Ipecac Research Articles

Rapid Emesis from High-Dose Ipecac Syrup in Adults and Children Intoxicated with Antiemetics or Other Drugs

The effect of ipecac syrup as an emetic in adults as well as children who had ingested antiemetics or other drugs was evaluated. Adults or children over five years of age were given 30 ml of ipecac syrup followed by 360 ml of water; children aged one to five years were given 15 ml ipecac syrup followed by 240 ml of water. If emesis was not induced within 30 minutes, a second dose was administered. Of 232 patients studied (199 adults and 33 children), 188 (81%) vomited following the first dose, 34 (15%) required two doses and seven (3%) did not vomit. Of 63 patients who had ingested drugs with antiemetic properties, 51 (81%) vomited following the first dose, nine (14%) required a second dose and three (5%) did not vomit. The time from ipecac administration to the onset of emesis in all 232 patients averaged 24.2 minutes. Ipecac was successful in inducing rapid emesis in both adults and children who had ingested antiemetics or other drugs, probably as a result of its irritating effect on the gastric mucosa.

In Vitro Evidence for Ipecac Inactivation by Activated Charcoal

The in vitro adsorption of the alkaloid emetine, a primary constituent of ipecac, on activated charcoal was studied. The results support the supposition that syrup of ipecac should not be given to counteract poisonings if activated charcoal is also to be administered.

Acute digoxin poisonings: review of therapy

Acute digoxin poisoning, its recognition and management, are reviewed. The uses of syrup of ipecac, gastric lavage, activated charcoal, cholestyramine, colestipol, edetate sodium and cathartics as measures to terminate the drug exposure are discussed. Measures to hasten digoxin elimination, such as the use of furosemide, hemodialysis and digoxin-specific antibodies are reviewed. Supportive management may include treatment with atropine, phenytoin, lidocaine, propranolol, glucose, insulin and sodium polystyrene sulfonate. Proper management of digoxin poisoning involves the use of standard decontamination procedures (emesis or gastric lavage). Activated charcoal is strongly recommended, followed by rapidly acting cathartics. Antiarrhythmic therapy usually involves atropine sulfate and phenytoin sodium.

Evaluation of a community-based poison education program.

This study suggests that: (1) a program directed at a specific town and coordinated by a local community group is more effective in transmitting poison control knowledge than is a statewide poison prevention week effort; (2) that transmission of educational material is optimized through programs directed at a specific age group (in this study ages 6 through 14); and, (3) that information about where to get the poison center number and actual acquisition of Ipecac syrup in homes was well transmitted.

Is the Message Clear?

To the Editor.— In their letter to the editor, Syrup of Ipecac: The Poison Retriever (238:399, 1977), Greensher and Mofenson claim, Identifying ipecac syrup as 'the retriever' in advertising and education campaigns should avoid its confusion with other dangerous products and lead to its greater availability. Though their attempt to educate is laudable, I believe that their solution fails to communicate to the intended audience. Educational research indicates that many Americans do not understand the written materials they come in contact with daily. For this reason, many industries have begun to rewrite their consumer literature so that it will be more readable for the general public. Unfortunately, what specialists in a given field consider more readable language often fails to meet the reading requirements of the general public. The phrase poison retriever on a bottle may confuse more people than it educates. A reader may infer that the contents

Is the Message Clear?-Reply

In Reply. — Dr Rosen's well-intentioned letter misses our purpose, but we are pleased that the letter caught his attention. There were two points that we wished to bring to the attention of practicing physicians. There has been serious confusion of ipecac syrup with other potentially harmful products (Purepac Oil of Wintergreen and Purepac Tincture of Benzoin). Adopting a slogan identifying ipecac syrup as Poison Retriever in educating the lay public may avoid confusion. Pediatric care should include a discussion on safety and the hazards of poisonings. It is at this time that physicians can explain the need for obtaining Syrup of Ipecac—The Poison Retriever for the home that has toddlers. The picture of the dog and the slogan are intended for education and recall purposes, not as a logo for the already overcrowded label on a 30-ml bottle of ipecac syrup.

Syrup of Ipecac: The Poison Retriever

ABSTRACT To Editor.— Ipecac syrup has become primary means of treating many of poisonings in children. The Nassau County Poison Control Center has encountered two cases of serious confusion of of Ipecac with two similarly labeled products (Purepac Oil of Wintergreen and Purepac Tincture of Benzoin). There have also been instances of pharmacists being unaware that it may be dispensed in a 30-ml bottle without a prescription.We have adopted slogan Syrup of Ipecac—The Poison Retriever (Figure) in educating on poison prevention. Identifying ipecac syrup as the poison retriever in advertising and education campaigns should avoid its confusion with other dangerous products and lead to its greater availability in medicine cabinet of every family with a small child.

Toxicology of ipecac: a review.

The general effectiveness and safety of Ipecac syrup, per se, has not been questioned, but rather an attempt has been made to consolidate pertinent literature dealing with the toxic manifestations of Ipecac fluid extract. Ipecac contains both emetine and cephaeline and the toxicity of Ipecac fluid extract is consistent with reports on the toxicity of both compounds. The majority of the work has involved emetine since it is in higher concentration in Ipecac fluid extract than is cephaeline. Comparison of the clinical picture presented in syrup or fluid extract of Ipecac overdose and emetine toxicity in amebiasis treatment permits us to summarize the general characteristics of Ipecac alkaloid toxicity as involving primarily gastrointestinal, cardiovascular, and neuromuscular foci.

Death After Use of Cupric Sulfate as Emetic

To the Editor.— Cupric sulfate as an emetic in the management of drug poisoning 1 has generally been replaced by safer agents, ie, ipecac syrup and apomorphine hydrochloride. Despite recognized toxicity of cupric sulfate, 2 it has been used as an emetic because it produces gastric irritation and vomiting, thus preventing absorption. This report of fatal sequelae of the use of cupric sulfate as an emetic illustrates the danger of this practice. Report of a Case.— A 44-year-old woman was brought to the emergency room following ingestion of alcohol and diazepam. Vital signs and results of a physical examination were unremarkable. Cupric sulfate, 10 ml of a 10% solution, was administered twice. When the patient failed to vomit, her stomach was lavaged with 2 liters of saline; green material was obtained. Approximately one hour later, the patient was lethargic, blood pressure was 88/64 mm Hg; pulse rate, 90 beats per

A clinical comparison of syrup of ipecac and apomorphine use in adults

A prospective, randomized study was performed to compare syrup of ipecac to apomorphine as the emetic of choice in poisoning cases. Of the 28 adults studied, 15 patients (54%) received 30 ml of ipecac orally and 13 received 0.1 mg/kg apomorphine subcutaneously. Emesis was successfully induced with initial therapy in 13 of 15 (87%) ipecac-treated patients and 10 of 13 (77%) apomorphine-treated patients. In the ipecac group the mean latency period before onset of vomiting was 11.6 minutes (range 4 to 26 min) and in the apomorphine group, 5.3 minutes (range 2 to 13 min) (P less than .01). In the ipecac group, one patient suffered moderate central nervous system (CNS) depression. No hypotension or respiratory depression was observed in this group. In the apomorphine group significant CNS depression developed in eight patients (62%), hypotension developed in five (38%) and respiratory depression in one. There was no consistent relationship between type of poison ingested and occurrence of side effects.

Telephone management of poisonings using syrup of ipecac.

Seven hundred and seventy-six cases were studied during a six-month period to see if induction of emesis could be successfully managed at home by telephone. Emesis was successful in 98.8% of cases. In 6.7% of all cases, symptoms were found at 4-hour follow-up that were referrable to the ingestion, but all were considered to be of minor consequence. No complications of vomiting occurred. Twenty-four hour follow-up investigation indicated no significant complications of induction of emesis or complications from managing the patient by telephone. It is our conclusion that, with appropriate telephone supervision, home-induced emesis of ingestions expected to produce mild to moderate symptoms is as effective as emergency room or physician office management of cases. Furthermore, the absence of adverse affects of complications arising from the induction of emesis at home in our cases confirms that this form of management is quite safe.

Dr. Pierce Replies

Dr. Manoguerra is correct in noting discordance between the two articles included in the symposium on poisoning in childhood. It is generally accepted that the combined use of syrup of ipecac and activated charcoal requires deferring the administration of the activated charcoal until emesis has been induced. Since activated charcoal should be administered within 30 minutes of ingestion to achieve significant inhibition of drug absorption and since syrup of ipecac frequently requires 30 minutes to induce emesis, combined use of the two therapeutic modalities has been precluded.

The Use of Charcoal

In reading the recently published article by Dr. Alexander Pierce on salicylate poisoning, I noticed what appears to be an oversight on the part of the author. Dr. Pierce recommends giving syrup of ipecac followed by a charcoal slurry and then repeating the ipecac in 20 minutes if vomiting has not yet occurred. It is widely known that activated charcoal will adsorb ipecac and retard its emetic activity. Drs. Corby and Decker,2 in the same issue, refer to this interaction in discussing the use of activated charcoal.

Management of Acute Poisoning With Activated Charcoal

Activated charcoal has been shown to be an effective complexing agent for many drugs. The quantitative in vivo evidence accumulated thus far indicates that this agent can be a very valuable adjunct in the initial phases of treating acute ingestions not only in the emergency room but also as a first aid measure in the home. It is well tolerated in extremely high single doses, and there is no known contraindication to its use in treatment of acute drug ingestion. It is immediately effective upon ingestion and can be given safely by nonprofessionals; hence, its inclusion in household first-aid supplies is warranted. In the emergency room, activated charcoal can be administered by lavage tube to an unconscious patient in large and repeated doses and can be continued throughout the acute phase of the clinical illness. The effectiveness of activated charcoal can be enhanced by emesis induced by apomorphine before or after charcoal administration. Since charcoal effectively adsorbs ipecac, syrup of ipecac should be given before the activated charcoal. Although it is not uniformly efficacious for all drugs, activated charcoal appears to be a generally useful adjunct for gastrointestinal decontamination.

Apomorphine-naloxone controlled rapid emesis

The emergency treatment of most ingestion problems involves gastric lavage or induction of emesis. Forceful emesis, superior to lavage, is usually induced by syrup of ipecac. A more rapid, efficient and controlled method utilizing apomorphine hydrochloride and a narcotic antagonist has not been popular because of difficulties in determining dosage in addition to the problems raised by the depressant properties of both the apomorphine and its antagonists. The absence of depressant effects with the newer antagonist, naloxone hydrochloride, renders it safer for use in terminating emesis induced by apomorphine. A dose calculated schedule, based on a level of 0.066 mg/kg for apomorphine and 0.01 mg/kg naloxone is provided along with a simple protocol for the mixing and administration of the drugs in emergencies.

A comparison of ipecac syrup and apomorphine in the immediate treatment of ingestion of poisons

The safety and effectiveness of apomorphine and ipecac syrup were compared on arandomized basis in the treatment of acute poisoning by ingestion in 86 children. Onset of vomiting was more rapid with apomorphine than with ipecac. Children in the apomorphine group vomited a greater number of times. There was significantly more central nervous system depression with apomorphine. Both drugs had similar failure rates. The time gained by the use of apomorphine is probably not clinically significant, and the central nervous system depression caused by the drug constitutes the major drawback to its routine use.

Induced Emesis—A Questionable Procedure for the Treatment of Acute Poisoning

The effectiveness of various methods of inducing emesis in poisoning cases is reviewed. The risks involved in mechanical stimulation of the posterior pharynx following distension of the stomach with aqueous fluid are discussed. The oral administration of dry mustard powder, table salt, copper sulfate, zinc sulfate, tartar emetic and ipecac syrup, and the parenteral administration of apomorphine as emetics are discussed. It is concluded that some means for inducing vomiting are ineffective and others are of questionable reliability. The oral administration of activated charcoal may serve as an alternative to induced emesis in the treatment of poisoning.

Treatment of the poisoned child.

Syrup of ipecac has measurable advantages over gastric lavage in evacuating the stomach of children with accidental poisoning, in terms of safety, effectiveness, and rapidity of action. The average period for action with ipecac is likely to be about 17 minutes, or 82 minutes, depending on whether the child is treated at home or in hospital. In contrast, the mean delay to completion of gastric lavage is estimated at 126 minutes, and this procedure has little place in the treatment of the child with poisoning.

Over-the-Counter Cough Mixtures

To the Editor:— Numerous communications have indicated the use of over-the-counter cough mixtures in huge amounts by addicts as a source of narcotics and psychedelic drugs. A recent popular book speaks of a young man who frequently consumed large amounts of a most innocent-sounding cough mixture for this purpose. Additives to these syrups might effectively control this problem, as has been suggested in other forms of medication, and this might be most effective here. Many authorities recommend ipecac in subemetic dosage in the treatment of cough, croup, and asthma. The usual dose of ipecac syrup is 0.5 to 1.0 ml. If equivalent amounts of ipecac per teaspoon were added to cough medication, it might increase its antitussive effect. Many cough syrups could stand improvement! But the addition of ipecac in this amount per usual dose would amount to a substantial emetic effect in a bottle of 120 ml, which seems

Induction of emesis by detergent ingredients and formulations

Beagle dogs were given two general-purpose granular synthetic detergent formulations, a liquid synthetic detergent formulation, sodium alkylbenzenesulfonate, sodium sulfate, sodium tripolyphosphate (STP), tetrapotassium pyrophosphate (TKPP), a sodium silicate, and ipecac syrup by gastric intubation. All materials induced emesis. Emesis occurred rapidly from the granular formulations, the sodium silicate, STP, and TKPP. Intravenous apomorphine HCl was used to demonstrate the antiemetic effectiveness of pretreatment with subcutaneous chlorpromazine HCl (CPZ). Except for ipecac syrup and apomorphine HCl, pretreatment with CPZ did not alter the emetic responses from the above. Of the materials tested, STP and TKPP are believed to make the greatest contribution to the prompt emetic action of most synthetic detergent formulations. TKPP was essentially equal in emetic potency to STP. Emesis following administration of the synthetic detergent formulations and ingredients is considered to result from a direct action upon the gastrointestinal mucosa. Pretreatment with CPZ appeared to inhibit delayed (centrally induced) emesis, but did not affect early emesis from action of ipecac syrup upon the gastrointestinal mucosa.