Emergency department physicians commonly see poisoned children who may need gastrointestinal decontamination. In 2006, 62.5% of poisoned patients who presented to a health care facility received some sort of decontamination.¹ A brief review of the pathophysiology of each of the methods of gastrointestinal decontamination is presented in this section.

Single-dose activated charcoal (SDAC) was the most common method of gastrointestinal decontamination used in poisoned patients in 2006 (9% of decontaminated patients).¹ The goals of activated charcoal are to prevent systemic absorption of toxic agents from the GI tract and to enhance elimination of toxic agents already absorbed.¹¹ Its use for the adsorption of ingested poisons became common in the 1960s, but its use for medicinal purposes was documented as early as 1500 BC.¹⁰ Ancient Egyptians used it to adsorb odor from rotting wounds. Other historical uses for charcoal include the purification of drinking water, treatment of epilepsy, and adsorbtion of toxic gases. Perhaps the most dramatic demonstration of its ability to adsorb ingested toxins occurred in 1831 when a pharmacist named Touery ingested a lethal dose of strych9 along with charcoal in front of a meeting of the French Academy and survived.¹⁰ Charcoal is made by the pyrolysis of wood or other carbonaceous material and activated by heating at high temperatures (600°C-900°C or 1112°F-1652°F.) This gives activated charcoal a complex pore structure with a surface area of 1000 to 2000 m2/g that allows it to adsorb poisons.¹¹ Activated charcoal is usually mixed with water and may contain preservatives, sorbitol, or other flavorings.⁴ To be effective, it must come in direct contact with the poison. It is commonly given in liquid form orally or via nasogastric tube. When given in multiple doses, it may enhance the elimination of certain drugs or toxins by interrupting the enteroenteric or enterohepatic circulation of the drug.^4,5

Gastric lavage was the next most common method of gastrointestinal decontamination used in 2006 (0.8% of decontaminated patients).¹ This method of decontamination aims to prevent the absorption of toxic substances by directly removing ingested particles from the stomach. It was first used in the U.S. in 1812 by a surgeon who used a lavage solution of brandy and water to decontaminate twin toddlers given toxic amounts of tincture of opium for pertussis.¹² It is accomplished by the sequential administration and aspiration of small fluid volumes via a large bore orogastric tube.⁶ However, the large caliber of orogastric tubes used with current gastric evacuation systems may preclude its use in the small child.

Whole bowel irrigation (WBI) was used infrequently to decontaminate poisoned patients in 2006 (0.2%).¹ WBI utilizes an osmotically balanced solution to physically expel the contents of the gastrointestinal tract from the body before absorption of toxins can occur.⁷

Despite the fact that it is no longer recommended by the AAP or AACT, syrup of ipecac was used infrequently for gastrointestinal decontamination in 2006 (0.2%).¹ It was approved by the Food and Drug Administration (FDA) for over-the-counter sale in 1965 and was used widely by pediatricians and poison centers in the following years.³ Syrup of ipecac was traditionally recommended by poison centers for 2 purposes — to start gastric emptying early and to keep patients from having to visit a health care facility.³ It is a liquid containing the alkaloids emetine and cephaeline, which induce vomiting through irritation of the GI mucosa and stimulation of the medullary chemoreceptor zone in the brain.^3,9 In 1983, the AAP Committee on Injury and Poison Prevention officially recommended that parents keep a bottle of syrup of ipecac in the home.² Its use peaked in 1985, when it was used in 15% of toxic exposures.¹ However, its effectiveness and safety have been questioned over the past 10 to 15 years. In 1997, when the AACT position statement on ipecac syrup stated that it “should not be administered routinely in the management of poisoned patients,” it was used in 1.5% of exposures, and its use has declined steadily since then.¹ In its 2003 policy statement on poison treatment in the home, the AAP joined the AACT and the AAPCC and went further to say that “ipecac should no longer be used routinely as a home treatment strategy [and that] existing ipecac in the home should be disposed of safely.”² Table 1 lists the most common substances involved in toxic exposures.

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