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Three Part Question

In [paracetamol poisoning] is [gastric lavage better than activated charcoal or nothing] at [reducing hepatotoxicity]?

Clinical Scenario

A 26 year old woman attends the Emergency Department 40 minutes after having taken 80 500mg paracetamol tablets. As the dose taken is high and within the last hour you wonder whether she would benefit from gastric lavage.

Search Strategy

Medline 1966-10/03 using the OVID interface.
[exp acetaminophen OR paracetamol.mp OR acetaminophen.mp] AND [exp poisoning OR poison$.mp OR exp overdose OR overdos$.mp] AND [exp gastric lavage OR gastric lavage.mp OR gastric decontamination.mp OR exp gastric emptying OR gastric emptying.mp OR exp irrigation OR washout.mp] LIMIT to human AND English.

Search Outcome

Altogether 63 papers found of which 59 were irrelevant or of insufficient quality. Four of the remaining papers are shown below the fifth is a position statement mentioned in the comments section.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Underhill TJ et al, 1990, UK	60 Patients taken 5g or more within 4 hours of attendance. Gastric lavage (14) vs ipecacuanha (21) vs activated charcoal(20) or nothing(5)	RCT	Plasma concentrations at 0,1.0,1.5 and 2.5 hours post treatment.	39.3% reduction in concentration compared to 52.2% charcoal	Small study
Buckley NA et al, 1999, Australia	981 consecutive paracetemol overdose Gastric lavage and charcoal vs charcoal alone vs nothing	Observational study	Patients developing high risk concentrations	No statistically significant improvement with lavage + charcoal than charcoal alone.
Grierson R et al, 2000, Canada	10 volunteers given 4.0g paracetemol Gastric lavage at 1 hour compared to no treatment as crossover	Crossover study	8 plasma concentrations over 8 hours	Reduction of 20% (95% CI 3-37%)	Small study Low dose Liquid paracetemol only
Christophersen AB et al, 2002, Denmark	12 volunteers given 50mg/kg paracetamol Lavage + charcoal vs charcoal	Crossover study	12 plasma concentrations over 7 hours	Charcoal 66% reduction in concentration, lavage + charcoal 48.2%	Small numbers Low dose

Comment(s)

The 1997 Joint Position Statement by the American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists (5) stated gastric lavage should not be routinely used for poisoned patients. A similar statement from the British Poisons Centres indicates that gastric lavage is only to be used within 60 minutes of overdose and only with drugs not absorbed by charcoal.

Editor Comment

For UK position statement on gastric lavage see http://www.spib.axl.co.uk/toxbaseindex.htm

Clinical Bottom Line

Gastric lavage is less effective than charcoal alone after paracetamol poisoning.

References

1. Underhill TJ, Greene MK, Dove AF. A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetemol overdose. Arch Emerg Med. 1990;7(3):148-154.
2. Buckley NA, Whyte IM, O'Connell DL et al. Activated charcoal reduces the need for N-acetylcysteine after acetaminophen (paracetemol) overdose. J Toxicol-Clin Toxicol. 1999;37(6):753-7.
3. Grierson R, Grren R, Sitar DS, Tenenbien M. Gastric lavage for liquid poisons. Ann Emerg Med 2000;35(5):435-439.
4. Christophersen AB, Levin D, Hoegberg LCG et al. Activated charcoal alone or after gastric lavage: a simulated large paracetamol intoxication. Br J Clin Pharmacol 2002;53:312-317.