When is gastric lavage indicated in acute poisoning?

Gastric Lavage Indications in Acute Poisoning

Gastric lavage should not be performed routinely and is only justified in extremely rare circumstances: when a patient has ingested a potentially lethal amount of a toxin, presents within 1-2 hours of ingestion, has a secured airway (intubated if obtunded), and trained personnel are available. 1, 2

Current Evidence Against Routine Use

The American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists explicitly recommend against routine gastric lavage due to lack of proven clinical benefit and significant potential for harm. 1, 3, 2 The 2013 position paper update reinforces that there is no evidence supporting routine use, and the evidence for benefit even in special situations remains weak. 2

Key Supporting Data:

• In ethylene glycol poisoning cases, gastric lavage was performed in only 10.5% of patients, demonstrating its limited role even in severe poisonings. 4
• Multiple studies show highly variable toxin removal that diminishes rapidly with time, with no controlled trials demonstrating improved clinical outcomes. 3, 2

Specific Indications (When Rarely Considered)

Gastric lavage may only be considered when ALL of the following criteria are met: 1, 5

• Timing: Ingestion occurred within 1-2 hours (maximum benefit within 60 minutes) 1, 3, 5
• Severity: Potentially life-threatening amount ingested 1, 3
• Airway protection: Patient is intubated or has intact airway reflexes 1, 3
• Trained personnel: Individuals with proper training and expertise are available 2
• Substance characteristics: Toxin forms concretions or requires urgent mechanical removal 6

Absolute Contraindications

Never perform gastric lavage in: 1, 3

• Corrosive ingestions (acids or alkalis) - causes severe tissue damage and perforation 1, 3
• Hydrocarbon ingestions with high aspiration potential 3
• Unprotected airway in obtunded patients without intubation 1, 3
• Prolonged time since ingestion (>1-2 hours) 1, 5
• Insignificant ingestions 6

Preferred Alternative: Activated Charcoal

Activated charcoal is the preferred decontamination method in most poisoning cases and should be administered within 2 hours of ingestion. 1, 7 The standard dose is 1-2 g/kg body weight. 1, 7

Activated Charcoal Advantages:

• Works through adsorption rather than mechanical removal 7
• Can provide benefit up to 2-4 hours post-ingestion for certain toxins 7
• Lower complication rate compared to gastric lavage 1
• May reduce drug absorption by approximately 23% when given 2-4 hours post-ingestion 7

Activated Charcoal Limitations:

• Ineffective for iron, lithium, alcohols, ethylene glycol, alkalis, fluoride, mineral acids, and potassium 7
• Requires intact airway or secured airway 7
• Contraindicated in corrosive ingestions 7

Documented Complications of Gastric Lavage

Gastric lavage carries significant risks: 1, 6

• Aspiration pneumonia 1, 6
• Cardiac arrhythmias and dysrhythmias 1, 6
• Esophageal or gastric perforation 1, 6
• Laryngospasm 1
• Hypoxia 1
• Accidental tracheal intubation 1, 6
• Electrolyte imbalances 1, 6
• Nasal trauma 6
• Hypothermia 6

Pediatric Considerations

Gastric lavage has extremely limited utility in children and should be avoided. 1 If absolutely necessary in a pediatric patient, a large-caliber orogastric tube (24-28 French) must be used, with recognition of higher complication risk due to smaller airway size. 1

Clinical Algorithm for Decision-Making

Step 1: Stabilize airway, breathing, and circulation first 7

Step 2: Determine time since ingestion:

• If >2 hours: Do not perform gastric lavage; consider activated charcoal only if appropriate 1, 5
• If <1-2 hours: Proceed to Step 3 1, 5

Step 3: Assess substance type:

• Corrosive or hydrocarbon: Absolutely contraindicated 1, 3
• Non-lethal amount: Do not perform 6
• Potentially lethal amount: Proceed to Step 4 1

Step 4: Assess airway protection:

• Unprotected airway in obtunded patient: Intubate first or do not perform 1, 3
• Protected airway: Proceed to Step 5 1

Step 5: Consider activated charcoal instead in nearly all cases 1, 7

Step 6: Only perform gastric lavage if trained personnel available and all above criteria met 2

Common Pitfalls to Avoid

• Never delay airway protection to perform gastrointestinal decontamination 7
• Never perform gastric lavage routinely based on outdated protocols 3, 2
• Never use in corrosive ingestions - this causes additional severe harm 1, 3
• Always contact poison control centers (1-800-222-1222) for expert guidance before attempting any decontamination 7
• Never attempt without proper training - complications are frequent and serious 2