GUT DECONTAMINATION

1. GUT DECONTAMINATION

2. Various methods • Emesis • Gastric lavage • Catharsis • Activated charcoal • Whole bowel irrigation.

3. Various methods • Emesis • Gastric lavage • Catharsis • Activated charcoal • Whole bowel irrigation.

4. 1. Emesis • Syrup of ipecac • Apomorphine • Warm saline or mustard water • Copper sulfate • Zinc sulfate

5. 1.1 Ipecac • Source - Root - Cephaelisipecacuanha or C. acuminata) • Active principles: Cephaeline, emetine, and traces of psychotrine. • Indications: Conscious and alert poisoned patient who has ingested a poison not more than 4 to 6 hours earlier. Mode of action: • Activation of peripheral sensory receptors in the gastrointestinal tract. • Stimulation of the chemoreceptor trigger.

6. 1.1 Ipecac Dose: • 30 ml (adult) - 15 ml (child). Note: • The patient should be sitting up. • If vomiting does not occur within 30 minutes, repeat the same dose once again. • If there is still no effect, stomach wash is repeated to remove not only the ingested poison but also the ipecac consumed.

7. 1.1 Ipecac Contraindications • Convulsions, or ingestion of a convulsant poison • Impaired gag reflex • Coma • Corrosive ingestion • Ingestion of petroleum distillates, or those drugs which cause altered mental status (phenothiazines, antihistamines, opiates, ethanol, benzodiazepines, tricyclics). • All poisons which are themselves emetic in nature

8. 1.1 Ipecac Complications • Cardiotoxicity(bradycardia, atrial fibrillation, myocarditis). • Aspiration pneumonia. • Oesophageal mucosal damage (due to protracted vomiting).

9. 1.2Apomorphine • Given subcutaneously, it causes vomiting within 3 to 5 minutes by acting directly on the chemoreceptor trigger zone. • Since apomorphineis a respiratory depressant, it is contraindicated in all situations

10. 1.3 Warm saline or mustard water • Its use results in severe hypernatremia. • Practically, patients or children refused to drink warm saline or mustard water leads to time waste. • Use of salt water as an emetic is deleted from the first aid chart of poisoning.

11. 1.4 Copper sulphate • induces emesis more often than common salt, but significant elevations of serum copper can occur leading to renal and hepatic damage. • It is also a gastrointestinal corrosive.

12. 1.4 Zinc sulphate • It has same toxicity like copper sulphate and in addition, it has narrow margin of safety.

13. Various methods • Emesis • Gastric lavage • Catharsis • Activated charcoal • Whole bowel irrigation.

14. According to the American Academy of Clinical Toxicology (AACT), and the European Association of Poison Centres and Clinical Toxicology (EAPCCT), gastric lavage should not be employed routinely in the management of poisoned patients.

15. Indications • Lavage should be considered only if a patient has ingested a life-threatening amount of a poison and presents to the hospital within 1 to 2 hours of ingestion. • Lavage beyond this period may be appropriate only in the presence of delayed gastric emptying, or sustained release preparations.

16. Indications • Some authorities still recommend lavageupto 6 to 12 hours post-ingestion in the case of salicylates, tricyclics, carbamazepine, and barbiturates. Precautions— • Never undertake lavage in a patient who has ingested a non-toxic agent, or a non-toxic amount of a toxic agent.

17. Contraindications • Recent surgery, • Advanced pregnancy • Coma. • Marked hypothermia, • Prior significant vomiting • Ingestion of acid or convulsant or petroleum distillate, and sharp substances.

18. Ryle’s tube

19. Procedure • The preferred route of insertion is oral. • Lubricate the inserting end of the tube with vaseline or glycerine, and pass it to the desired extent. • Use a mouth gag so that the patient will not bite on the tube. • Lavage is carried out using 200 to 300 ml of warm (38o C) saline or plain water of liquid.

20. Complications • Aspiration pneumonia. • Laryngospasm. • Sinus bradycardia and ST elevation on the ECG. • Perforation of stomach or oesophagus (rare).

21. Various methods • Emesis • Gastric lavage • Catharsis • Activated charcoal • Whole bowel irrigation.

22. Catharsis means purification by purging the gastrointestinal tract (particularly the bowel) of all poisonous material. • The two main groups of cathartics* include • Ionic solution or Saline • Saccharides

23. 3.1Ionic solution or Saline • Alters physico-chemical forces within the intestinal lumen • Leading to osmotic retention of fluid • Which activates motility reflexes and • Enhances expulsion. Recommended cathartics -- Magnesium citrate: 4 ml/kg -- Magnesium sulfate: 30 gm (250 mg/kg in a child) -- Sodium sulfate: 30 gm (250 mg/kg in a child).

24. 3.2Saccharides • Sorbitolis a cathartic with better efficacy than saline, but not used in young children due to risk of fluid and electrolyte imbalance • It occurs naturally in many ripe fruits • Prepared industrially from glucose, retaining about 60% of its sweetness. • Sorbitolis used as a sweetener in some medicinal syrups

25. 3.2Saccharides MOA -- Reduces the transient time of drugs in GIT Dose -- Dose of sorbitol: 50 ml of 70% solution (adult). Contraindications: –– Corrosives –– Existing electrolyte imbalance –– Severe diarrhoea –– Recent bowel surgery –– Abdominal trauma –– Renal failure. Oil based cathartics should never be used in poisoning

26. Various methods • Emesis • Gastric lavage • Catharsis • Activated charcoal • Whole bowel irrigation.

27. Use of activated charcoal is the sole decontamination measure in ingested poisoning • It is a fine, black, odourless, tasteless powder made from burning wood, coconut shell, bone, sucrose, or rice starch which is treated with activating agent (steam, carbon dioxide, etc.). • The particles are extremely small, but have an extremely large surface area. • Each gram of activated charcoal works out to a surface area of 1000 square metres.

28. Mode of action— Decreases the absorption of various poisons by adsorbing them on to its surface. Activated charcoal is effective to varying extent, depending on the nature of substance ingested

29. Dose 1 gm/kg body weight (usually 50 to 100 gm in an adult, 10 to 30 gm in a child). Procedure Add four to eight times the quantity of water to the calculated dose of activated charcoal mix to produce a slurry or suspension. Administered to the patient after emesis or lavage, or as sole intervention. The slurry should be shaken well before administration.

30. Contraindications • Absent bowel sounds • Small bowel obstruction • Caustic ingestion • Ingestion of petroleum distillates.

31. Various methods • Emesis • Gastric lavage • Catharsis • Activated charcoal • Whole bowel irrigation.

32. This method is recommended for late presenting overdoses when several hours have elapsed since ingestion. It involves the instillation of large volumes of a suitable solution into the stomach in a nasogastric tube over a period of 2 to 6 hours producing voluminous diarrhoea. Previously, saline was recommended for the procedure but it resulted in electrolyte and fluid imbalance.

33. Today, special solutions are used such as • PEG-ELS (i.e. polyethylene glycol and • electrolytes lavage solution, which is an • isosmolar electrolyte solution), and • PEG-3350 (high molecular weight • polyethylene glycol) • which are safe and efficacious, without producing any significant changes in serum electrolytes, serum osmolality, body weight, or haematocrit.