Method of gut decontamination

Report By: Fawad Azam - Medical student
Institution: MRI
Date Submitted: 5th July 2005
Last Modified: 14th July 2005
Status: Blue (submitted but not checked)

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
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

Search 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

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bosse GM et al 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)
Hulten BA et al 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

Comment(s)

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.

Clinical 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 Journal of emergency medicine 13 (2): 203-9, 1995 Mar-Apr
Hulten BA. Adams R. Askenasi R. Dallos V. Dawling S. Heath A. Volans G. Activated charcoal in tricyclic antidepressant poisoning Human Toxicology 1988; 7(4):307-10
Kulig W, Bar-Or D, Cantrill SV et al Management of acutely poisoned patients without gastric emptying Annals Emergency Medicine 1985; 14:562-7