Module 6: Summary of GI Decontamination

This final module provides a high-level review of the key concepts and clinical applications of gastrointestinal (GI) decontamination strategies covered throughout the course.

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6.1 Key Takeaways on the Selective Use of GI Decontamination

• GI decontamination aims to limit systemic absorption and enhance elimination of toxins from the GI tract. However, no particular method is universally preferred and must be tailored to the specific clinical scenario.
• Activated charcoal adsorbs toxins in the GI tract and can be administered as a single dose or multiple doses. It is most effective within 1 hour of ingestion but may have some benefit even hours later in massive ingestions. Dosing is 1 g/kg up to 100 g in adults and 0.5-1 g/kg in children.
• Gastric lavage involves irrigating the stomach with water or saline and can retrieve tablets/capsules. It should only be used within 1 hour of ingestion for substantial, life-threatening ingestions when charcoal is inadequate. Risks include aspiration, fluid/electrolyte shifts, and perforation.
• Whole bowel irrigation with polyethylene glycol solution mechanically cleanses the entire GI tract but has limited evidence. It can be used for iron, lithium, or illicit drug packet ingestions when charcoal is ineffective.
• Ipecac syrup is no longer recommended to induce vomiting due to lack of proven benefit and risks of aspiration. Similarly, cathartics alone provide no clinical advantage.
• Contraindications for GI decontamination include inability to protect airway, bowel obstruction/perforation, caustic ingestion, and need for endoscopic visualization. Decontamination is avoided in many mild to moderate ingestions.
• Position statements provide guidelines for weighing risks versus benefits of GI decontamination based on limited clinical evidence. Protocols exist for specific toxins but allow flexibility based on clinical judgment.

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6.2 Areas for Further Learning

• Optimize utilization of GI decontamination guided by institutional protocols and consultations with poison control experts.
• Understand the pharmacokinetic properties, formulation, and toxic dose of the ingested substance. This informs decisions on the need for GI decontamination.
• Recognize the practical challenges of administering GI decontamination, such as charcoal palatability, achieving adequate charcoal ratios, proper lavage technique, and patient acceptance of whole bowel irrigation.
• Consider the risks of pulmonary aspiration based on the patient’s mental status and airway protective reflexes before pursuing gastric decontamination.
• Investigate the evidence for enhanced elimination techniques like multiple-dose charcoal, urinary alkalinization, and extracorporeal removal for specific toxins.
• Stay up to date on position statements and guidelines as new clinical evidence emerges for the risks versus benefits of GI decontamination modalities.

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6.3 References

• Chyka PA, Seger D, Krenzelok EP, Vale JA. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila). 2005 Jan;43(2):61-87.
• Engebretsen KM, Kaczmarek KM, Morgan J, Holger JS. High-risk ingestions in pediatric patients. Pediatr Clin North Am. 2015 Apr;62(2):375-98.
• Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015 Jan;53(1):5-12.
• Yu ZF, Tian Y, Wang YY, Chen M, Fan CQ, Cao ZJ, Dong ZQ. The role of gastrointestinal decontamination for acute yellow oleander poisoning. Clin Toxicol (Phila). 2009 Apr;47(4):203-10.
• Benson BE, Hoppu K, Troutman WG, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013 Mar;51(3):140-6.
• Chapman SB, Aks SE. Clinical controversies in ED toxicology: Routine GI decontamination has too many risks and few benefits. Am J Emerg Med. 2016 Feb;34(2):302-4.

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6.4 Cited Guidelines and Protocols

Throughout this course, we have referenced several key guidelines and protocols that provide foundational knowledge and guidance on the use of gastrointestinal decontamination. Here, we provide a summary and links to these resources for your ongoing reference.

1. The American Academy of Clinical Toxicology (AACT) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT): These organizations have jointly issued a series of position statements on the use of various GI decontamination strategies, including activated charcoal, gastric lavage, and whole bowel irrigation. These documents provide comprehensive reviews of the available evidence and clear recommendations for clinical practice.
   • Position statement: single-dose activated charcoal
   • Position paper: gastric lavage
   • Position paper: whole bowel irrigation
2. The American Association of Poison Control Centers (AAPCC): The AAPCC maintains up-to-date guidelines on the management of poisonings, including the use of GI decontamination. These guidelines are available to all member poison control centers.
   • AAPCC Guidelines
3. The World Health Organization (WHO): The WHO publishes a series of handbooks on poison management, which include chapters on GI decontamination. These resources are particularly useful for understanding the global context of poisoning and its management.
   • Handbook of Poisoning: Prevention, Diagnosis and Treatment
4. The United States Food and Drug Administration (FDA): The FDA provides guidelines on the safe and effective use of ipecac syrup for home use, which offer valuable insights into the risks and benefits of this GI decontamination method.
   • FDA Guidelines on Ipecac Syrup

Remember that guidelines and protocols are subject to change as new evidence emerges, and it is important to regularly check these resources to ensure that your practice is aligned with the most current recommendations.