Lavage or not to lavage – hazards due to deviation from National Guidelines

K A Naser,I B Gawarammana,R A Abeysekara

doi:10.4038/jccp.v49i1.7842

Abstract

Self-poisoning with organophosphorus (OP) compounds has contributed to a large number of deaths in the developing world over many decades. While, most deaths are due to the inherent properties of the OP compounds, an important sub group of patients die due to iatrogenic causes, prevention of which will reduce death rates. In most developing countries, there is no continuous medical education of doctors who deliver primary care in rural villages which lead to iatrogenic deaths and disability. We present two patients who presented unconscious to primary care units following ingestion of OP compounds. Both patients received gastric lavage by medically unqualified personnel, with unprotected airways and without informed consent. Both patients were transferred to a specialized unit with an unprotected airway and both aspirated gastric contents which lead to mechanical ventilation and prolonged hospital stay. In both cases, the medical management deviated from accepted good clinical practice and National Guidelines. Reducing deaths from pesticide self-poisoning would require a coordinated effort involving new antidote development and optimizing medical care given to these patients at both primary and tertiary care units. Minimizing iatrogenic causes of morbidity and mortality would require a National approach at undergraduate and postgraduate levels. New mechanisms to improve knowledge of resuscitation, airway management and adherence to good clinical practice by primary care doctors should be initiated.

Highlights

Self-poisoning with pesticides is a major public health problem across the Asia Pacific Region[1]
It is estimated that globally 250-370,000 people die from pesticide poisoning each year[2]
Following an extensive review of the literature, the American and European academies of toxicology recommend that gastric lavage should not be employed routinely, if ever, in the management of poisoned patients and that the results of clinical studies in overdose patients weigh heavily on the side of showing a lack of beneficial effect[5]

Summary

Introduction

Self-poisoning with pesticides is a major public health problem across the Asia Pacific Region[1]. Gastric lavage with a Ryle's nasogastric tube has been performed by an attendant and transferred to a tertiary health care hospital after ninety minutes following ingestion. On admission the patient was drowsy (GCS 8/15), charcoal was seen coming out from nose and mouth, had bilateral lung crepitations, blood pressure was 120/ 70mmHg, pulse rate 78 bpm. Patient required only two 0.6mg boluses of Atropine (total dose of 1.2mg) to counteract cholinergic signs During hospital stay he developed pneumonia and was discharged after 11 days. On admission to the toxicology unit, the patient was drowsy (GCS 8/15), had bilateral pin point pupils, blood pressure 110/70 mmHg, pulse rate 80 beats per minute, and there were bilateral lung crepitations with a peripheral Oxygen saturation of 85%.

Discussion

World Health Organisation