Pediatric Gastrointestinal Decontamination Clinical Pathway

Pediatric Gastrointestinal Decontamination Risk Management Pitfalls

Risk Management Pitfalls:

1. “I wanted to do SOMETHING for this child. His parents brought him all the way here and were very worried.” Perhaps the hardest thing to do for children who present after an ingestion is nothing. When a child presents more than 1 hour after ingestion, there is no conclusive evidence for decontamination of any method.

2. “He was too sleepy to drink the activated charcoal, so we gave it via NG tube.” Children with depressed mental status are at high risk of aspiration and should have an airway secured prior to any method of decontamination. It is essential to thoroughly assess the patient’s mental status, including his or her ability to protect the airway, before treatment.

3. “If a patient presents with an overdose, I pump the stomach! Isn’t that standard of care?” Gastric lavage, or ‘pumping the stomach,’ is not standard of care for adults or children who have ingested a toxin. The available evidence shows that it adds no benefit to SDAC in poisoned patients. In addition, it carries a significant risk of aspiration.

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Pediatric Gastrointestinal Decontamination Case Study

Case Study:
Late in your evening shift in the emergency department (ED), you receive a call from your local EMS unit. They are on the way to the ED with a 3-year-old male. About an hour ago, he came to his mother complaining of nausea and abdominal pain. When questioned, he admitted to playing with medication bottles in the upstairs bathroom. His mother found several open bottles and pills scattered about the bathroom. She states that “many” pills were missing from several of the bottles. The medications included prenatal vitamins, acetaminophen, a diuretic, a beta-blocker, and 2 other medications in unlabeled bottles that were left in the home by the boy’s grandmother. The boy cannot say when he took the pills, but the mother states that he had been playing alone upstairs for about an hour prior to complaining of abdominal pain. The boy is awake and alert with stable vital signs. Your charge nurse pulls a 40 French orogastric tube from the supply room and asks, “Should we pump his stomach?”

Case Study Conclusion:
You reassure the charge nurse that this awake and alert child with a normal heart rate and blood pressure does not need gastric lavage. From a detailed interview with the mother, you determine that the child may have ingested these pills between 1 and 2 hours ago. A call to the grandmother reveals that she had left some penicillin and aspirin at the home. A complete physical examination shows no abnormalities. After phone consultation with poison control and your local toxicologist, you order a urine toxicology screen, aspirin level, acetaminophen level (to be drawn in 3 hours), iron level (to be drawn in 3 hours), 12- lead electrocardiogram, and 1 g/kg of activated charcoal. He takes the charcoal orally without incident. You ask the social worker to do an assessment of the family and discuss poison prevention with them while you wait for his labs. All of his laboratory values are normal, and he remains stable and asymptomatic during his ED stay. After 8 hours, he is discharged from the ED with plans to follow up by phone with social work and poison control.

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