Decontamination

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Related FACEM curriculum (2022) learning objectives:

• ME 3.8.1.6(c) Principles of management of toxicological presentations including: Indications for decontamination
• ME 3.8.2.5 Identify patients requiring decontamination.

• Aimed at reducing absorbed dose of toxins to mitigate clinical toxicity.
• Methods include:
  • Induced emesis (syrup of ipecac)
  • Gastric lavage
  • Activated charcoal
  • Whole bowel irrigation
• No longer routine for self-poisoned patients due to limited benefits and risks.
• Requires clinical judgement to balance risks, benefits, and resources.

General Considerations

• Reserved for life-threatening toxicity unresponsive to supportive care or antidotes.
• Requires knowledge of toxin absorption kinetics (most toxins absorbed within 1 hour).
• Contraindicated if resuscitation or airway protection is incomplete.

Induced Emesis (Syrup of Ipecac)

• Induces vomiting via central and peripheral mechanisms; onset ~18 mins.
• Largely abandoned; negligible toxin removal after 1 hour.

Technique

• Dose: 15 mL (children), 15–30 mL (adults) with water.
• Repeat if no vomiting within 30 minutes.

Contraindications

• Non-toxic ingestion, sub-toxic doses, infants <12 months.
• Decreased consciousness, seizures, corrosive or hydrocarbon ingestion.

Complications

• Prolonged vomiting (10–20%), diarrhoea (20–30%), aspiration, rare physical injuries.

Gastric Lavage

• Removes gastric contents via sequential fluid administration and aspiration.
• Ineffective >1 hour post-ingestion; rarely indicated.

Technique

• Performed in resuscitation bay; airway must be protected.
• Patient positioned left decubitus, 20° head down.
• Large-bore tube (36–40G) passed gently, confirming placement.
• Administer and aspirate 200 mL warm water/saline until clear effluent.

Contraindications

• Incomplete resuscitation, unprotected airway, corrosive or hydrocarbon ingestion.

Complications

• Pulmonary aspiration, hypoxia, laryngospasm, water intoxication, hypothermia.

Single-Dose Activated Charcoal (SDAC)

• Adsorbs toxins, reducing further absorption.
• Most effective within 4 hours, especially immediate administration.
• Indicated for severe poisoning where toxins remain in the GI tract.

Technique

• Dose: 50 g (adults), 1 g/kg (children), orally or via nasogastric tube.
• May mix with ice cream for children.
• Intubation required for uncooperative or unconscious patients.

Contraindications

• Non-toxic ingestion, agents not bound to AC (e.g., metals, hydrocarbons).
• Decreased consciousness without intubation.

Complications

• Aspiration, impaired antidote absorption, corneal abrasions, staff distraction.

Whole Bowel Irrigation (WBI)

• Cleanses bowel using polyethylene glycol-electrolyte solution (PEG-ELS).
• Reserved for life-threatening ingestions unresponsive to other treatments.

Indications

• Iron >60 mg/kg, slow-release potassium chloride >2.5 mmol/kg, arsenic, lead.
• "Body packers" with ingested drug packets.

Technique

• Continuous PEG-ELS infusion: 2 L/hour (adults), 25 mL/kg/hour (children).
• Administer metoclopramide to reduce vomiting.
• Continue until effluent is clear (~6 hours).

Contraindications

• Ileus, intestinal obstruction, uncooperative patients, intubated/ventilated patients.

Complications

• Nausea, abdominal bloating, pulmonary aspiration, non-anion gap metabolic acidosis.