Gastric lavage: Difference between revisions
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==Background==
==Background==
if greater than 2 hrs or toxin already in intestine, gastric decontam not helpful
*Gastrointestinal decontamination technique meant to empty stomach of toxic substances<ref>https://litfl.com/gastric-lavage/</ref>
*Once widely used, now rarely applied
**Little evidence for efficacy
**High risk of complications
*Almost never used in conscious and cooperative patients
**Especially lacks utility when oral [[activated charcoal]] is likely to be successful


-   helpful however if delayed emptying or decreased intest motility
==Indications==
*Life-threatening poisoning (or history is not available) and unconscious presentation (eg [[Colchicine]])
*Life-threatening poisoning and presentation within 1 hour
*Life-threatening poisoning with drug with [[anticholinergic]] effects and presentation within 4 hours
*Ingestion of sustained release preparation of significantly toxic drug
*Large [[salicylate]] poisonings presenting within 12 hours
*[[Iron toxicity|Iron]] or [[lithium toxicity]]
*Paraquat ingestion (common in developing world)


-    always use charcoal asap unless agent/ quantity not toxic, agent not absorbed to charcoal, or delay so long absorption is complete
==Contraindications==
*Corrosive ingestions or esophageal disease
*The poison ingestion is not toxic at any dose
*The poison ingestion is adsorbed by charcoal and adsorption is not exceed by quantity ingestion
*Presentation many hours after poisoning
*A highly efficient antidote such as [[NAC]] is available


-   gastric emptying before charcoal- higher risk of aspiration, intubation, icu- not routinely recommended
==Technique<ref>https://litfl.com/gastric-lavage/</ref>==
#[[Intubate]] patient
#Place patient in left lateral decubitus position with head 20 degrees downward
#Externally measure length of lavage tube needed to reach stomach
#Lubricate appropriately sized lavage tube and gently pass through esophagus to stomach
#*Adults and adolescents: 36–40 French
#*Children: 22–28 French
#Confirm placement of tube
#*Aspiration of gastric contents
#*Auscultation of air over the epigastrium
#*XR
#Using funnel or lavage syringe, aspirate any stomach contents
#Gently instil 200 - 250 mL warned saline into the stomach for adults, or 10 - 15 mL/kg for children (to maximum 250 mL)
#Allow instilled saline to flow out of tube and into bucket near bed
#Repeat instillation and drainage until effluent is clear
#Once effluent is clear, may instil activated charcoal if indicated


-    gastric emptying helpful if symptomatic within 1 hr, symptomatic with agents that slow gi motility, sustained release meds or massive/ life threatening amount
==Complications==
*Increase gastric delivery of tablets into the small bowel
*Aspiration of gastric contents (3% of patients)
*[[Esophageal Rupture]] (rare)
*Profound [[bradycardia]], cardiac arrest, and asystole may be precipitated by lavage in poisonings with [[propranolol]], [[calcium channel blockers]] and other drugs affecting cardiac conduction
**[[Atropine]] should be used to block the increased vagal tone associated with the procedure in these situations


==See Also==
*[[Activated Charcoal]]
*[[Whole Bowel Irrigation]]


==Does GI Decont Change Pt Outcome?==
==References==
 
*Benson BE et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clinical Toxicology 2013;51:140-146.
-    effect only if used early- no effect if late
*Vale JA. Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35(7):711-9
 
-    however, no prospective trial has proven charcoal or ipecac- only suggests it
 
-    also, gi decont benefit never disproved either
 
==Risks==
#  aspiration- by cns depression, loss of gag reflex, spont or induced emesis, manipulation of airway or gi tract
#ipecac assoc with asp if used incorrectly-
##charcoal usually not assoc with asp- but can be
##charcoal asp worse than gastric content asp because causes granulomatous reaction, tissue reaction to sorbitol or povidone, increased lung microvascular permeability
##risk of gastric lavage include unnecessary intubation
##intubation for airway protection/ aspiration not 100% protective
#lavage can also damage throat, esoph, stomach
 
==Which Pt Not Need GI Decon?==
 
-    most preschool pts do not need decont
 
-    no need for decon if nontoxic dose or substance or drug taken so long ago already absorbed.
 
-    Gi decon reasonable if all pt and all symptomatic pt unless full absorption already occurred- risks of single dose low.  
 
-    However- if low risk pt and uncooperative- may not be worth trauma/ risk to staff or pt
 
==Benefit of GI Emptying Before Charcoal?==
 
-    no- especially not if present late, are asymptomatic.
 
-    Gastric emptying will not add benefit to charcoal
 
-    Benefit of charcoal not even proven but is considered state of the art to give unless full absorption already occurred
 
==Will Some Pts Benefit From Aggressive GI Decon?==
 
-    charcoal not useful for iron, lithium alcohol, caustics, hydrocarbons
 
-    even with sustained release meds, if most of drug has moved beyond stomach, lavage will only hold up charcoal
 
-    if pt given ipecac and vomits long time before ED presentation- probably don't need additional charcoal for pediatric pts
 
 
 
ED physician needs to evaluate each ingestions individually and design treatment plan. If substance poorly aborbed to charcoal- try gastric lavage unless have prolonged delay. Usually charcoal alone is best choice.  If late presenting pt and asymptomatic- no gi decon needed. If ealy and symptomatic- personal choice to do gastric lavage followed by charcoal or just charcoal- examine relative risk.
 
==See Also==
[[Charcoal]]


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Tox]]
[[Category:Toxicology]]

Revision as of 00:18, 11 June 2019

Background

  • Gastrointestinal decontamination technique meant to empty stomach of toxic substances[1]
  • Once widely used, now rarely applied
    • Little evidence for efficacy
    • High risk of complications
  • Almost never used in conscious and cooperative patients

Indications

  • Life-threatening poisoning (or history is not available) and unconscious presentation (eg Colchicine)
  • Life-threatening poisoning and presentation within 1 hour
  • Life-threatening poisoning with drug with anticholinergic effects and presentation within 4 hours
  • Ingestion of sustained release preparation of significantly toxic drug
  • Large salicylate poisonings presenting within 12 hours
  • Iron or lithium toxicity
  • Paraquat ingestion (common in developing world)

Contraindications

  • Corrosive ingestions or esophageal disease
  • The poison ingestion is not toxic at any dose
  • The poison ingestion is adsorbed by charcoal and adsorption is not exceed by quantity ingestion
  • Presentation many hours after poisoning
  • A highly efficient antidote such as NAC is available

Technique[2]

  1. Intubate patient
  2. Place patient in left lateral decubitus position with head 20 degrees downward
  3. Externally measure length of lavage tube needed to reach stomach
  4. Lubricate appropriately sized lavage tube and gently pass through esophagus to stomach
    • Adults and adolescents: 36–40 French
    • Children: 22–28 French
  5. Confirm placement of tube
    • Aspiration of gastric contents
    • Auscultation of air over the epigastrium
    • XR
  6. Using funnel or lavage syringe, aspirate any stomach contents
  7. Gently instil 200 - 250 mL warned saline into the stomach for adults, or 10 - 15 mL/kg for children (to maximum 250 mL)
  8. Allow instilled saline to flow out of tube and into bucket near bed
  9. Repeat instillation and drainage until effluent is clear
  10. Once effluent is clear, may instil activated charcoal if indicated

Complications

  • Increase gastric delivery of tablets into the small bowel
  • Aspiration of gastric contents (3% of patients)
  • Esophageal Rupture (rare)
  • Profound bradycardia, cardiac arrest, and asystole may be precipitated by lavage in poisonings with propranolol, calcium channel blockers and other drugs affecting cardiac conduction
    • Atropine should be used to block the increased vagal tone associated with the procedure in these situations

See Also

References

  • Benson BE et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clinical Toxicology 2013;51:140-146.
  • Vale JA. Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35(7):711-9
  1. ↑ https://litfl.com/gastric-lavage/
  2. ↑ https://litfl.com/gastric-lavage/
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