Emesis is achieved by administration of syrup of ipecac. Syrup of ipecac is a plant-derived compound composed of two alkaloidal substances—emetine and cephaeline—which work both peripherally on the stomach and centrally on the chemotactic trigger zone to induce vomiting. Dosing of syrup of ipecac is 15 mL for children 1 to 12 years of age, and 30 mL for adults, usually followed by sips of water. The dose may repeated once if vomiting does not occur after 30 min. Approximately 90 percent of patients vomit within 20 min after the first dose, and up to 97 percent vomit if a second dose is given. A typical patient vomits less than 3

to 5 times, and symptoms usually resolve within 2 h.

The ingested toxin should be suspected as the cause if protracted vomiting occurs. Contraindications to the administration of syrup of ipecac include ingestions with potential to alter mental status; active or prior vomiting; caustic ingestion; a toxin with more pulmonary than GI toxicity (e.g., hydrocarbons); and potential for seizures. Rare but potential complications of syrup of ipecac-induced emesis include aspiration, Boerhaave syndrome, Mallory-Weiss tear, and intractable vomiting.

The clinical situations where syrup of ipecac would be used in the hospital setting are limited. Most patients reach the hospital beyond the time frame when the use of syrup of ipecac would be beneficial, because the toxin has been absorbed or has passed through the pylorus. Also, even when syrup of ipecac is given with activated charcoal in less than 60 min after ingestion, it does not alter outcome when compared to treatment with activated charcoal and a cathartic. Ipecac's administration also prolongs the time to administration of oral antidotes by 1 to 6.5 h.3

Syrup of ipecac may still be indicated, especially when it can be given in the home immediately after an ingestion of a known toxin that is still expected to be in the stomach and that does not have the previously listed contraindications. Possible rare hospital indications for its use include very recent ingestions of substances not expected to compromise the airway or lead to altered mental status or hemodynamic derangement or seizure, a recent ingestion of a pill that is known not to be able to fit into the holes of the appropriately sized orogastric tube, or a substance known not to adsorb to activated charcoal (see the following sections).

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