RRSIDEAD • Decontamination
Decontamination Overview
As with any basic and advanced life support it is important to have a systematic approach to managing toxicological emergency presentations. Pioneers in the field developed RRSIDEAD as a mnemonic to remember the key steps in Tox patient assessment and management.
D is for Decontamination
- R – Resuscitation
- R – Risk Assessment
- S – Supportive Care
- I – Investigations
- D – Decontamination
- E – Enhanced Elimination
- A – Antidotes
- D – Disposition
RRSIDEAD Tox Tutes: Decontamination
Listen to the Tox Tutes below and find out who you would give charcoal to and who gets the whole bowel irrigation. Then test yourself with a few “show and reveal” questions.
Tox Tute AUDIO
Tox Tute VIDEO
Questions
Q1. What four methods are available for gastrointestinal decontamination? Which two do we no longer use due to safety concerns?
Reveal the Answer
- Induced emesis (syrup of ipecac)
- Gastric lavage
- Activated charcoal
- Whole bowel irrigation
Note: The last two are the only two methods currently recommended
Q2. What is the dose of activated charcoal in adults and in children?
Reveal the Answer
- Adults = 50g
- Children = 1g/kg. After a trial on our own staff we all agreed that mixing charcoal with icecream is rather tasty, comically named Batman icecream. In fact the charcoal is fairly tasteless, don’t eat too much though as the sorbitol is a laxative.
Q3. What agents bind poorly to charcoal?
Reveal the Answer
Hydrocarbons
Alcohols:
- Ethanol
- Isopropyl alcohol
- Ethylene glycol
- Methanol
Metals:
- Lithium
- Iron
- Potassium
- Lead
- Arsenic
- Mercury
Corrosives:
- Acids
- Alkalis
Q4. What are the potential complications of activated charcoal?
Reveal the Answer
- Mess
- Pulmonary aspiration of activated charcoal
- Direct administration into the lungs via a misplaced NG tube (potentially fatal)
- Impaired absorption of subsequent oral antidotes or other therapeutic agents
- Corneal abrasions
- Distraction of staff from resuscitation and other supportive care priorities
Q5. What are the contraindications of activated charcoal?
Reveal the Answer
- Initial resuscitation incomplete
- Non-toxic ingestion
- Sub-toxic dose
- Agent not bound to activated charcoal
- Corrosive ingestion
- Risk assessment indicating a good outcome with supportive care and antidote therapy alone
- Uncooperative patient
- Decreased level of consciousness, delirium or poor concentration (unless their airway is already protected with an endotracheal tube)
- Risk assessment suggesting potential for imminent onset of seizures or decreased level of consciousness
Q6. List the 6 potentially useful scenarios for whole bowel irrigation.
Reveal the Answer
- Iron overdose >60mg/kg
- Slow-release postassium chloride ingestion >2.5 mmol/kg
- Life-threatening slow-release verapamil or diltiazem ingestions
- Symptomatic arsenic trioxide ingestion
- Lead ingestion
- ‘Body packers’
Q7. What are the contraindications to whole bowel irrigation?
Reveal the Answer
- Risk assessment suggesting a good outcome with supportive care and antidote therapy alone
- Uncooperative patient
- Inability to place a nasogastric tube
- Uncontrolled vomiting
- Risk assessment suggesting potential for decreased conscious state or seizures in the subsequent four hours.
- Ileus or intestinal obstruction
- Intubated and ventilated patient (relative contraindication)
Q8. How do you perform whole bowel irrigation?
Reveal the Answer
- The patient requires 1:1 nursing for at least 6 hours.
- Place a nasogastric tube and confirm position on xray.
- Give activated charcoal if the agent will bind
- Administer PEG (polyethylene glycol) solution via the nasogastric tube at 2L/hour by continuous infusion (children 25ml/kg/hr). (If not already made up the solution or powder will have dilution instructions to mix with water)
- Where possible administer metoclopramide to minimise vomiting and enhance gastric emptying.
- Position the patient on a commode if possible.
- Continue irrigation until effluent is clear (this may take up to 6 hours)
- Stop irrigation is there is abdominal distension or loss of bowel sounds.
- Abdominal xrays can be useful to track radio-opaque substances.
- Expelled packages may be counted in body packers.
References
- American Academy of Clinical Toxicology and the European Association of Poison Centers and Clinical Toxicologists. Position paper: whole bowel irrigation. Clinical Toxicology 2004; 42:843-854
- American Academy of Clinical Toxicology and the European Association of Poison Centers and Clinical Toxicologists. Position paper: single-dose activated charcoal. Clinical Toxicology 2005; 43:61-87
- Bailey B. Gastrointestinal decontamination triangle. Clinical toxicology 2005; 1:59-60
- Benson BE, Hoppu K, Troutman WG et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clinical Toxicology 2013; 51:140-146
- Homer J, Troutman WG, Hoppu K et al. Position paper update: ipecac syrup for gastrointestinal decontamination. Clinical Toxicology 2013; 51:134-139
- Isbister GK, Pavan Kumar VV. Indications for single dose activated charcoal administration. Current Opinion in Critical Care 2011; 17:351-357
- FAST HUGS in BED Please
LITFL Further Reading
- Toxicology Basics: Principles of RRSIDEAD in toxicology and toxinology
- Drugs and Synthetic Toxicants: Assessment and management of poisoning
- Antidotes: Chemical management for ingested drugs, toxicants and toxins
- Toxins: Assessment and management of envenoming (Toxinology)
- Antivenoms: Chemical management of toxins and envenoming.
- Toxicological Conundrums: Toxicology emergency management in clinical context.
- Toxicology Resources: Toxicology and toxinology resources on the web
Further Reading
- Toxicology in a Box – Flashcards
- Toxicology Handbook 3e
- Toxicology Secrets 1e
- Goldfrank’s Toxicologic Emergencies 10e
- Poisoning and Drug Overdose 7e
- Oxford Desk Reference – Toxicology
Toxicology Library
BASICS
Emergency Physician and Clinical Toxicologist who thinks that life exists outside Emergency Departments and that there is a wide and wonderful world outside the web.