Method of gut decontamination
Date First Published:
July 5, 2005
Last Updated:
July 14, 2005
Report by:
Fawad Azam, Medical student (MRI)
Three-Part Question:
In [Tricyclic antidepressant overdose] which [method of gastric decontamination] is better at [reducing toxicity and improving clinical outcome]
Clinical Scenario:
A 28 year old male dentist presents to the emergency department following a suspected Amitriptyline overdose. You remember that tricyclic antidepressants delay gastric emptying and wonder whether gastric lavage or activated charcoal would be of benefit
Search Strategy:
MEDLINE 1966-June Week 4 2005 OVID Interface
EMBASE 1980 to 2005 Week 27 OVID Interface
EMBASE 1980 to 2005 Week 27 OVID Interface
Search Details:
Medline:[{exp ANTIDEPRESSIVE AGENTS, TRICYCLIC OR tricyclic.mp. OR amitriptyline.mp. OR exp AMITRIPTYLINE OR desipramine.mp. OR exp DESIPRAMINE OR clomipramine.mp. OR exp CLOMIPRAMINE OR doxepin.mp. OR exp DOXEPIN OR dothiepin.mp. OR exp DOTHIEPIN OR imipramine.mp. OR exp IMIPRAMINE OR lofepramine.mp. OR exp LOFEPRAMINE OR nortriptyline.mp. OR exp NORTRIPTYLINE OR trimipramine.mp. OR exp TRIMIPRAMINE} AND {overdose.mp. OR exp OVERDOSE OR exp POISONING} AND {gastric lavage.mp. OR exp Gastric Lavage OR irrigation.mp. OR exp IRRIGATION OR lavage.mp. OR exp Decontamination OR gastric decontamination.mp OR washout.mp OR gut decontamination.mp} AND {charcoal.mp. OR CHARCOAL} LIMIT to English Language and Humans
Embase:Medline:[{exp ANTIDEPRESSIVE AGENTS, TRICYCLIC OR tricyclic.mp. OR amitriptyline.mp. OR exp AMITRIPTYLINE OR desipramine.mp. OR exp DESIPRAMINE OR clomipramine.mp. OR exp CLOMIPRAMINE OR doxepin.mp. OR exp DOXEPIN OR dothiepin.mp. OR exp DOTHIEPIN OR imipramine.mp. OR exp IMIPRAMINE OR lofepramine.mp. OR exp LOFEPRAMINE OR nortriptyline.mp. OR exp NORTRIPTYLINE OR trimipramine.mp. OR exp TRIMIPRAMINE} AND {overdose.mp. OR exp OVERDOSE OR exp POISONING} AND {gastric lavage.mp. OR exp Gastric Lavage OR irrigation.mp. OR exp IRRIGATION OR lavage.mp. OR exp Decontamination OR gastric decontamination.mp OR washout.mp OR gut decontamination.mp} AND {charcoal.mp. OR CHARCOAL} LIMIT to English Language and Humans
Embase:Medline:[{exp ANTIDEPRESSIVE AGENTS, TRICYCLIC OR tricyclic.mp. OR amitriptyline.mp. OR exp AMITRIPTYLINE OR desipramine.mp. OR exp DESIPRAMINE OR clomipramine.mp. OR exp CLOMIPRAMINE OR doxepin.mp. OR exp DOXEPIN OR dothiepin.mp. OR exp DOTHIEPIN OR imipramine.mp. OR exp IMIPRAMINE OR lofepramine.mp. OR exp LOFEPRAMINE OR nortriptyline.mp. OR exp NORTRIPTYLINE OR trimipramine.mp. OR exp TRIMIPRAMINE} AND {overdose.mp. OR exp OVERDOSE OR exp POISONING} AND {gastric lavage.mp. OR exp Gastric Lavage OR irrigation.mp. OR exp IRRIGATION OR lavage.mp. OR exp Decontamination OR gastric decontamination.mp OR washout.mp OR gut decontamination.mp} AND {charcoal.mp. OR CHARCOAL} LIMIT to English Language and Humans
Outcome:
Medline: 24 papers were found, 22 were irrelevant or of insufficent quality
Embase: No additional papers were found on Embase
The 2 papers are shown below
Embase: No additional papers were found on Embase
The 2 papers are shown below
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparison of three methods of gut decontamination in tricyclic antidepressant overdose Bosse GM, Barefoot JA, Pfiefer MP, Rodgers GC 1995 USA | 51 TCA overdose Group 1=50 gm Charcoal only (n=22) Group 2=Lavage followed by 50 gm Charcoal (n=14) Group 3=25 gm Charcoal Followed by Lavage then 25 gm charcoal (n=15) |
RCT | Mean Length stay in Hospital (hrs) | No Statistically significant difference (1) 93.3; (2) 107.2; (3) 66.7 (p=0.473) | Small Sample (low power) Not blinded Group 3 had a higher GCS hence may not be comparable at baseline |
| Mean Length Stay in ICU (hrs) | No Statistically significant difference (1) 66.9; (2) 54.1; (3) 34.4 (p=0.436) | ||||
| Mean duration sinus Tachycardia (hrs) | No Statistically significant difference (1) 20.8; (2) 30.8; (3) 32.2 (p=0.594) | ||||
| Mean mechanical ventilation time (hrs) | No Statistically significant difference (1) 43.4; (2) 24.1; (3) 17.8 (p=0.321 | ||||
| Aspiration | No Statistically significant difference (1) 2/22; (2) 3/14; (3) 15/3 (p=0.501) | ||||
| Activated charcoal in tricyclic antidepressant poisoning Hulten BA. Adams R. Askenasi R. Dallos V. Dawling S. Heath A. Volans G. 1988 Sweden | 91 patients with suspecte TCA overdose 43 Gastric Lavage only 34 Gastric Lavage + 20g Activated Charcoal |
Randomised Control Trial | Peak plasma concentrations | No difference | This information was from the abstract |
| Plasma half-lives | No difference | ||||
| Plasma drug concentration versus time curve | No difference | ||||
| Toxic symptoms | Toxic symptoms greater in gastric lavage only group, however this was not statistically significant |
Author Commentary:
There seems to be no significant difference between gastric lavage and activated charcoal. However Kulig et al [1]showed that gastric lavage improved clinical outcomes when performed within one hour compared to no treatment. The European toxocologists consensus statement is based upon this.
Bottom Line:
Gastric Lavage should be performed within one hour of ingestion. After this period there in no significant difference between these methods of gut decontamination.
References:
- Bosse GM, Barefoot JA, Pfiefer MP, Rodgers GC. Comparison of three methods of gut decontamination in tricyclic antidepressant overdose
- Hulten BA. Adams R. Askenasi R. Dallos V. Dawling S. Heath A. Volans G.. Activated charcoal in tricyclic antidepressant poisoning
- Kulig W, Bar-Or D, Cantrill SV et al. Management of acutely poisoned patients without gastric emptying