Telephone management of poisonings using syrup of ipecac

Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons

The use of gastric emptying techniques, including ipecac-induced emesis, in the management of poisoned patients has declined significantly in recent years. Historically, poison centers used ipecac syrup in two ways. Ipecac syrup was administered to patients prior to referral to the emergency department in attempts to start the gastric emptying process as early as possible. Additionally, poison centers used ipecac syrup in attempts to keep patients from requiring referral to medical facilities. In these situations, ipecac syrup was administered in the home and poison center staff performed follow-up telephone calls to gauge progress and outcome. Studies to determine the effectiveness of ipecac syrup demonstrate that it induces vomiting in a high percentage of people to whom it is administered and that it decreases the gastrointestinal absorption of ingested substances in a time-dependent fashion. However, the effectiveness of ipecac syrup in affecting patient outcome has not been studied in adequate clinical trials. Its effectiveness in preventing drug absorption has only been documented for a limited number of substances and is substantially reduced if it is given more than 30-90 minutes following ingestion of the toxic material. There are potentially significant contraindications, adverse effects and related problems associated with the use of ipecac syrup. It is the consensus of the panel that the circumstances in which ipecac-induced emesis is the appropriate or desired method of gastric decontamination are rare. The panel concluded that the use of ipecac syrup might have an acceptable benefit-to-risk ratio in rare situations in which: there is no contraindication to the use of ipecac syrup; and there is substantial risk of serious toxicity to the victim; and there is no alternative therapy available or effective to decrease gastrointestinal absorption (e.g., activated charcoal); and there will be a delay of greater than 1 hour before the patient will arrive at an emergency medical facility and ipecac syrup can be administered within 30-90 minutes of the ingestion; and ipecac syrup administration will not adversely affect more definitive treatment that might be provided at a hospital. In such circumstances, the administration of ipecac syrup should occur only in response to a specific recommendation from a poison center, emergency department physician, or other qualified medical personnel. The panel decided not to address the issue of whether ipecac should remain a nonprescription, over-the-counter product. The panel does not support the routine stocking of ipecac in all households with young children but was unable to reach consensus on which households with young children might benefit from stocking ipecac. Instead, the panel concluded that individual practitioners and poison control centers are best able to determine the particular patient population, geographic and other variables that might influence the decision to recommend having ipecac on hand.

High-performance liquid chromatographic assay with fluorescence detection for the determination of cephaeline and emetine in human plasma and urine

A high-performance liquid chromatographic assay method for the quantitation of ipecac alkaloids (cephaeline and emetine) in human plasma and urine is described. Human plasma or urine was extracted with diethylether under alkaline conditions following the addition of an internal standard. Concentrations of alkaloids and internal standard were determined by octadecylsilica chromatographic separation (Symmetry C18 columns, plasma analysis; 15 cmx4.6 mm I.D., 5 microm particle size, urine analysis; 7.5 cmx4.6 mm I.D., 5 microm particle size). The mobile phase consisted of buffer (20 mmol/l 1-heptanesulfonic acid sodium salt, adjusted to pH 4.0 with acetic acid)-methanol (51:49, v/v). Eluate fluorescence was monitored at 285/316 nm. The lowest quantitation limits of cephaeline and emetine were 1 and 2.5 ng/ml, respectively, in plasma, and 5 ng/ml in urine. Intra- and inter-day relative standard deviations were below 15%. The assay is sensitive, specific and applicable to pharmacokinetic studies in humans.

Influence of time until emesis on the efficacy of decontamination using acetaminophen as a marker in a pediatric population

STUDY OBJECTIVE

To determine the extent of drug removal by emesis at different times after the ingestion of a toxic substance.

DESIGN

Multicenter retrospective chart review.

METHODS

Using the American Association of Poison Control Centers' aggregate data base, children who had ingested acetaminophen and who were referred to a health care facility by one of 11 poison centers during a two-year period were identified. Charts of these patients were reviewed to determine the quantity ingested per kilogram of body weight, method of decontamination used, the timing of decontamination, and the serum acetaminophen concentration obtained four hours after ingestion.

RESULT

Charts of 455 patients met all requirements for inclusion. When emesis occurred within one-half hour after ingestion, mean serum acetaminophen concentration drawn four hours after ingestion was approximately half that in a control group that received no decontamination. Emesis had less impact when it was delayed further and had no demonstrable impact when it occurred more than 90 minutes after ingestion.

CONCLUSION

Many factors must be considered when deciding if and by what method a given patient should receive decontamination. When delayed gastric emptying is not expected, emesis can at best decrease a toxic burden by half if it occurs early. Medical care givers must continue to scrutinize management practice to ensure that syrup of ipecac is given only in situations in which it is likely to make a difference in outcome and in which it is the most effective agent to achieve this goal.

The effect of fluid volume on syrup of ipecac emesis time

Large volumes of fluid have been recommended to aid rapid ipecac-induced emesis, however, large volume intake may also have deleterious effects. We prospectively studied 121 children treated at home by a regional poison center to determine if a relationship existed between fluid volume and time to emesis. These children were treated in the usual manner except that parents were asked to measure the volume of fluid given and to note the time that fluid was given and the time of first emesis. The time ranged from 6 to 58 minutes (mean 20.6) with two who failed to respond and the volume ranged from 0 to 28 ounces (mean 6.7 ounces). In children who respond to ipecac, there is no significant relationship between the amount of fluid given and the time until emesis. We conclude that the traditional recommendation of forcing fluid with syrup of ipecac does not hasten emesis in children.

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.

Syrup of ipecac in children less than one year of age

A prospective study was conducted to determine if children less than one year of age developed any complications from syrup of ipecac-induced emesis. All patients in the study were derived from cases received by the poison center. Syrup of ipecac (10 ml) was administered with clear fluids to 24 children less than twelve months of age (mean age 8.7 months; median age 9.0 months; range 3.0-12.0). The average time for the onset of emesis was 26.10 minutes. All children vomited with a single dose of syrup of ipecac. No adverse sequelae such as aspiration or prolonged episodes of emesis were observed. Contrary to the popular belief that emesis may be contraindicated in children less than twelve months of age, we believe that emesis can be safely induced in the home setting in these young children.

Absorption of ipecac alkaloids in emergency patients

Syrup of ipecac contains the nauseant alkaloids emetine and cephaeline. Although thousands of doses are given yearly, no data exist on the absorption of these alkaloids in man. We gave 30 mL of USP Syrup to ten adult patients. Blood and urine samples were obtained at approximately one-half and two hours after administration, and the entire volume of vomitus was saved. The samples were then analyzed for cephaeline and emetine by a high-performance liquid chromatographic (HPLC) assay developed in our laboratory. All patients vomited within 30 minutes, but the amounts of alkaloid regurgitated varied from 22 +/- 14% in six patients to 80 +/- 16% in the remaining four. Only six patients had emetine or cephaeline in their blood by two hours (range, 5 to 73 ng/mL), although ten patients had detectable concentrations of the alkaloids in their urine. Measured over two hours, no patient eliminated more than 0.5% of the dose by the urinary route. In our study ipecac was absorbed by all who received it; the extent of absorption varied widely, and elimination by the renal route was small.

Emergency induction of emesis using liquid detergent products: a report of 15 cases

Solutions of liquid detergent products were used to induce emesis in 15 patients who could not or would not obtain syrup of ipecac. Four patients refused to drink any of the solution and two others refused part, one of whom vomited. In the patients who drank all or part of the solution, 91% (10/11) vomited with a mean time to the onset of emesis of 6.5 min. None of these patients developed symptoms attributable to the ingested poison or the detergent solution. Liquid detergent solutions may be a useful alternative emetic for the poison center when a patient cannot be given syrup of ipecac.

The effect of temperature of concurrently administered fluid on the onset of ipecac-induced emesis

The time of onset of ipecac-induced emesis is not significantly influenced by the temperature of concurrently administered fluid. The average time of emesis with syrup of ipecac administered with cold (10 degrees C) versus warm (40 degrees C) water was found to be 30:59 and 30:18 min, respectively. The difference in induction time is not statistically or clinically significant.