SFGH 3.25 AM REPORT PEARLS: GI decontamination in the setting of ingestion

  • First pass imaging = KUB
    • As part of the first-line of diagnosis/management in the setting of an unknown ingestion, one could consider ordering a KUB, as a means of estimating the pill burden. This could potentially lead to a push for endoscopic removal of the ingested toxin/medication over other strategies that will be mentioned below.
    • The radiodensity of medications has been studied in the literature and the most recent data that I could find is from an article in 1998 in the Mayo Clinic Proceedings entitled “The radiodensity of medications seen on x-ray films” by Florez et al. They analyzed 50 prescription and nonprescription medications and all 50 medications were visible on plain x-ray films (though varied in their degree of radiodensity).
  • Methods of GI decontamination after ingestion
    • It is important to note that the overwhelming majority of adult patients with toxic ingestions have an uncomplicated course and require supportive care only.
    • There are no controlled clinical trials that show that the routine use of GI decontamination methods reduce morbidity or mortality.
    • The use of any of these methods is guided by the following:
      • Potential severity of poisoning
      • Presenting symptoms
      • Time from ingestion (usually only helpful within 1-2 hours)
      • Potential risk to the patient of the interventions that are being considered
    • General guidelines:
      • Protected airway (e.g., patient alert and protecting airway or intubated) is essential prior to initiation of any procedure! GI decontaminatinon should not be pursued if a patient is somnolent.
    • We will discuss two methods for GI decontamination that are often discussed in the literature and were mentioned this morning – activated charcoal and whole bowel irrigation.
    • Activated charcoal
      • Most likely to be of benefit within 1 hour of poison ingestion
        • Absorption is decreased by up to 95% if given within 5 minutes and up to 50-75% if given within one hour
      • Activated charcoal should not be used in the following situations:
        • Nontoxic ingestions
        • Patients who present after a time period when poison absorption is considered complete (e.g., typically > 2 hours after ingestions)
        • Agents that are not bound by activated charcoal (see attached PPT slide)
        • Patients who are at increased risk of aspiration (e.g., due to mental status, intestinal obstruction = absolute contraindication, decreased peristalsis = relative contraindication)
      • Adverse effects
        • Aspiration is the most common concern that clinicians cite when choosing not to administer activated charcoal, however, overall the rate of aspiration is thought to be < 1 percent (from observational studies and retrospective chart reviews).
    • Whole bowel irrigation
      • Thought to be helpful in the following situations:
        • Toxic ingestions of sustained-release or enteric coated pill formulations – if started within 2 hours
        • Significant ingestions of toxins not adsorbed by activated charcoal (e.g., iron, lead)
        • Ingestions of illicit drugs
      • Contraindications:
        • Ileus, bowel obstruction, or intestinal perforation
        • GI hemorrhage
        • Hemodynamic instability
        • Intractable emesis

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