D is for Decontamination
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Induced emesis (syrup of ipecac)
Whole bowel irrigation
(The last two are the only two methods currently recommended)
Adults = 50g
Children = 1g/kg. After a trial on our own staff we all agreed that mixing charcoal with icecream is rather tasty, comically named Batman icecream. In fact the charcoal is fairly tasteless, don’t eat too much though as the sorbitol is a laxative.
Pulmonary aspiration of activated charcoal
Direct administration into the lungs via a misplaced NG tube (potentially fatal)
Impaired absorption of subsequent oral antidotes or other therapeutic agents
Distraction of staff from resuscitation and other supportive care priorities
Initial resuscitation incomplete
Agent not bound to activated charcoal
Risk assessment indicating a good outcome with supportive care and antidote therapy alone
Decreased level of consciousness, delirium or poor concentration (unless their airway is already protected with an endotracheal tube)
Risk assessment suggesting potential for imminent onset of seizures or decreased level of consciousness
Iron overdose >60mg/kg
Slow-release postassium chloride ingestion >2.5 mmol/kg
Life-threatening slow-release verapamil or diltiazem ingestions
Symptomatic arsenic trioxide ingestion
Risk assessment suggesting a good outcome with supportive care and antidote therapy alone
Inability to place a nasogastric tube
Risk assessment suggesting potential for decreased conscious state or seizures in the subsequent four hours.
Ileus or intestinal obstruction
Intubated and ventilated patient (relative contraindication)
The patient requires 1:1 nursing for at least 6 hours.
Place a nasogastric tube and confirm position on xray.
Give activated charcoal if the agent will bind
Administer PEG (polyethylene glycol) solution via the nasogastric tube at 2L/hour by continuous infusion (children 25ml/kg/hr). (If not already made up the solution or powder will have dilution instructions to mix with water)
Where possible administer metoclopramide to minimise vomiting and enhance gastric emptying.
Position the patient on a commode if possible.
Continue irrigation until effluent is clear (this may take up to 6 hours)
Stop irrigation is there is abdominal distension or loss of bowel sounds.
Abdominal xrays can be useful to track radio-opaque substances.
Expelled packages may be counted in body packers.
- American Academy of Clinical Toxicology and the European Association of Poison Centers and Clinical Toxicologists. Position paper: whole bowel irrigation. Clinical Toxicology 2004; 42:843-854
- American Academy of Clinical Toxicology and the European Association of Poison Centers and Clinical Toxicologists. Position paper: single-dose activated charcoal. Clinical Toxicology 2005; 43:61-87
- Bailey B. Gastrointestinal decontamination triangle. Clinical toxicology 2005; 1:59-60
- Benson BE, Hoppu K, Troutman WG et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clinical Toxicology 2013; 51:140-146
- Homer J, Troutman WG, Hoppu K et al. Position paper update: ipecac syrup for gastrointestinal decontamination. Clinical Toxicology 2013; 51:134-139
- Isbister GK, Pavan Kumar VV. Indications for single dose activated charcoal administration. Current Opinion in Critical Care 2011; 17:351-357
- Murray L, Little M, Pascu O, Hoggett K. Toxicology Handbook 3rd Edition. Elsevier 2015. ISBN 9780729542241