Is gastric lavage (stomach pumping) recommended as a treatment for poisoning or overdose?

Gastric Lavage is NOT Recommended for Routine Use in Poisoning or Overdose

Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients, as there is no evidence showing it improves clinical outcomes and it may cause significant morbidity including aspiration pneumonia, perforation, and dysrhythmias. 1, 2

Evidence Against Routine Use

Lack of Clinical Benefit

• Multiple position statements from the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists consistently conclude that gastric lavage lacks proven benefit in improving patient outcomes 1, 3, 2
• A prospective study of 808 overdose patients found that gastric lavage did not reduce emergency department length of stay, intubation time, or ICU length of stay 4
• The same study demonstrated that gastric lavage was actually associated with higher rates of ICU admissions (P = .0001) and aspiration pneumonia (P = .0001) 4
• Experimental studies show highly variable amounts of marker removal that diminish rapidly with time 1, 2

Significant Risks and Complications

• Serious complications include: hypoxia, cardiac dysrhythmias, laryngospasm, gastrointestinal or pharyngeal perforation, fluid and electrolyte abnormalities, and aspiration pneumonitis 2
• Recent publications continue to demonstrate that gastric lavage may be associated with serious complications 1

Absolute Contraindications

Gastric lavage must never be performed in the following situations:

• Loss of airway protective reflexes unless the patient is first intubated tracheally 3, 2
• Corrosive ingestions (strong acids or alkalis) as they can cause severe tissue damage and perforation 5, 3, 2
• Hydrocarbon ingestion with high aspiration potential 3, 2
• Risk of gastrointestinal hemorrhage due to underlying medical or surgical conditions 2

Rare Exceptions Where Gastric Lavage Might Be Considered

If gastric lavage is considered at all, it should only be in extremely rare circumstances meeting ALL of the following criteria:

• Patient has ingested a potentially life-threatening amount of poison 3
• Presentation is within 60 minutes of ingestion (some sources suggest 1-2 hours maximum) 3, 6
• The substance ingested is not amenable to activated charcoal and the amount is too great for charcoal alone 6
• The patient has a secured airway (intubated if protective reflexes are impaired) 3, 2
• The procedure is performed only by individuals with proper training and expertise 1

Even when these criteria are met, clinical benefit has not been confirmed in controlled studies 3

Preferred Alternative: Activated Charcoal

Activated charcoal is the preferred decontamination method over gastric lavage in most poisoning cases 7, 6

Activated Charcoal Guidelines:

• Should be administered within 2 hours of ingestion (up to 4 hours for certain substances like nortriptyline and paracetamol) 7, 6
• Requires an intact or secured airway 7
• Standard dose is 1-2 g/kg body weight 7
• Not effective for: iron, lithium, alcohols, ethylene glycol, alkalis, fluoride, mineral acids, potassium, and corrosive substances 7
• Multiple-dose activated charcoal may be beneficial for substances with enterohepatic circulation (theophylline, carbamazepine, quinine, dapsone, phenobarbital) 7, 6

Clinical Data from Poisoning Cases

In systematic reviews of poisoning cases (ethylene glycol and salicylate), gastric lavage was used in only a minority of patients:

• In ethylene glycol poisoning: gastric lavage was performed in only 47 of 446 cases (10.5%) 8
• In salicylate poisoning: gastric lavage was used in only 18% of cases 8

These low utilization rates in published case series reflect the current consensus against routine use.

Critical Pitfalls to Avoid

• Do not delay airway protection to perform gastric lavage 7, 9
• Do not use gastric lavage routinely when activated charcoal is the evidence-based alternative 7, 9
• Do not attempt gastric lavage for caustic ingestions, as this can worsen tissue damage 5
• Always contact poison control centers for expert guidance before considering any decontamination method 7, 9
• Never allow lay rescuers to perform gastric lavage without direction from poison control or emergency medical personnel 7

Algorithm for Decontamination Decision-Making

1. Secure the airway first - ensure adequate oxygenation and ventilation 7, 9
2. Identify the substance - determine if it binds to activated charcoal 7
3. Assess timing - determine time since ingestion 7, 6
4. Rule out contraindications - check for caustic ingestion, hydrocarbon ingestion, or impaired airway reflexes 7, 5, 2
5. Contact poison control for expert guidance 7, 9
6. Administer activated charcoal if appropriate (within 2 hours, substance binds to charcoal, no contraindications) 7, 6
7. Consider gastric lavage only in the extraordinarily rare case meeting all criteria above, and only if performed by trained experts 1, 3