Module 4: Protocols and Guidelines of GI Decontamination

This module will review the key protocols, position statements, and clinical guidelines that inform best practices for GI decontamination after ingestions. We will cover:

• Overview of consensus guidelines on GI decontamination
• Specific protocols for common toxins and drugs
• Adjunctive therapies and post-decontamination monitoring

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4.1 Overview of Consensus Guidelines on GI Decontamination

Several professional toxicology organizations have published influential position statements and guidelines on the use of GI decontamination methods:

• American Academy of Clinical Toxicology (AACT)
• European Association of Poisons Centres and Clinical Toxicologists (EAPCCT)
• American College of Medical Toxicology (ACMT)

These statements aim to synthesize the evidence and provide recommendations for selective use of GI decontamination. Some key points:

• Routine use of GI decontamination is not recommended after most ingestions. Risks may outweigh benefits.
• However, GI decontamination does have a role in carefully selected patients based on toxin characteristics, amount, time since ingestion, etc.
• Activated charcoal is the preferred method when GI decontamination is indicated.
• Gastric lavage should be restricted to very specific situations of life-threatening ingestion within 1 hour.
• Ipecac is no longer recommended.
• Whole bowel irrigation is reserved for special cases like iron, lithium, or drug packets.

The guidelines also outline contraindications where GI decontamination should be avoided due to aspiration risk, lack of benefit, or safety concerns.

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4.2 Specific Protocols for Common Toxins and Drugs

In addition to the general guidelines above, specific protocols have been developed for GI decontamination in certain high-risk ingestions:

Acetaminophen:

• Activated charcoal 50-100 g in adults or 1 g/kg in children if ingestion of >150 mg/kg and presenting within 2 hours.
• Consider gastric lavage only if ingestion of massive dose and intubation within 1 hour of ingestion.

Iron:

• Do not use activated charcoal.
• Whole bowel irrigation preferred for substantial iron ingestions.

Calcium Channel Blockers:

• Activated charcoal 50-100 g in adults or 1 g/kg in children if presenting within 1 hour.
• Consider gastric lavage for life-threatening ingestion within 1 hour.

Lithium:

• Activated charcoal for acute lithium ingestions.
• Whole bowel irrigation for patients on chronic lithium with acute on chronic ingestion.

Drug Packets (“Body Packers”):

• Whole bowel irrigation preferred to rapidly clear packets.
• Avoid oral activated charcoal due to absorption concerns.
• Consider surgical removal if occlusion, leakage, or perforation occurs.

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4.3 Adjunctive Therapies and Post-Decontamination Monitoring

Other aspects of care following GI decontamination include:

• Administering antiemetics for activated charcoal-induced vomiting
• Electrolyte monitoring after repeated doses of activated charcoal or whole bowel irrigation
• Laxatives or stool softeners if activated charcoal causes constipation
• Observation for delayed toxicity symptoms even after GI decontamination
• Psychiatric assessment in intentional self-poisonings or substance abuse cases

Thorough monitoring and supporting care is essential to ensure proper passage of adsorbed toxins and prevent further absorption or delayed toxicity.