG, et al. Position paper update: gastric lavage for
gastrointestinal decontamination. Clin Toxicol (Phila) 2013; 51:140.
47. Hoffman RM, Maskell KF, Cumpston KL. A local survey of gastric lavage for
gastrointestinal decontamination in a new century: The future marches on. Am J
Emerg Med 2018; 36:1114.
48. Saetta JP, March S, Gaunt ME, Quinton DN. Gastric emptying procedures in the self-
poisoned patient: are we forcing gastric content beyond the pylorus? J R Soc Med
1991; 84:274.
49. Saetta JP, Quinton DN. Residual gastric content after gastric lavage and ipecacuanha-
induced emesis in self-poisoned patients: an endoscopic study. J R Soc Med 1991;
84:35.
50. Tandberg D, Diven BG, McLeod JW. Ipecac-induced emesis versus gastric lavage: a
controlled study in normal adults. Am J Emerg Med 1986; 4:205.
51. Christophersen AB, Levin D, Hoegberg LC, et al. Activated charcoal alone or after
gastric lavage: a simulated large paracetamol intoxication. Br J Clin Pharmacol 2002;
53:312.
52. Kulig K, Bar-Or D, Cantrill SV, et al. Management of acutely poisoned patients without
gastric emptying. Ann Emerg Med 1985; 14:562.
53. Pond SM, Lewis-Driver DJ, Williams GM, et al. Gastric emptying in acute overdose: a
prospective randomised controlled trial. Med J Aust 1995; 163:345.
54. Trent MS, Kim U. Cocaine packet ingestion. Surgical or medical management? Arch
Surg 1987; 122:1179.
55. Höjer J, Troutman WG, Hoppu K, et al. Position paper update: ipecac syrup for
gastrointestinal decontamination. Clin Toxicol (Phila) 2013; 51:134.
56. American Academy of Pediatrics Committee on Injury, Violence, and Poison
Prevention. Poison treatment in the home. American Academy of Pediatrics
Committee on Injury, Violence, and Poison Prevention. Pediatrics 2003; 112:1182.
57. Curtis RA, Barone J, Giacona N. Efficacy of ipecac and activated charcoal/cathartic.
Prevention of salicylate absorption in a simulated overdose. Arch Intern Med 1984;
144:48.
58. Auerbach PS, Osterloh J, Braun O, et al. Efficacy of gastric emptying: gastric lavage
versus emesis induced with ipecac. Ann Emerg Med 1986; 15:692.
59. Tandberg D, Wood DA. Ipecac-induced emesis and gastric lavage are equally
unpleasant. Vet Hum Toxicol 1988; 30:109.
60. Albertson TE, Derlet RW, Foulke GE, et al. Superiority of activated charcoal alone
compared with ipecac and activated charcoal in the treatment of acute toxic
ingestions. Ann Emerg Med 1989; 18:56.
61. Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42:243.

Topic 321 Version 28.0
GRAPHICS
Agents for which activated charcoal is not recommended
Heavy metals
Arsenic
Lead
Mercury
Iron
Zinc
Cadmium
Inorganic ions
Lithium
Sodium
Calcium
Potassium
Magnesium
Fluoride
Iodide
Boric acid
Corrosives
Acids
Alkali
Hydrocarbons
Alkanes
Alkenes
Alkyl halides
Aromatic hydrocarbons
Alcohols
Acetone
Ethanol
Ethylene glycol
Isopropanol
Methanol
Essential oils
Graphic 77553 Version 2.0
Contributor Disclosures
Robert G Hendrickson, MD, FACMT, FAACT No relevant financial relationship(s) with ineligible
companies to disclose. Shana Kusin, MD No relevant financial relationship(s) with ineligible companies
to disclose. Stephen J Traub, MD No relevant financial relationship(s) with ineligible companies to
disclose. Michele M Burns, MD, MPH No relevant financial relationship(s) with ineligible companies to
disclose. Michael Ganetsky, MD No relevant financial relationship(s) with ineligible companies to
disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

Gastrointestinal Decontamination of The Poisoned Patient - UpToDate

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Gastrointestinal decontamination of the poisoned

Gastrointestinal decontamination refers to the practice of functionally removing an

This topic provides an overview of the approach to gastrointestinal decontamination in

APPROACH TO GASTROINTESTINAL DECONTAMINATION

Indications — AC is most likely to benefit patients when administered while toxin

Contraindications — Contraindications to the administration of a single-dose of

activated charcoal (SDAC) include:

● Depressed mental status without airway protection (risk of aspiration)

The decision to intubate a poisoned patient is often complicated, but it should be

● Late presentation (ie, no toxin is likely to remain in the stomach)

● Presence of intestinal obstruction (absolute contraindication) or concern for

● Children up to one year of age: 10 to 25 g, or 0.5 to 1.0 g/kg

Administration — AC is available as a powder that is mixed with water to form a slurry.

Because sorbitol with AC may cause electrolyte imbalances, it is not recommended in

given but only for one dose.

Complications — The overall rate of AC-associated complications reported in the

Evidence of efficacy and adverse effects

Activated charcoal: Clinical trials — Randomized controlled trials of poisoned

● A trial of 1479 poisoned patients randomly assigned to receive AC or no

● A trial of 71 patients with an overdose of tricyclic antidepressants (TCA) randomly

● A trial of 327 patients, who were randomly assigned to receive AC or no

Three observational studies of poisoned patients examined the question of AC efficacy in

● A prospective observational series of patients with toxic acetaminophen

lower rate of liver injury among patients given AC in addition to N-acetylcysteine

● An observational study of 200 patients with massive (>40 g) acetaminophen

● A retrospective series described 981 consecutive patients poisoned with

● Interruption of enterohepatic recirculation

Indications — MDAC may be helpful in life-threatening ingestions of the following

● Carbamazepine (see "Carbamazepine poisoning")

Contraindications — Contraindications to the use of MDAC are similar to those of SDAC,

● Presence of intestinal obstruction (absolute) or concern for decreased peristalsis

Administration — Administration is similar to that of AC, but the concurrent use of a

Complications — In addition to the complications associated with single-dose AC,

● In contrast, a randomized controlled trial of 401 patients poisoned with yellow

● Another randomized trial comparing the use of MDAC with no intervention in

Complications of MDAC administration are similar to those associated with single-dose AC

Additional concerns specific to the repeated administration of AC include the development

● Potentially toxic ingestions of sustained-release or enteric coated pill formulations

Contraindications — Contraindications to WBI include:

● Ileus, bowel obstruction, or intestinal perforation

● Children 9 months to 6 years: 500 mL/hr

Complications — There is a paucity of published data regarding complications

Contraindications — GL is contraindicated in the following cases:

Complications — Complications associated with GL are significant and include the

● A randomized trial of self-poisoned patients reported that 52 percent of radio

● In a study of poisoned patients, endoscopy performed immediately following gastric

● In a randomized controlled trial of 808 poisoned patients, symptomatic patients

● An observational study of 981 consecutive patients poisoned with acetaminophen

● In a volunteer study comparing GL administered with AC versus administration of AC

Endoscopy/surgery — Endoscopic or surgical removal of poisons may be indicated when

Outdated treatments — The following modalities of GI decontamination have been used

Syrup of Ipecac — Previously a mainstay of prehospital and emergency department

Cathartics — Cathartics (eg, magnesium citrate, magnesium sulfate, sorbitol, mannitol)

Dilution — Dilution was historically recommended following the ingestion of acidic or

Society guideline links — Links to society and government-sponsored guidelines from

SUMMARY AND RECOMMENDATIONS

While various decontamination procedures can reduce blood concentrations of some

● AC should be withheld in situations where clinical benefit is not expected, including:

● Gastric lavage is not recommended for routine decontamination. Rarely, gastric

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2. Position statement and practice guidelines on the use of multi-dose activated