Aug 21, 2017: August 21, 2017 Why Does The Tennessee Poison Control Center Seldom Recommend GI Decontamination?

Recommendations regarding GI decontamination are not consistent between Poison Centers.  With a new academic year, it is always good to review the basis for the recommendations of the TN Poison Center.  Although single dose activated charcoal used to be administered in 70% of ingestions, the national data demonstrates that it is now administered in less than 10% of ingestions. Administration has markedly decreased due to understanding of the significant morbidity from charcoal aspiration. ds 
Things can get confusing when discussing GI Decontamination for patients who have ingested toxins.  After moving to Tennessee, I noted that the poison control center does not usually recommend GI decontamination, which confused the picture even more. Here is what I learned.
Ipecac syrup is no longer recommended for decontamination as clinical studies do not demonstrate a significant reduction in serum drug concentrations after emesis is induced.  With induced vomiting the risk of aspiration is high, increasing the potential for serious secondary complications.  Today, there is no clinical scenario where ipecac syrup is indicated.  
Single dose activated charcoal, administered either by mouth or nasogastric tube, has previously been recommended.   Charcoal does prevent the absorption of some ingested toxins; However, it is now evident that activated charcoal is not as safe as we once thought.  Studies show that aspiration of activated charcoal leads to increased pulmonary microvascular permeability, and can cause both acute and chronic lung disease.  While activated charcoal is not intended to make the patient vomit, it often does.  Aspiration of charcoal may  cause acute respiratory insufficiency and chronically long-term pulmonary sequela where symptoms can mimic reactive airway disease.  In addition more recent studies show that patients receiving single dose activated charcoal do not have better outcomes than those not receiving GI decontamination. Therefore, the most recent literature supports that the risks outweigh the benefits of single dose activated charcoal, making it seldom recommended by the Tennessee Poison Control Center. Cases in which activated charcoal may be recommended include ingestion of a chemotherapeutic agent, or an agent in which a very small amount can cause morbidity/mortality such as the ingestion of colchicine. Please call the Poison Center if you have any questions about GI decontamination. 
This question prepared by Jessica Barnes, Peds Emergency Medicine Fellow  La Boehner Fellowship program

Arnold, Thomas C., et al. “Aspiration of Activated Charcoal Elicits an Increase in Lung Microvascular Permeability.” Journal of Toxicology: Clinical Toxicology, vol. 37, no. 1, 1999, pp. 9–16., doi:10.1081/clt-100102402.

Graff, G. R., et al. “Chronic Lung Disease After Activated Charcoal Aspiration.” Pediatrics, vol. 109, no. 5, Jan. 2002, pp. 959–961., doi:10.1542/peds.109.5.959.

Merigian, Kevin S., and Kari E. Blaho. “Single-Dose Oral Activated Charcoal in the Treatment of the Self-Poisoned Patient: A Prospective, Randomized, Controlled Trial.” American Journal of Therapeutics, vol. 9, no. 4, 2002, pp. 301–308., doi:10.1097/00045391-200207000-00007.

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Donna Seger, MD
Medical Director
Tennessee Poison Center
Poison Help Hotline: 1-800-222-1222