Rapid point-of-care identification of oral medications in gastric lavage content by ambient mass spectrometry in the emergency room.

RATIONALE: Acute poisoning should be handled with high efficiency in order to minimize morbidity and mortality in the emergency room. Unfortunately, history-taking and physical examination are not always reliable. Mis-swallowing of oral medications is common in the pediatric group. This study aimed at developing a rapid point-of-care ambient mass spectrometric method for the early identification of ingested oral medications in gastric lavage content. METHODS: Four different types of oral medications that are most commonly mis-swallowed by children were diluted to different concentrations. Each of these chemical solutions was mixed with human gastric lavage content. A direct metallic sampling probe was dipped into the solution. It was then inserted promptly into the thermal desorption electrospray ionization source to carry out ionization and subsequent mass spectrometric analysis of the medications. The corresponding compounds were identified through matching of the obtained mass spectrometric data with those provided by well-established databases. RESULTS: Since no pretreatment of the specimen was required, the sampling step, and the subsequent thermal desorption electrospray ionization and mass spectrometric detection of the medications were completed within 30 s. Mass spectra were obtained for four different kinds of oral medication. The limit-of-detection of the four tested oral medications in gastric lavage content is at sub-ppm level, which is sensitive enough for emergency medicine applications since the quantities of medications ingested by pediatric patients are usually much higher. CONCLUSIONS: Thermal desorption electrospray ionization mass spectrometry, with informational support provided by an online mass spectral database, allows for early point-of-care identification of mis-swallowed oral medications in the evacuated gastric lavage contents obtained from gastric lavage of patients in the emergency room, and it is promising in providing important toxicological information to ensure the appropriateness of the subsequent medical management. Copyright © 2016 John Wiley & Sons, Ltd.

Systematic review of controlled clinical trials of gastric lavage in acute organophosphorus pesticide poisoning.

BACKGROUND: Organophosphorus pesticide (OP) self-poisoning is a major problem in the developing rural world. There is little clinical trial data to guide therapy, hindering the identification of best therapy. Despite the recognition of adverse effects, gastric lavage is commonly done in Asia. We aimed to identify studies assessing its effectiveness. METHOD: We systematically searched the literature for controlled clinical studies that assessed the effect of gastric lavage in OP pesticide self-poisoning. RESULTS: All 56 studies identified were Chinese and reported benefit from the intervention studied, including multiple gastric lavages, use of norepinephrine or pralidoxime in the lavage fluid, concurrent treatment with naloxone or scopolamine, insertion of the gastric tube via a laparotomy incision, and lavage later than 12 h post-ingestion. However, only 23 were RCTs and none presented adequate methodology for their quality to be assessed. The patient population and study treatment protocol were not defined - large variation in case fatality in the control arm of the studies (from 4.5 to 93%) suggests marked variation between studies and likely between study arms. No study compared an intervention against a control group receiving no gastric lavage or provided any data to indicate whether a significant quantity of poison was removed. CONCLUSION: Despite widespread use of multiple gastric lavages for OP pesticide poisoning across Asia, there is currently no high-quality evidence to support its clinical effectiveness. There is a need for studies to identify in which patients and for what duration gastric lavage is able to remove significant quantities of poison. Following these studies, large clinical trials will be required to address the effectiveness and safety of gastric lavage (either single or multiple) in acute OP pesticide poisoning.

[Design of a novel automatic gastric lavage machine].

In this paper, the design of a safe and multifunctional gastric lavage machine is presented. The microprocessor samples and analyzes the air pressure, time rate of pressure change, volume, and limit signals, then controls the relays and the electromagnetism valves to adjust the operating condition in real time. The machine has many functions, such as gastric lavage, aspirating, digital displaying, alarming, and so on.

[Gastric cleansing]. / Lavado gástrico.

Numerous cases in emergency wards are due to the ingestion of potentially toxic substances. One of the most utilized procedures under these circumstances is gastric cleansing. This procedure is a technique habitually practiced by nursing personnel but is not without its risks. Therefore, the motive of this article is to make known the indications, contraindications, related complications of gastric cleansing and its integral patient care process in order to offer quality care methods which enable their being performed in an effective and efficient manner, under the maximum security conditions with the minimum inconveniences for the patient while at the same time describing the system most commonly used by our service.

Lavado gástrico / Gastric cleansing

Numerosas asistencias en los centros de urgencias se deben a la ingestión de sustancias potencialmente tóxicas. Uno de los procedimientos más utilizados en estas situaciones es el lavado gástrico. Se trata de una técnica habitualmente practicada por Enfermería no exenta de riesgo. Por ella el motivo de este artículo es dar a conocer las indicaciones, contraindicaciones, complicaciones asociadas y el proceso de atención integral del paciente con elfin de ofrecer los cuidados de calidad que permitan su realización de forma eficaz y eficiente, bajo las máximas condiciones de seguridad y el mínimo de incomodidades para el usuario, y a la vez describir el sistema mayoritariamente utilizado en nuestro servicio

Numerous cases in emergency wards are due to the ingestion of potentially toxic substances. One of the most utilized procedures under these circumstances is gastric cleansing. This procedure is a technique habitually practiced by nursing personnel but is not without its risks. Therefore, the motive of this article is to make known the indications, contraindications, related complications of gastric cleansing and its integral patient care process in order to offer quality care methods which enable their being performed in an effective and efficient manner, under the maximum security conditions with the minimum inconveniences for the patient while at the same time describing the system most commonly used by our service

Heat stroke : a review of cooling methods.

The prognosis of heat stroke in patients is directly related to the degree of hyperthermia and its duration. Therefore, the most important feature in the treatment of heat stroke is rapid cooling. Several cooling methods have been presented in the literature including immersion in water at different temperatures, evaporative cooling, ice pack application, pharmacological treatment and invasive techniques. This article describes the various cooling techniques in terms of efficacy, availability, adverse effects and mortality rate. Data suggest that cooling should be initiated immediately at time of collapse and should be based on feasible field measures including ice or tepid water (1-16 degrees C), which are readily available. In the emergency department, management should be matched to the patient's age and medical background and include immersion in ice water (1-5 degrees C) or evaporative cooling.

Postoperative peritonitis originating from the duodenum: operative management by intubation and continuous intraluminal irrigation.

BACKGROUND: The mortality rate associated with postoperative peritonitis remains high, especially when the source of infection cannot be eradicated. Such is the case with peritonitis arising from the duodenum, as primary closure is futile and intubation alone may be followed by local complications. METHODS: Forty-nine consecutive patients with postoperative peritonitis originating from a duodenal leak and a mean Acute Physiology And Chronic Health Evaluation II score of 17.7 were treated according to the following procedure: a three-channelled spiral drain was inserted through the leak and extraluminal drains were placed near the duodenal defect. Intraluminal irrigation was undertaken immediately through the infusion channel of the spiral drain. RESULTS: Eleven patients died and 26 suffered complications. The mean duration of intubation was 21 days. CONCLUSION: Intubation with intraluminal irrigation has proved effective in a homogeneous group of patients with peritonitis due to duodenal leakage.

The wide-channel endoscope optimizes the success of emergency endoscopy.

INTRODUCTION: Success of emergency endoscopy in upper GI-hemorrhage for diagnostics and treatment is limited by masses of blood clots, food or both. Using standard endoscopes supported by adjuvant techniques bleeding source can be defined in 90 to 95%. These procedures are often time consuming. Only bleeding sources which are defined can be treated. This is difficult in cases of ongoing hemorrhage. Circulatory shock may occur as well as aspiration of gastric contents. For these reasons we developed the new wide-channel endoscope. METHODS: This endoscope (GIF-XT-30, Olympus, Tokyo) has two channels, one with a diameter of 6 mm and a jet channel with 1 mm. The outer diameter at the distal end is 13.7 mm. A three-way stopcock for suction and water input is connected to the 6 mm channel. RESULTS: We achieved complete evacuation of stomach contents in 122 of 123 patients (= 23% of all emergency patients in this series) with upper GI-bleeding, in whom complete gastric cleaning and identification of the bleeding source had proved impossible using standard endoscopes. Gastric emptying using the big channel endoscope was possible within 5 minutes in all successful cases. Optimal conditions for therapeutic procedures were therefore provided. CONCLUSIONS: The possibilities of this instrument enable a more aggressive technique of moving fixed coagula from ulcers to localize the vessel that is to be treated. Even in cases of provoked severe Forrest I A hemorrhage permanent visual control can be achieved. It is an indispensable tool for major endoscopic centers in emergency situations.

A comparison of three gastric lavage methods using the radionuclide gastric emptying study.

To determine the percentage of liquid gastric contents experimentally removable by available orogastric lavage systems, five healthy young volunteers were asked to ingest 1 mCi of liquid technicium-99m diethylenetriaminepentaacetic acid (Tc99m-DTPA) mixed with 50 ml tap water. Five minutes afterwards, the radionuclide was lavaged using one of three different techniques-a single syringe method, a closed gravity drainage system, and a closed double syringe method--while continuous radioisotope camera images were taken. Control images, with no lavage performed, were also taken. All of the orogastric lavage methods removed a mean of between 80% and 85% of the stomach contents. The double syringe method was the quickest, while the single syringe method was least tolerated. When compared with control, none of the lavage techniques pushed gastric contents into the duodenum. Thus, in terms of amount of liquid gastric contents removed, there was no one method that removed more than the others. Caution should be exercised in assuming that 80-85% of a liquid gastric ingestion can be removed by lavage in the uncontrolled clinical setting. The use of any orogastric lavage for ingestion evacuation should be undertaken knowing that it is a morbid procedure and usually not necessary.

Management of esophageal coins in children by bougienage: a case report.

A three-year-old child with a coin lodged in his esophagus is treated with bougienage after x-ray pinpoints the coin's location.

Evaluation of gastric emptying using radionuclides: gastric lavage versus ipecac-induced emesis.

STUDY OBJECTIVES: To compare the efficacy of gastric lavage and ipecac-induced emesis by using a radionuclide marker in a simulated overdose and to determine the amount of material recoverable after lavage fluid appears clear. DESIGN: Case-control, prospective cross-over study. SETTING: Nuclear medicine department of Valley Medical Center, Fresno, California. TYPE OF PARTICIPANTS: Fourteen male and five nonpregnant female adult volunteers with no pre-existing gastrointestinal disease and no medication use. INTERVENTIONS AND MEASUREMENTS: In phase 1, each volunteer ingested 30 capsules labeled with a measured amount of Tc99m with 75 mL H2O followed in five minutes by ipecac-induced emesis. In phase 2, two to four weeks later, each subject was lavaged after ingesting 30 labeled capsules. After lavage appeared clear, a 1,000-mL supplemental lavage was done and analyzed separately. All emesis or gastric lavage fluid was collected and measured for tracer activity. RESULTS: All subjects in the ipecac group vomited with an average time from ipecac to emesis of 19 minutes. Two subjects withdrew from the study, refusing to complete lavage due to discomfort. Based on retrieved material, ipecac-induced emesis returned significantly more tracer (mean +/- SD, 54.1 +/- 21.3%) than lavage until clear (mean +/- SD, 30.3 +/- 17.4%) (P = .0021). Supplemental lavage returned 12.9% of the total recovered marker (SD, 11.6%). The total of initial and supplemental returns from lavage was 35.5% (SD, 21.0%). This return was significantly less than that returned by ipecac-induced emesis (P = .016). CONCLUSION: In this study, ipecac-induced emesis was significantly more effective than gastric lavage in emptying the stomach after simulated overdose. Significant amounts of ingested material are recoverable in gastric lavage return after it appears clear.

Accidental administration of activated charcoal into the lung: aspiration by proxy.

We report a case of accidental activated charcoal instillation into the lung of a 30-year-old man being managed for a cyclic antidepressant overdose. The patient was treated with multidose activated charcoal, and between his first and second doses, he pulled his nasogastric tube out of position. The tube was reinserted past the endotracheal tube into the right mainstem bronchus, and a dose of activated charcoal with sorbitol was administered into the lung. He subsequently developed an adult respiratory distress syndrome but gradually improved after bronchoscopic removal of charcoal and supportive care. He was discharged 14 days later.

Gastric lavage in accident and emergency.

There are few specific treatments available to neutralise the effect of ingested toxic agents. For most overdose patients presenting to accident and emergency (A&E) departments, therefore, the aim of treatment is to limit the systemic absorption of the drug or drugs taken. Gastric lavage is a traditional intervention for managing overdose patients in A&E and the author outline how this procedure may be performed.

Malposition of pediatric gastric lavage tubes demonstrated radiographically.

Gastric lavage may be indicated in the initial treatment of toxic substance ingestion. We retrospectively surveyed the charts of 36 pediatric patients who underwent gastric lavage to evaluate the clinical and radiographic evidence indicating proper tube placement. Only 14 patients had a radiograph prior to lavage, and 50% of these documented malposition. The most common was excess tube insertion, stretching the stomach inferiorly towards the pelvis. The traditionally acceptable clinical test by auscultation of insufflated air was favorable in 100% of patients, thus failing to detect all of the malpositionings documented radiographically. We suggest that initial insertion of tube length be based on the patient's height or length using an adaptation of Strobel's previously published formula for esophageal pH probe placement: Tube Insertion Depth (TID), orogastric = 9.7 cm + (0.226 x length of patient in cm) and TID, nasogastric = 8 cm + (0.252 x length of patient in cm). These formulae have been displayed in graphic form for easy use. Diagnostic imaging remains the only certain means to document tube placement. Prospective studies to validate the formulae in clinical use are ongoing.