**7. Decontaminations**

Decontamination of poisoned patient means remove the patient from the toxin and remove the toxin from patient, either outside patient's body by gross washing or inside the body by gastrointestinal decontamination or enhance elimination.

Enhanced elimination methods are not routinely used in poisoned patients. The indications

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Multiple dose activated charcoal (MDAC): it can be used in cases of carbamazepine,

Extracorporeal elimination (e.g. haemodialysis, hemofiltration, and haemoperfusion, plasma-

Antidote is a substance that can prevent further poisoning from specific substances. The table below showing most common antidote used in emergency department (see **Table 1**) [4].

First time acetaminophen had been clinically used was in 1950 and since that time acetaminophen become most common over-the-counter antipyretic and analgesic used in public. Acetaminophen is the most common cause of acute liver failure in the United States [9, 10].

Acetaminophen metabolized in the liver and converted to nontoxic metabolites via glucuronidation (40–67%) and sulfation (20–46%). In therapeutic doses of acetaminophen, the small amount of NAPQI formed which detoxified by conjugation with reduced glutathione (GSH). Glutathione is an important tripeptide which is reduced in a NADPH dependent reaction,

In large overdoses of APAP, the usual pharmacokinetic pathways are overwhelmed and saturation of the nontoxic pathways occurs. Endogenous glutathione is depleted and NAPQI cannot be detoxified. Leaving excess NAPQI to bind to intracellular proteins, cause cell death [11].

Symptoms are frequently nonspecific or absent in early Acetaminophen toxicity.

Can be used in cases of lithium, carbamazepine, salicylates, theophylline, and toxic.

for Enhanced elimination include [4]:

• Slow endogenous rate of elimination

Phenobarbital, Dispone sever toxicities,

pheresis and exchange transfusion:

**8. Acetaminophen poisoning**

and used to reduce oxidants (such as NAPQI).

**8.1. Mechanism of action**

**8.2. Clinical features**

• Poor outcome despite supportive care/antidote

There are different techniques to enhance elimination:

Can be used in cases of Salicylates Phenobarbitone.

Alcohols: ethylene glycol and methanol metformin.

• Severe toxicity

Urinary alkalinisation:

**7.6. Antidotes**

#### **7.1. Gross decontamination**

Patient must be fully undressed and washed thoroughly with copious amount of water; all the clothing must be removed, and decontamination must be in isolated specific area. Gross decontamination used in chemical, biological and radiation exposure.

#### **7.2. Gastrointestinal decontamination**

There are multiple methods used for gastrointestinal decontamination including:

Emesis and gastric Lavage.

Induced vomiting by ipecac syrup and gastric lavage: those methods were used in the past and now rarely indicated because there is no evidence supporting them. They can decrease absorption and they may also increase the risk of complications. Syrup ipecac and gastric Lavage may be considered in conscious, alert patients with ingestion of potentially number of toxic drugs and present in a very short time after ingestion (<1 h). Contradictions includes: unprotected airway, Corrosive/hydrocarbon ingestion and unstable patient status (hypotensive-seizure) [6].

#### **7.3. Activated charcoal**

Activated charcoal is super-heating carbonaceous material. Activated charcoal works by reducing the absorption of substance in the gastrointestinal lumen but it is not effective in metal, alcohols, corrosive, and lithium. Most effective action can be achieved when activated charcoal is given within the first hour of ingestion. Contraindications: absent gut motility or perforation, caustic ingestion and unprotected airway (can be given through nasogastric tube if patient intubated).Complications: aspiration of activated charcoal led to pneumonitis, ARDS and other complications such as small bowel obstruction [7].

#### **7.4. Whole-bowel irrigation**

Whole-bowel irrigation is a mechanical cleansing of the whole gastrointestinal track reducing toxin absorption. The whole-bowel irrigation can be done by Polyethylene glycol solution. Indication includes: substance with a prolonged absorption phase like sustained released medication, potential toxin not absorbed by activated charcoal such—(metals, lithium) and Body packers or suffers. Adverse effects of whole bowel irrigation could be: vomiting, bloating and rectal irritation. Contradiction: absent bowel sound or perforation [8].

#### **7.5. Enhanced elimination**

Enhanced elimination is a method used to increase the rate of toxic removal from the body so reducing the severity and duration of clinical intoxication.

Enhanced elimination methods are not routinely used in poisoned patients. The indications for Enhanced elimination include [4]:

• Severe toxicity

**7. Decontaminations**

252 Essentials of Accident and Emergency Medicine

**7.1. Gross decontamination**

Emesis and gastric Lavage.

**7.3. Activated charcoal**

**7.4. Whole-bowel irrigation**

**7.5. Enhanced elimination**

**7.2. Gastrointestinal decontamination**

gastrointestinal decontamination or enhance elimination.

decontamination used in chemical, biological and radiation exposure.

ARDS and other complications such as small bowel obstruction [7].

ing and rectal irritation. Contradiction: absent bowel sound or perforation [8].

reducing the severity and duration of clinical intoxication.

There are multiple methods used for gastrointestinal decontamination including:

Decontamination of poisoned patient means remove the patient from the toxin and remove the toxin from patient, either outside patient's body by gross washing or inside the body by

Patient must be fully undressed and washed thoroughly with copious amount of water; all the clothing must be removed, and decontamination must be in isolated specific area. Gross

Induced vomiting by ipecac syrup and gastric lavage: those methods were used in the past and now rarely indicated because there is no evidence supporting them. They can decrease absorption and they may also increase the risk of complications. Syrup ipecac and gastric Lavage may be considered in conscious, alert patients with ingestion of potentially number of toxic drugs and present in a very short time after ingestion (<1 h). Contradictions includes: unprotected airway, Corrosive/hydrocarbon ingestion and unstable patient status (hypotensive-seizure) [6].

Activated charcoal is super-heating carbonaceous material. Activated charcoal works by reducing the absorption of substance in the gastrointestinal lumen but it is not effective in metal, alcohols, corrosive, and lithium. Most effective action can be achieved when activated charcoal is given within the first hour of ingestion. Contraindications: absent gut motility or perforation, caustic ingestion and unprotected airway (can be given through nasogastric tube if patient intubated).Complications: aspiration of activated charcoal led to pneumonitis,

Whole-bowel irrigation is a mechanical cleansing of the whole gastrointestinal track reducing toxin absorption. The whole-bowel irrigation can be done by Polyethylene glycol solution. Indication includes: substance with a prolonged absorption phase like sustained released medication, potential toxin not absorbed by activated charcoal such—(metals, lithium) and Body packers or suffers. Adverse effects of whole bowel irrigation could be: vomiting, bloat-

Enhanced elimination is a method used to increase the rate of toxic removal from the body so


There are different techniques to enhance elimination:

Multiple dose activated charcoal (MDAC): it can be used in cases of carbamazepine, Phenobarbital, Dispone sever toxicities,

Urinary alkalinisation:

Can be used in cases of Salicylates Phenobarbitone.

Extracorporeal elimination (e.g. haemodialysis, hemofiltration, and haemoperfusion, plasmapheresis and exchange transfusion:

Can be used in cases of lithium, carbamazepine, salicylates, theophylline, and toxic.

Alcohols: ethylene glycol and methanol metformin.

#### **7.6. Antidotes**

Antidote is a substance that can prevent further poisoning from specific substances. The table below showing most common antidote used in emergency department (see **Table 1**) [4].
