Gastrointestinal Decontamination

For most hydrocarbon ingestions, gastrointestinal decontamination would provide little benefit; supportive care and appropriate treatment of coexisting ingestions are all that is required. The necessity for GI decontamination depends on the type of hydrocarbon and route of exposure. The risk of systemic toxicity by intestinal absorption has to be weighed against the risks of aspiration associated with gastric emptying. The majority of hydrocarbon ingestions, which consist of aliphatic hydrocarbons mixtures (see Table 17.4.-1), do not require GI decontamination. These agents have poor GI absorption and their toxicity is limited primarily to pulmonary aspiration. In the typical childhood accidental ingestion, the actual amount ingested is usually one swallow or about 5 mL. Suicidal ingestions, which involve larger amounts of hydrocarbons, frequently are associated with spontaneous emesis, and further decontamination is usually not required. Some recommend GI decontamination if emesis has not occurred and the dose is greater than 1 to 2 mL/kg, although this strategy has not been studied.

GI decontamination may be warranted when the ingested hydrocarbon is known to have good GI absorption and may cause significant systemic toxicity (e.g., toluene, chloroform, wood distillates) or an additive in the toxic agent (e.g., organophosphate pesticides are often mixed in petroleum distillates). The CHAMP mnemonic (camphor, halogenated hydrocarbons, aromatic hydrocarbons, metals, pesticides) is helpful in remembering most situations where GI decontamination should be considered. Unfortunately, little data is available that evaluates the clinical benefits of gastrointestinal decontamination in these settings.

If the patient presents to the ED shortly after the ingestion of these toxic hydrocarbons, aspiration with a small nasogastric tube may be useful. In patients who present with an altered mental status, the airway should be protected with a cuffed endotracheal tube, although in smaller children under eight years of age, the cuff should be kept inflated only during the period of lavage because of cuff-related injury from prolonged inflation. Ipecac-induced emesis has been advocated in the past but its risks appear to outweigh any potential benefits.

Although activated charcoal may adsorb some hydrocarbon compounds, its use is not recommended for most hydrocarbon ingestions. Charcoal instillation may distend the stomach increasing the risk for vomiting and aspiration. The use of charcoal should only be considered if one of the CHAMP-type hydrocarbons has been ingested.

The use of cathartics to hasten GI transit and facilitate decontamination has no proven efficacy in hydrocarbon ingestions. Many patients will already have diarrhea from the hydrocarbon, and further catharsis is not required. Oil-based cathartics, which had been used in the past to thicken the ingested hydrocarbon to increase its viscosity and decrease the subsequent risk of aspiration, are contraindicated. They may actually increase GI absorption and are associated with an increased risk of lipoid pneumonia when aspirated.

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