Gastric Lavage and Activated Charcoal Application

by Elif Dilek Cakal

Case Presentation

A 22-year old female presented to the emergency department 15 minutes after she had committed suicide by taking 30 pills of 500 mg acetaminophen. She had no known chronic diseases. Her blood pressure was 134/87 mmHg; temperature, 36.4°C; heart rate of 70 bpm and regular; respiration 15 bpm; and O2 saturation 99%. At the time of arrival, she was asymptomatic. Nothing was remarkable on examination. Gastric lavage was performed. 1 mg/kg of activated charcoal was given to the patient. IV N-acetylcysteine treatment was started. She was admitted to the hospital.

Gastric Lavage Procedure

Emergency Indications

Gastric Lavage (GL) should not be undertaken routinely. Whether gastric lavage positively alters the morbidity or mortality of the poisoned patient, even applied shortly after the intake, is controversial. GL is indicated only if:

  • Oral intake < 60 minutes
  • The life-threatening dose of the toxic substance is ingested

Contraindications

  • Patients with compromised airway reflexes, unless they are intubated. If the critical situation of the patient indicates intubation, then, gastric lavage may be performed. Intubation, only for decontamination, is not recommended.
  • Non-toxic or non-life-threatening intoxications.
  • Hydrocarbons intake (unless containing highly toxic substances such as pesticides).
  • Oral intake of caustic substances.
  • Poisonings with toxic substances; those are more toxic to lungs than to gastrointestinal system.
  • Poisonings with pills that are known not to fit through the holes of the gastric tube
  • Known esophageal structures.
  • History of gastric bypass surgery.

Emergency Physician (EP) must be cautious in combative patients and patients with medical conditions such as bleeding disorders.

Equipment and Patient Preparation

Equipment for GL includes:

  • Intravenous access and monitoring
  • A large suction catheter
  • Local analgesics and lubricants
  • Intubation equipment
  • Sedatives (if necessary)
  • Restraints (if necessary)
  • Bite block or oral airway
  • Oral or nasogastric tubes
    • 36- to 40-French or 30 English-gauge tubes in adults (oral)
    • 24- to 28- French-gauge in children (oral)
  • Lavage systems
    • Commercially available
    • Intermittent aliquots of lavage fluid can be given and withdrawn manually
  • Activated charcoal (see below)
  • Normal saline or water

Before starting, the steps of the procedure must be explained to patients in an attempt to gain cooperation. If the patient is too agitated, sedatives in anxiolytic doses may be used. EP must keep in mind that significantly altered level of consciousness due to sedation warrants intubation.

Although there is no adequate data in humans to show that tube diameter or route is important, the oral route is primarily preferred for the gastric lavage. Nasogastric tubes are less traumatic for patients and are preferred in liquid ingestions and children.

Place all patients in the left lateral decubitus position in Trendelenburg to facilitate the content removal and to decrease the aspiration risk. Supine position greatly increases aspiration risk, unless the patient is intubated.

The tube must be measured from the corner of the mouth to the mid-epigastrium in order to avoid kinking and complications.

Procedure Steps

A video explaining the steps of the insertion of the gastric tube

  1. Explain the procedure to the patient.
  2. Collect the equipment and place the patient in the left lateral decubitus position.
  3. Put a bite block or oral airway into the patient’s mouth.
  4. Introduce to pass the tube gently
  5. When the pharynx is reached, put the patient’s chin on the chest to facilitate passage of the tube into the esophagus.
  6. Confirm the placement
  7. Aspirate and remove the gastric contents before gastric irrigation
  8. Repeatedly introduce 200–300 mL of lavage solution (10 mL/kg body weight in children up to a maximum of 300 mL) into the stomach and then remove them
  9. Continue lavage until the fluid becomes clear
  10. Administer activated charcoal via tube
  11. Clamp off and remove the tube

Hints and Pitfalls

  • The procedure is intended to be therapeutic, not punitive.
  • In some situations, Gastric lavage may be helpful for up to 2 hours:
    • Highly toxic drugs
    • Drugs not absorbed by activated charcoal
    • Sustained release or enteric-coated products
  • Auscultation of the stomach generally confirms the placement of the tube during injection of air with a 50-mL syringe and aspiration of gastric contents. Radiographic confirmation should be considered, especially in children and intubated patients.
  • A cough, stridor, or cyanosis indicates that the tube has entered the trachea; withdraw the tube immediately and reattempt passage.

Post Procedure Care and Recommendations

  • For most patients, a short period of observation of vital signs is adequate.
  • The nature of the poisoning will lead the management.

Complications

GL is generally safe but not harmless.

Complications of GL include:

  • Misplacement of the gastric tube into the trachea.
  • Pulmonary aspiration of gastric content of lavage fluid, especially in patients with compromised airway reflexes.
  • Aspiration pneumonia.
  • Laryngospasm and hypoxia, especially in patients with lung diseases.
  • Esophageal lacerations or perforation.
  • Gastric perforation.
  • Fluid and electrolyte disturbances, especially in children.
  • Hypothermia.
  • Nasal, oral, pharyngeal, pyriform sinus injuries.
  • Pulmonary hemorrhage, pneumothorax, and empyema.

Pediatric, Geriatric, and Pregnant Patient Considerations

  • Gastric lavage is always a difficult procedure to apply to children. Nasogastric tubes may be preferred. 10 mL/kg aliquots of lavage solution up to a maximum of 300 mL is given and removed. Because electrolyte disturbance has occurred in children who were lavage with tap water, prewarmed (45°C) normal saline is generally recommended for children.
  • Elderly patients are susceptible to cardiac consequences of both procedure and the poisoning; therefore, their vital signs should be monitored closely.
  • Gastric lavage and activated charcoal are considered safe for pregnant patients. Poisonings that are toxic to the fetus as well as toxic to mother must be considered.

Activated Charcoal Application

Emergency Indications

  • Oral intake < 60 minutes
  • the life-threatening dose of the toxic substance

Multi-Dose Activated Charcoal (MDAC) Indications

  • Life-Threatening Oral Intake of
    • Carbamazepine
    • Dapsone
    • Phenobarbital
    • Quinine
    • Theophylline

Contraindications

  • For patients with compromised airway reflexes, unless they are intubated. If the critical situation of the patient indicates intubation, then, gastric lavage may be performed. Intubation, only for decontamination, is not recommended.
  • Oral intake of caustic substances
  • Late presentation
  • Increased risk and severity of aspiration associated with AC use (e.g., hydrocarbon ingestion)
  • Need for endoscopy (e.g., significant caustic ingestion)
  • Toxins poorly adsorbed by AC (e.g., metals including iron and lithium, alkali, mineral acids, alcohols)
  • Presence of intestinal obstruction (absolute contraindication) or concern for decreased peristalsis (relative contraindication)

Equipment and Patient Preparation

There is no specific equipment for activated charcoal administration. However, drinking the charcoal can be very unpleasant for many patients, especially children. Therefore, mixing with fruit juice can be an option. In addition, if necessary nasogastric or orogastric tube placement can facilitate the active charcoal treatment.Procedure Steps

Procedure Steps

  • Recommended empirical single-dose of activated charcoal is as follows:
    • <1 year – 0.5-1 g/kg or 10-25 g
    • 1-12 years – 0.5-1 g/kg or 25-50 g
    • >12 years – 1-2 g/kg or 25-100 g
By James Heilman, MD [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], from Wikimedia Commons
By James Heilman, MD [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], from Wikimedia Commons
  • Multidose activated charcoal
    • Give the recurrent dose of charcoal by 0.5 g/kg (≤50 g) every 4 hours
  • How to administer:
    • If the patient is awake and cooperative, AC may be given orally. Alternatively, it may be given by gastric or nasogastric tube, if these procedures are indicated.
    • Mixing the activated charcoal with fruit juices increases tolerability.
    • If the patient is unconscious or airway is compromised, gastric lavage should be done, and activated charcoal should be given after intubation. Tracheal intubation is not recommended solely in order to give activated charcoal. Only activated charcoal is to be given, the nasogastric tube is adequate and is preferred.
    • If MDAC is indicated, the gastric tube should be withdrawn after gastric lavage and the first dose of activated charcoal. Further doses should be given via nasogastric tube.

Hints and Pitfalls

  • The substances that cannot bind to activated charcoal are as follows:
    • Lithium
    • Strong acids and bases
    • Metals and inorganic minerals
    • Alcohols
    • Hydrocarbons
  • Multi-dose activated charcoal enhances elimination of (But not necessarily indicated in all)
    • Amitriptyline
    • Aspirin
    • Caffeine
    • Carbamazepine
    • Cyclosporine
    • Dapsone
    • Digoxin
    • Disopyramide
    • Nadolol
    • Phenobarbital
    • Phenytoin
    • Piroxicam
    • Quinine
    • Sotalol
    • Sustained-release thallium
    • Theophylline
    • Valproate
    • Vancomycin
  • MDAC increase the risk of constipation and bowel obstruction in some cases. Therefore, consider adding a cathartic agent to the second or third dose of AC.

Post Procedure Care and Recommendations

  • Control possible nausea and vomiting.
  • Look for traces of aspiration or gastrointestinal complications.

Complications

Complications of AC and MDAC include:

  • Constipation, diarrhea, vomiting
  • Pulmonary aspiration

Pediatric, Geriatric, and Pregnant Patient Considerations

  • In pediatric and geriatric patients, extra caution should be exercised to avoid and monitor complications.
  • Activated charcoal is considered safe for pregnant women.

References and Further Reading

  • American Academy of Clinical Toxicology and European Association of Poisons Centers and Clinical Toxicologists. Position Statement: Gastric Lavage. J Toxicol Clin Toxicol 1997; 35:711–719.
  • Vale JA, Kulig K. Position paper: gastric lavage. J Toxicol Clin Toxi- col 2004; 42:933–943.
  • Merigian KS, Woodard M, Hedges JR, Roberts JR, Stuebing R, Rashkin MC. Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990; 8:479–483.
  • Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985; 14:562–567.
  • Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW. Gastric emptying in acute overdose: a prospective randomized controlled trial. Med J Aust 1995; 163:345–349.
  • Holstege CP, Meekins PE. Decontamination of the Poisoned Patient. In: Roberts JR, Hedges JR, editors. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Elsevier; 2010: 760-772.
  • Ozkan S. Gastrointestinal Dekontaminasyon. In: Acilde Klinik Toksikoloji. Satar S, editor. Adana: Nobel; 2009:89-93.
  • https://www.youtube.com/watch?v=bCWrRMIDJNU&feature=youtu.be accessed at 01.06.2016.
  • Holstege CP, Meekins PE. Decontamination of the Poisoned Patient. In: Roberts JR, Hedges JR, editors. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Elsevier; 2010: 760-772.
  • Akdur O. Aktif Komur. In: Acilde Klinik Toksikoloji. Satar S, editor. Adana: Nobel; 2009:95-99.