Although the best method of gastrointestinal decontamination in TCA ingestions remains undefined, a few generalizations are still possible. 14 The risks associated with using syrup of ipecac outweigh any beneficial effects, and its use cannot be recommended. Activated charcoal (AC) has been shown to effectively bind TCAs and decrease their absorption. Therefore, all patients should receive 1 g/kg of AC. Whether gastric lavage and AC is better than AC alone remains unproven. Studies have shown that the gastric lavage is most effective when it is performed within the first few hours after ingestion. Most emergency physicians opt to perform gastric lavage and give AC to patients who present relatively early after TCA ingestion. The proper method of performing gastric lavage in alert patients is to place the patient in the left lateral decubitus position to prevent pulmonary aspiration. Obtunded patients require endotracheal intubation prior to performing gastric lavage. Asymptomatic patients with reliable histories of minimal TCA ingestions can be treated with AC alone and observed for toxicity. Some authors have recommended giving repeat doses of AC to enhance TCA elimination, but these recommendations should be viewed cautiously in the setting of decreased intestinal motility.
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