Skip to main content
PMC home page
The BMJ logoLink to The BMJ
. 2000 Mar 11;320(7236):711.

Managing self poisoning

Gastric lavage is perhaps more important in developing countries

Madhur Dev Bhattarai 1
PMCID: PMC1117718  PMID: 10710589

Editor—In their clinical review of recent advances in the management of self poisoning, Jones and Volans briefly discuss gastric lavage and state: “many clinical toxicologists rarely use this method now.”1 The impression given could support the abandonment of gastric lavage. This could be particularly deleterious in developing countries.

In developing countries, poisons consumed are commonly toxins such as organophosphorus compounds and aluminium phosphide, and thus mortality is high. The organophosphorus compounds are usually consumed in liquid form. In such cases of poisoning, prevention of absorption of even a small amount may make a considerable difference. Furthermore, antidotes to poisons and intensive care may not be available. Any intervention, such as gastric lavage, which can be carried out easily cannot be neglected. The value of gastric lavage depends on the amount, toxicity, and effect of the poison and the time since consumption. Its role in certain cases should have been highlighted.

References

BMJ. 2000 Mar 11;320(7236):711.

Common sense makes no sense

Dilip DaCruz 1

Editor—Although Jones and Volans's article updating doctors on the management of poisoning is welcome and informative, I was a little bemused by the contradictions in it.1-1

We are told that gastric lavage should not be used unless two criteria are met: it should be used within an hour of ingestion of the poison, and the amount of toxin should be substantial. Though these criteria are repeated often in the literature there is no evidence to support either of them. The literature indicates only that there is no difference in outcome when gastric lavage is used. But Jones and Volans—like the authors of the papers quoted—give way to that devil, common sense.

It makes sense to try to remove a toxin before it is absorbed; therefore, when the poisoning may be serious, scrap the evidence, go for common sense, and do a gastric lavage. How, in real life, we are accurately to determine the time of ingestion and amount of toxin ingested in a group of patients who are notoriously unreliable is a moot point.

We see the same reversion to common sense in Jones and Volans' update on carbon monoxide poisoning. The most rapid way to displace and eliminate carbon monoxide is to use hyperbaric oxygen—there is no doubt about this fact in the literature. But if we are informed that the usefulness of hyperbaric oxygen is far from proved then surely we must consider it seriously in all patients on the grounds of common sense, or we must not use it at all on the grounds of evidence. Incidentally, there is no evidence showing selective benefit in those patients who have been obtunded, and to preach such a qualification is unjustified.

I welcome evidence based medicine wholeheartedly but can't help smiling when I encounter authorities making clearcut recommendations ... up to a point—the point after which they get cold feet.

References

BMJ. 2000 Mar 11;320(7236):711.

Guidelines for accident and emergency departments are needed

Mehmood Chaudhry 1,2, Rakesh Khanna 1,2

Editor—In their review on the management of self poisoning Jones and Volans suggest that decontaminating the gut by gastric lavage or administration of activated charcoal be carried out within one hour of ingestion of the toxin.2-1 In practice, however, it is rare for such patients to present at an accident and emergency department and to be assessed within one hour of ingestion. There are many reasons for this, including patients' delay in seeking help, transportation time to hospital, and triage category. The average time from receipt of an emergency call to arrival at hospital is 38 minutes for all patients in the West Midlands area (S Edwards, West Midlands Ambulance Service, personal communication). Additionally, the standard UK triage system assigns asymptomatic poisonings to category 3 (to be seen within one hour of arrival).2-2

As similar recommendations on time since ingestion have already been implemented in many accident and emergency departments, gastric lavage is now seldom performed. With this loss of training opportunity for new staff, the skills needed to perform the procedure safely may be lost, with the result that it may not be performed in the few patients in whom it remains indicated.

Clearly, the sooner activated charcoal is given the better. It has been given successfully in the prehospital setting.2-3 This is probably the best way, and in many cases the only way, of administering it in the one hour time frame that clinical toxicologists recommend.

Although the authors suggest a carboxyhaemoglobin level of >40% as an indication for hyperbaric oxygen therapy, another recent review has suggested a much lower (>20%) level as an indication for this therapy.2-4

Unlike other authors,2-4,2-5 Jones and Volans do not include pregnancy as a special indication for hyperbaric oxygen therapy. The fact that two recent publications in journals from the BMJ Publishing Group should give different recommendations for managing important aspects of such a common problem illustrates the divergence of opinion in this area and the problems faced by accident and emergency staff while making decisions.2-1,2-4

These issues need to be clarified, and consensus guidelines relevant to the realities in accident and emergency departments need to be drawn up. This should ideally be done by a joint working party of UK toxicologists, prehospital care providers, hyperbaric therapy clinicians, and accident and emergency clinicians.

References

  • 2-1.Jones AL, Volans G. Management of self poisoning. BMJ. 1999;319:1414–1417. doi: 10.1136/bmj.319.7222.1414. . (27 November.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Mackway-Jones K, editor. Emergency triage. London: BMJ Publishing Group; 1997. [Google Scholar]
  • 2-3.Allison TB, Gough JE, Brown LH, Thomas SH. Potential time savings by prehospital administration of activated charcoal. Prehosp Emerg Care. 1997;1:73–75. doi: 10.1080/10903129708958791. [DOI] [PubMed] [Google Scholar]
  • 2-4.Turner M, Hamilton-Farrell MR, Clark RJ. Carbon monoxide poisoning: an update. J Accid Emerg Med. 1999;16:96–98. doi: 10.1136/emj.16.2.92. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-5.Ernst A, Zibark JD. Carbon monoxide poisoning. N Engl J Med. 1998;339:1603–1608. doi: 10.1056/NEJM199811263392206. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Mar 11;320(7236):711.

Indications for the use of whole bowel irrigation are weak

Michael Trimble 1

Editor—I was surprised to see in Jones and Volans' review of management of self poisoning the headline advice that when a potentially lethal amount of a drug is not adsorbed by activated charcoal, whole bowel irrigation with polyethylene glycol solution is recommended.3-1

One of the references cited is the American Academy of Clinical Toxicologists/European Association of Poisons Centres and Clinical Toxicologists' position statement on whole bowel irrigation. The position statement represents a thorough review of the literature and appraisal of the data concerning whole bowel irrigation (WBI) and states: “There are no established indications for the use of WBI.... The use of WBI for the removal of ingested packets of illicit drugs and in the management of patients who have ingested substantial amounts of poisons not adsorbed to activated charcoal is also of theoretical benefit.”3-2 This seems a weak foundation for such a strong recommendation of a procedure that is not without complications.

References

  • 3-1.Jones AL, Volans G. Management of self poisoning. BMJ. 1999;319:1414–1417. doi: 10.1136/bmj.319.7222.1414. . (27 November.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.American Academy of Clinical Toxicologists and European Association of Poisons Centres and Clinical Toxicologists. Position statement: whole bowel irrigation. J Clin Toxicol. 1997;35:753–762. doi: 10.3109/15563659709162571. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Mar 11;320(7236):711.

Body packers need careful treatment

John Hollingsworth 1,2, Robin Jones 1,2

Editor—We support most of Jones and Volans' recommendations concerning the management of self poisoning, which have been reached using an evidence based approach.4-1 However, we think that their suggestions for managing self poisoning among drug couriers who have ingested packets of drugs (body packers) are based on anecdotal case histories and contradict most of the published literature. Some of these suggestions may be dangerous.

Methods of drug smuggling are becoming increasingly sophisticated, which has led to the development of packaging that is more tolerant of gastrointestinal transit. Breakdown of packages is now thought to be relatively rare. Most authors therefore recommend a conservative approach to body packers who have no symptoms.4-2

Although there are reports of success, we do not recommend endoscopic removal of packages from the stomach or colon owing to the considerable danger of perforation on capture. With the average package of cocaine containing 10 times the median lethal dose, perforation is likely to be fatal.

The use of whole bowel irrigation and laxatives is more controversial and needs more controlled research. However, Caruana et al report a series of 50 patients treated with mineral oil without a single instance of a package degrading.4-3 Visser et al cast doubt on the use of mineral oil in their report of a single case, but their patient had shown signs of cocaine toxicity before the oil was given, which suggests that the packet was already starting to degrade.4-4

In conclusion, we recommend a conservative approach to treating body packers with no symptoms. Endoscopy is contraindicated and surgery should be reserved for those with delayed transit, bowel obstruction, or signs of toxicity or passage of damaged packages.

References

  • 4-1.Jones LJ, Volans G. Management of self poisoning. BMJ. 1999;319:1414–1417. doi: 10.1136/bmj.319.7222.1414. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-2.Glass JM, Scott HJ. “Surgical mules": the smuggling of drugs in the gastrointestinal tract. J R Soc Med. 1995;88:450–453. [PMC free article] [PubMed] [Google Scholar]
  • 4-3.Caruana DS, Weinbach B, Goerg D, Gardner LB. Cocaine packet ingestion: diagnosis, management and natural history. Ann Intern Med. 1984;100:73–74. doi: 10.7326/0003-4819-100-1-73. [DOI] [PubMed] [Google Scholar]
  • 4-4.Visser L, Stricker B, Hoogendoorn M, Vinks A. Do not give paraffin to packers. Lancet. 1998;352:1352. doi: 10.1016/S0140-6736(98)08302-0. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Mar 11;320(7236):711.

Poisons database is still not on the NHS net

R Harris 1

Editor—A couple of points about Jones and Volans' clinical review.5-1 Firstly, ketamine is not just a veterinary anaesthetic but is still available in most operating theatres.

Secondly, it is appalling that a poisons database is still not on the NHS net (but then again, what is; not even the British National Formulary). Why is so much spent on setting up the NHS net and so little of practical value put on it?

References

BMJ. 2000 Mar 11;320(7236):711.

Authors' reply

Alison L Jones 1, Glyn Volans 1

Editor—We agree with Bhattarai that the evidence on which the European and American guidelines have been created is largely from more developed countries and involves overdoses of pharmaceutical agents. However, it is probable, given the number of studies to date, that gastric lavage is unlikely to be of established value beyond one hour after ingestion of a variety of agents. When it is carried out too late, the stomach contents may have passed into the small bowel and gastric lavage would not be expected to retrieve such material, except if gastric emptying were in some way delayed. In addition, gastric lavage can actually push the gastric contents beyond the pylorus, which enhances absorption.6-1 We must remain vigilant to the possibility of exceptions, but, from our experience in Nepal with the World Health Organization, we would not recommend using gastric lavage with water for aluminium or zinc phosphate poisoning, as contact with water liberates phosphine gas, which is a potent respiratory toxin. Gastric lavage with vegetable oil is preferred under such circumstances.

Chaudhry and Khanna make practical points about the implications of the new guidelines for decontamination in accident and emergency departments. As the evidence for the efficacy of gastric lavage and activated charcoal is only for its use within an hour, it is important that such patients are triaged rapidly. If a considerable delay in transit to hospital is anticipated, general practitioners may be best placed to give activated charcoal, providing the patient is not too drowsy or at risk of fits.6-2

Trimble shows that the evidence on which some recommendations have been made is a few case reports, and randomised controlled clinical trials are often not available. The guidelines are exactly that—guidelines and not protocols. The lack of an evidence base behind the bowel irrigation guidelines may reflect limited experience of the procedure, but it is a potentially important advance in treating patients with overdose of slow release formulations or substances that do not bind to charcoal. We wanted to raise awareness of whole bowel irrigation and to indicate when we, as clinicians, would consider using it in our patients, though clearly more data collection is needed to show efficacy.6-3 Whole bowel irrigation may offer a new conservative approach to treating body packers. Sadly, there are still sudden deaths from packages that rupture, and, as Hollingsworth and Jones point out, the need for removal must be judged by risk assessment. When signs of toxicity are developing, such as cocaine toxicity, the need for urgent removal is pressing and the risk assessment strongly favours removal of the packet.

When our article was submitted to the BMJ, TOXBASE was not available on the internet. It is now available at www.spib.axl.co.uk. We contribute to updating TOXBASE and strongly support its use as a first line in helping to answer poisons inquiries.

References

  • 6-1.Saetta JP, March S, Gaunt ME, Quinton DN. Gastric emptying procedures in the self-poisoned patient: are we forcing gastric content beyond the pylorus? J R Soc Med. 1991;84:274–276. doi: 10.1177/014107689108400510. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6-2.Allison TB, Gough JE, Brown LH, Thomas SH. Potential timesavings by prehospital administration of activated charcoal. Prehosp Emerg Care. 1997;1:73–75. doi: 10.1080/10903129708958791. [DOI] [PubMed] [Google Scholar]
  • 6-3.American Academy of Clinical Toxicologists and European Association of Poisons Centres and Clinical Toxicologists. Position statement: whole bowel irrigation. J Clin Toxicol. 1997;35:735–762. doi: 10.3109/15563659709162571. [DOI] [PubMed] [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES