Ipecac syrup. Its use as an emetic in poison control

Effects on a Poison Center's (PC) triage and follow-up after implementing the no Ipecac use policy

For years, The American Academy of Pediatrics (AAP) had supported home use of syrup of Ipecac. However, due to mounting evidence that Ipecac use did not improve outcome nor reduce Emergency Department (ED) referrals, the AAP in November of 2003 issued a statement that Ipecac not be used for the home management of poison ingestion. To determine if the cessation of the use of Ipecac for home ingestions is associated with an increased number of follow-up calls, an increased time of observation at home and an increase in the number of ED referrals for care by poison center staff were administered. Fifty randomly selected pediatric (<6 years) cases that received Ipecac ("Ipecac" group) from January 1, 2003 to October 31, 2003 were selected for study. Up to two controls ("no Ipecac" group) were matched by age, amount ingested, and by toxin. Controls were selected from the 2004-2006 time period (Ipecac no longer in use). Fifty "Ipecac" cases and 84 "no Ipecac" controls were analyzed. The groups had no significant differences with respect to percent symptomatic, median time post-ingestion, mean age, and distribution of toxin categories (e.g., antidepressants, beta blockers, etc.). The "no Ipecac" group had nearly ten times the odds of ED referral compared to the "Ipecac" group, (OR = 9.9, 95%CI 3.3-32.2). The mean total hours of follow-up was not significantly different between the groups (diff = -1.1, t = -1.8, p = 0.07). The mean number of follow-up calls was significantly less in the "no Ipecac" group (diff = -1.4 calls, t = -6.8, p < 0.001). Toxicology consults were greater in the "no Ipecac" group (chi (2 )= 4.05, p = 0.04); however, consults were not associated with ED referral. For the time period from 2004 to 2006, the "no Ipecac" policy resulted in an increase in ED referrals at our center. While prior studies have shown that not using Ipecac did not affect clinical outcome, our research suggested that it may have initially influenced triaging outcome. Since the use of Ipecac by centers was once a commonly used home remedy for some ingestions (albeit without rigorously established efficacy), poison center personnel had to transition to the "no Ipecac" policy. Although our referrals increased during a transitional period of time, referral rates have since stabilized and returned to baseline.

Gastrointestinal decontamination for acute poisoning

Gastric decontamination remains an important element in the therapy of pediatric poisoning; however, several issues remain unresolved. Additional studies, particularly in the clinical setting, are necessary to establish optimal therapeutic recommendations. Based on the data presented in this review, the following general recommendations can be made for gastric decontamination in children: If it is necessary to remove an ingested toxin, ipecac syrup is the preferred method if contraindications to its use are not present. The dose should be 30 ml in children older than 1 year of age and 10 ml in children 6 to 12 months of age. Pending further studies, the use of emetics in children younger than 6 months of age cannot be generally recommended, particularly in the home setting. Gastric lavage should be considered to be of very limited use in pediatric patients. Lavage using small nasogastric tubes, except under special circumstances, is nonproductive and cannot be advocated. If it must be used, a large-bore orogastric hose should be used. Administration of activated charcoal prior to lavage should be considered. In situations in which prompt induction of emesis is not possible or contraindications to emesis exist, activated charcoal followed by, or mixed with, a cathartic (preferably sorbitol) should be used as an alternative to removal of gastric contents. Patients with significant symptoms from ingestion requiring hospitalization should receive repeat doses of charcoal and cathartic until symptoms resolve. Activated charcoal should be given in conjunction with other appropriate therapies. Although the data to substantiate this recommendation are limited, particularly in pediatric patients, it is a benign therapy that holds promise of increasing drug elimination.

Are consumers provided with adequate information on the actions and uses of ipecacuanha syrup?

The results of a study to assess the level of consumer information about the action and uses of Ipecacuanha Syrup (Emetic) Australian Pharmaceutical Formulary (APF) are reported. Of 40 community pharmacies selected at random from the 321 pharmacies in the Perth metropolitan area, four were unable to supply the syrup. Dosage information provided on the labels of branded products was, for the most part, comprehensive and in line with APF recommendations. Syrup samples dispensed under pharmacy labels provided much less detailed dose information and no information on contraindications on the labels. Counselling by pharmacists was mostly adequate, but information provided by pharmacy assistants was much less detailed. The active alkaloid content of about 77% of the samples of ipecacuanha syrup was within +/- 12% of the target concentration; the remainder had only 56%-58% of the required alkaloid concentration, which indicates a need for more stringent quality control.

Management of acutely poisoned patients without gastric emptying

During an 18-month period, 592 acute oral drug overdose patients were studied prospectively in a controlled, randomized fashion to determine the efficacy of gastric emptying procedures in altering clinical outcome. Patients presenting on even-numbered days had no gastric emptying procedures performed, and they were compared to patients presenting on odd-numbered days who received either syrup of ipecac or gastric lavage. Patients were carefully followed for evidence of subsequent clinical improvement or deterioration after initial management. Syrup of ipecac did not significantly alter the clinical outcome of patients who were awake and alert on presentation to the emergency department (ED). Gastric lavage in obtunded patients led to a more satisfactory clinical outcome (P less than .05) only if performed within one hour of ingestion. Gastric emptying procedures in the ED for initial treatment of drug overdose are generally not of benefit unless gastric lavage is performed within one hour of ingestion in obtunded patients.

Mallory-Weiss syndrome: an unusual complication of ipecac-induced emesis

A young presented to the emergency department after ingesting multiple drugs. Upper gastrointestinal bleeding developed after emesis was induced with syrup of ipecac. A small Mallory-Weiss tear of the cardioesophageal junction was found at endoscopy. This case is presented to alert physicians to this uncommon complication of ipecac-induced emesis.

The effect of carbonated beverages on ipecac-induced emesis

To determine the effect of carbonated beverages on syrup of ipecac, 24 pediatric patients were randomly administered six ounces of water or a carbonated beverage with syrup of ipecac. Changes in the abdominal girth, the volume of emesis, and time of emesis were monitored in all patients. In the carbonated beverage group a significant difference (P less than 0.05) was observed between the baseline and 10-min post-ipecac administration abdominal girth measurements. The time of emesis and volume of emesis were not significantly different in the water or carbonated beverage groups. We conclude that carbonated beverage administration does not alter the effectiveness of syrup of ipecac.

Toxicology of ipecac: a review

The general effectiveness and safety of Ipecac syrup, per se, has not been questioned, but rather an attempt has been made to consolidate pertinent literature dealing with the toxic manifestations of Ipecac fluid extract. Ipecac contains both emetine and cephaeline and the toxicity of Ipecac fluid extract is consistent with reports on the toxicity of both compounds. The majority of the work has involved emetine since it is in higher concentration in Ipecac fluid extract than is cephaeline. Comparison of the clinical picture presented in syrup or fluid extract of Ipecac overdose and emetine toxicity in amebiasis treatment permits us to summarize the general characteristics of Ipecac alkaloid toxicity as involving primarily gastrointestinal, cardiovascular, and neuromuscular foci.

Inhibition of salicylate and lithium absorption in the human intestine by copper sulfate

Copper sulfate, given orally in an emetic dose, decreased the absorption of therapeutic doses of acetylsalicylic acid or lithium carbonate, more than was expected judging from the recovery of salicylic acid in the vomit. Ten volunteers participated.

Drug overdosage in children

The epidemiology and prevention of drug overdosage in children is discussed. The emergency treatment of acute drug overdosage is outlined together with aspects of the intensive care management in relation to conscious state, convulsions, respiratory failure, circulatory failure and arrhythmias with some emphasis on tricyclic antidepressants.

Treatment of the poisoned child

Syrup of ipecac has measurable advantages over gastric lavage in evacuating the stomach of children with accidental poisoning, in terms of safety, effectiveness, and rapidity of action. The average period for action with ipecac is likely to be about 17 minutes, or 82 minutes, depending on whether the child is treated at home or in hospital. In contrast, the mean delay to completion of gastric lavage is estimated at 126 minutes, and this procedure has little place in the treatment of the child with poisoning.