The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Gastric Lavage

by Rodd Daigle with
Patrick Hymel

Indications

• Accidental or intentional poisonings
  
• Ingestion of nontoxic or insignificant amounts of toxic substances
  
• Possible ingestion of strong alkalis
  
• Ingestion of hydrocarbons

Complications

• NEVER needlessly endanger yourself in order to care for a patient. If the patient is intoxicated, make sure that you have adequate assistance and/or medical immobilization so that you may perform this procedure safely.
  
• ALWAYS gown, mask (with eye protection) and glove. I would recommend shoe covers if they are available and you value your shoes.

Equipment

• Large diameter rubber gastric hose (32 - 50 French). See Figure 1.
  
• block or elliptical endoscopy bite block (if intubation is to be oral)
  
• Lubricating or local anesthetic jelly (if inserting a nasogastric tube)
  
• 50 ml catheter tipped syringe
  
• Tape
  
• Y connector and clamp
  
• Cuffed endotracheal (ET) tube
  
• 3 L tap water
  
• Activated charcoal (1 gm/kg) with Sorbitol (25 mg/kg)
  
• Note: ready - made lavage kits are often available

Procedure

1. Gown, mask (with eye protection) and gloves should ALWAYS be worn.
   
2. Detennine level of consciousness (LOC), if the patient has a decreased LOC then his airway-protective reflexes will be decreased, and aspiration of gastric contents into lungs is likely. If there is doubt, check for a gag reflex. If gag reflex is absent, or the Glasgow Coma Scale(GCS) is < 9- INTUBATE.
   
3. If the patient doesn't blink reflexively after touching the eyelashes, probably there is an impaired neuro exam and an unprotected airway, requiring a cuffed ET tube.
   
4. Place patient in the left lateral decubitus position with the head lowered about 10' (this decreases the passage of gastric contents into the duodenum during lavage, and reduces the possibility of pulmonary aspiration of gastric contents.
   
5. Restrain the uncooperative patient's hands.
   
6. Estimate tube length; it should stretch from the nose, around the ear and to the midepigastrum.
   
7. Tubes of 36 French or larger should be passed orally.
   
8. If performing nasogastric incubation, lubricate tubing with jelly.
   
9. Have patient put his chin on his chest to facilitate entrance of tubing into the esophagus.
   
10. Gently push tubing through nose or mouth.
    
11. Confirm tube's entrance into the stomach by auscultation over the gastric region while injecting air with the 50-ml catheter tipped syringe.
    
12. Carefully aspirate gastric contents, repositioning the lavage tube often.
    
13. Tape the lavage tube in place.
    
14. Administer tap water using the Y connector and clamping the drainage arm of the lavage tube.
    
15. Administer several aliquots of about 200 ml for adults and 10 ml/kg for children, draining after each infusion.
    
16. Continue lavage for 3 L after gastric returns are clear.
    
17. Activated charcoal (I gm/kg) is then introduced through the ravage tube.
    
18. Clamp the lavage tube, to avoid drippina fluid into the trachea, and gently pull out.
    
19. If repetitive doses of activated charcoal are to be administered, the lavage tube should be removed and a standard nasogastric tube should be inserted.

Complications

• Serious esophageal injury or perforation in cases of strong alkali ingestion.
  
• Pulmonary aspiration of gastric contents.
  
• Kinking of lavage tubing.
  
• Inadvertent tracheal incubation.
  
• Nasal mucosal and turbinate injury.
  
• Severe dilutional hyponatremia in children ravaged with tap water.
  
• Washing of gastric contents into duodenum.
  
• Mucosal injury or perforation of the stomach or lower esophagus
  
• Hypothermia due to cold lavage fluid.

Interpretation of Results

• When return lavage fluid does not clear, it is recommended to continue to lavage for at least an additional 3 L.
  
• Clear return fluids indicate that lavage was probably successful.

Follow-Up

• Activated charcoal (I gm/kg) is normally administered following lavage. A cathartic (sorbitol) may be added although the utility has not been demonstrated.
  
• CXR

Related Procedures

• There are some experts who recommend pushing a bolus of activated charcoal FIRST, BEFORE you begin aspirating gastric contents. It is thought that the charcoal is useful in this way due to the reflexive gastric emptying that occurs upon ravage. This way the charcoal gets pushed along with the ingestant (to absorb and deactivate it) as the ingestant get pushed into the small bowel
• Whole bowel irrigation. This is used in patients such as drug packers and those with sustained release tablet poisonings (such as iron, antihypertensives and some NSAIDS).
  
• Repetitive dose charcoal, multidose activated charcoal (MDAC)-Tylenol, aspirin, dilantin, theophylline, phenobarbital, and tricyclic antidepressants
  
• Ipecac-induced emesis. Rarely indicated. Absolutely contraindicated in caustic or hydrocarbon ingestion.