Emergency Care

Emergency Care/ Injuries and Poisonings Cervical Spine Injuries Wound Management Bites and Stings Minor Burns Seizures Gastrointestinal Decontamination

David Kramer, M.D.

1

Cervical Spine Injuries   

Cervical spine injuries are uncommon in children. They are

Uncommon in children

really not that uncommon in children, but because injuries to the

Higher fulcrum in children causes most injuries to be upper

C-spine in childhood are usually to the upper C-spine, they are

C-spine

frequently fatal. So if we were to look at trauma related fatalities

"Adult" pattern of injury occurs after 8 years of age

in young children, we would find quite a number of upper Cspine injuries. In an emergency department it is quite uncommon to see a child come in with a C-spine injury without a terribly morbid series of other injuries. The typical frontal impact in an automobile accident, where the head comes forward, that fulcrum being higher in the C-spine causes the injuries to be C1,C2 or C3 in a vast majority of children less than eight years of age. Once they are over eight, that fulcrum is down around C6. And after eight years of age, you'll see more of an adult pattern of C-spine injuries in children.

2

Evaluation of Cervical Spine Injuries 

Every child who has had a bump on the head does not need C-

Clinical "clearing" of C-spine Injuries

spine x-rays. We frequently will "clear" a C-spine clinically.

• Normal level of consciousness

However, if there is any question, we'll leave the collar in place

• Normal neurological examination

and we will do radiographs. First of all, the child needs a normal

• No neck pain

level of consciousness. And people ask, "At what age does a

• No neck tenderness

child really have a normal level of consciousness?" A coopera-

• No "distracting" injury, such as an abdominal injury

tive four or five-year-old who can tell us that the neck doesn't

• Full voluntary range of motion

hurt is in many cases a child whose neck can be cleared clinically. But again, the younger they are and the less cooperative, the less likely we are to trust the clinical approach for clearing the C-spine after a significant head injury. Of course, we want a normal neurological examination. No neck pain and no neck tenderness. Any serious injury, any femur fracture or another very painful injury, can cause endogenous endorphin release and can cause a child to really be distracted from the neck injury. And so when a child says there is no neck pain when there is another very serious painful injury, we don't trust that the absence of reporting really means that the neck is not injured. And then once we have gone through these various parameters, we'll ask a child to fully move the neck voluntarily. If we've met all of these criteria, then we'll take the C-spine collar off.

The presence of a collar when a child arrives to the Emergency Department does not obligate one to obtain C-spine films. Conversely, the fact that a child arrived in the Emergency Department without a collar doesn't mean it is inappropriate for you to put one on if you think it is indicated. So we are not required to continue what are perhaps the mistakes of others. I would use your own independent judgment to determine whether or not a collar should be placed or perhaps can be removed without radiographs.

3

Radiographic Evaluation of Cervical Spine Injuries

Radiographs include three views, a lateral and anteroposterior, from which I get very little information, and then the open-mouth odontoid view. Recognizing the odontoid is the part of the C-

• Lateral

spine most frequently fractured in C-spine injuries in young

• Anteroposterior

children, we really want to exclude a fracture of the odontoid in

• Open-mouth odontoid view

children with head and neck injuries. If there is any question,

- Flexion/extension views, CT scan, MRI as needed

either clinically or from these radiographs, flexion or extension views are obtained to look for ligamenta injury. CT scan or MRI can be ordered to better clarify the status of the cervical spine.

The most common reading of a pediatric C-spine that is not abnormal

but

may

appear

a

bit

abnormal

is

the

pseudosubluxation C2 on C3. It can also occur on C4. Radiographically, the C2 seems to ride forward on C3, but the posterior elements align. And the more the neck is flexed, the more exaggerated the C2 on C3 pseudosubluxation will appear. It is challenging to read C-spine films in children because there is much more cartilage. Furthermore, even with significant C-spine fractures, there is more recoil, so when they come to the Emergency Department the fractured fragments may be better aligned and the neck may be more in place. Children can injure their spinal cord without a radiographic abnormality. The typical situation involves a child that has a significant injury and a transient, either paralysis or paresthesias that are reported, and then a period where, by clinical examination, they appear to be okay, or children who have persistent neurologic deficits, and in cases where there is a suspicion, based on the neurological exam or based on the specific history, you need to worry about a spinal cord injury without an obvious fracture. In those cases, a CT scan, or even better an MRI, are useful.

With C2 on C3 pseudosubluxation, bringing the chin down both widens the prevertebral soft tissue and causes C2 to ride forward a bit on C3. If you look at a line between the spinous process of C1, C2 and C3, you can see there is pretty good alignment, indicating that it's a pseudosubluxation and not a true subluxation. This is the ring of C1, C2, and the odontoid, the normal predental space and the rest of the cervical spine. This is just another diagram of a C2 on C3 pseudosubluxation that rides forward a bit and you can see that the line through the posterior elements lines up. Whereas in this particular patient where there

4

Cervical Spine Injuries Interpretation

is a real subluxation of C2 on C3, you draw a line from here to here and it misses the cortex of the spinous process of C1. Now,

of Radiographs

that is a subtle finding but there is also prevertebral soft tissue swelling and clinical symptomatology. So if there is any question

 

C2-3 pseudosubluxation increases with neck flexion Radiolucent cartilage and greater recoil to normal position after fracture makes interpretation of pediatric C-spine

about whether the subluxation is a pseudosubluxation or a real subluxation, look at the clinical examination and leave the collar in place if there is a persistent concern.

radiographs challenging



Spinal cord injury without radiographic abnormality

Most severe motor vehicle injuries involve a frontal impact. With a frontal impact in the forward facing restrained passenger, the head will fly forward and it will pull C1 forward on C2. The ligaments that run behind the odontoid can cause pressure and push anteriorly on the odontoid and cause a type-2 fracture of the odontoid. And this, far and away, is the most common significant C-spine injury that we see in children. It is particularly seen in kids in forward facing car seats where they are adequately restrained. Furthermore, it is a little bit of a tricky injury because these children do not impact with the interior of the car and so they are not necessarily bruised. They are not necessarily bleeding, and they may look relatively well, but still have an injury. It usually involves quite a significant deceleration with a frontal impact.

5

Management of Cervical Spine Injuries

With children who have C-spine injuries, all emergency care starts with "airway, breathing and circulation". The C-spine

 

Support Airway, Breathing, and Circulation Immobilize the cervical spine in all children with suspected C-spine injury to prevent secondary injury



Optimal immobilization requires stiff collar and spine board with shoulder mattress pad or occipital recess

needs to immobilized in all children with suspected C-spine injury and that includes a stiff collar and immobilization on a spine board. An occipital recess or shoulder mattress pad is best for proper alignment. But recognize that even with full immobilization, there is still 10-15º of movement of the cervical spine. We don't know if that is very significant or not, but certainly if a C-spine injury has occurred we want to make every effort to prevent any secondary injury through proper immobilization.

6

Wound Management--Lacerations Wound management. Tetanus prophylaxis needs to be consid-

General Principles

       

ered. For lacerations of the hand or other parts of the body, it is

Support Airway, Breathing, Circulation

important to do a neurologic assessment and an assessment for

Tetanus Prophylaxis

tendon involvement. The neurologic assessment needs to take

Neurologic assessment before injecting anesthetic

place before instilling the lidocaine. Because some degree of

Assess tendon function

weakness can be the result of the lidocaine infusion and once the

Remove foreign material

numbing has taken place, our ability to assess the neurologic

Débride devitalized tissue

function is greatly reduced. You want to remove as much foreign

Decontaminate with voluminous saline irrigation

material from the wound as possible. Débride any devitalized

Consider antibiotic prophylaxis for high risk wounds

tissue.

All wounds are contaminated to some degree. Our goal isn't to sterilize the wound, but it is to reduce the bacterial counts. There is a clear relationship between bacterial counts in a wound when it is closed and the likelihood of developing a wound infection. To reduce bacterial counts, irrigation with large volumes of saline is the most effective way to cleanse the wound. If the child has a very small, superficial wounds in a highly vascular area, one need not use 3 liters of fluid to decontaminate. But for wounds where the risk is high, either because of location or by mechanism of injury, using a large volume of saline with significant pressure will help to decontaminate. Consider antibiotic prophylaxis for high risk wounds. High risk wounds, like facial wounds, should be treated because of the risk of cosmetic problems, even though facial wounds get infected quite infrequently. And then hand wounds and extremity wounds, especially highly contaminated hand and extremity wounds. These get infected at a higher rate than wounds in more vascular areas.

7

Wound Management of Lacerations For wound closure, we all live in fear that if we were to use

Wound Closure

epinephrine-containing lidocaine in the toes or in the ears, that



Do not use epinephrine containing anesthetic on fingers,

the toes would fall off. People I know who are podiatrists say they

nose, ear

routinely use epinephrine-containing solutions in surgery on the

Débride jagged margins

foot and never have problems with it. I think there is probably not

    

Close subcutaneous dead space Undermine if margins are difficult to approximate Evert wound margins Approximate--don't strangulate--with sutures

much reason to include the epinephrine and I think to be safe I want you to avoid epinephrine in distribution of end arteries. You want to debride jagged margins because wound closure will better be affected and cosmetic result will be improved if we are reapproximating relatively straight margins.

You need to close the subcutaneous dead space. If one only closes the overlying skin and with continued transudation of fluid and perhaps persistent bleeding, a collection of fluid or a hematoma develops below the closed wound. That will be a nidus for a thick scar which will distort the surface of the skin. And even if the skin closure is beautiful, if there is some elevation or depression from the subcutaneous scarring, the cosmetic result from the wound closure will be inferior. So you want to close subcutaneous dead space. Sometimes the margins are difficult to reapproximate, in which case undermining, which is really loosening up the skin at the wound margin from the subcutaneous tissue so there is really less tension in the skin, can be a useful technique. And if possible, we want to put in sutures to try to evert the wound margins for optimum cosmetic result. We don't want to suture too tightly. We want to approximate, not strangulate the wound.

8

Wound Management of Lacerations -Special Situations

Then there are some special situations like wounds that occur at the Vermillion Border. What we know is that without an exact







reapproximation of the Vermillion Border, there will be a very

Vermillion Border - exact re-approximation is required for

visible scar. And even half a millimeter of misalignment is quite

a good cosmetic result. Consider consulting a plastic

noticeable, especially on the front of a child's face like this. Make

surgeon.

sure that exact margin reapproximates. I would have a low

Highly contaminated wounds, and non-facial wounds over

threshold for consulting a plastic surgeon if you have wounds

18 hours old, can be decontaminated, dressed, and left

through the Vermillion Border. In particular, oblique wounds

open for 3-5 days for delayed closure.

through the Vermillion Border are difficult to perfectly

Puncture wounds should be cleansed and observed.

reapproximate.

Foreign bodies should be removed



Delayed development of Pseudomonas osteomyelitis is associated with puncture wounds through sneakers.

Highly contaminated wounds and non-facial wounds that are over 18 hours old are at great risk for developing wound infections. Dressing a wound like that, starting a child on oral antibiotic, bringing them back at three to five days for a delayed closure of that wound when it has already declared itself as to whether or not it will get infected is probably a wise choice. Wounds of the scalp or of the face get infected so infrequently, probably because of the higher vascular nature of those tissues, that they can probably be safely closed without increasing the infection rate even beyond the 18 hours time. If it is a very contaminated wound, if it's a wound on a piece of farm machinery, military wounds, other kinds of highly contaminated wounds, we may be more careful with our closure. But a fresh, sharp wound, even if there is a delay, can be safely closed in certain locations.

Puncture wounds should be cleansed externally. Just cleansing the skin is reasonable, making sure there are no remaining foreign bodies that need to be removed.

Children who have a puncture wound through a sneaker are at risk for developing Pseudomonas osteomyelitis. Pseudomonas osteomyelitis usually comes from the Pseudomonas that resides within the insole of most sneakers - in that moist, wet environment. There is probably direct inoculation by the nail which comes up through the sneaker and then into the bone. We don't have

prophylactic

antibiotics

to

prevent

Pseudomonas

osteomyelitis. Ciprofloxacin, if we can use it in the younger child, may be effective. But this is a rare complication that occurs weeks later. It is not the same time course that you will see with a cellulitis from a wound two or three days later presenting with signs of infection.

9

Bites and Stings--Rabies Rabies is a problem we deal with on a regular basis, although I

 

The prevalence of rabies varies geographically. Local

haven't seen a case of rabies in a child in my lifetime. But rabies

public health authorities should be consulted.

has become endemic in the wild animal population in many parts

Bites by Domestic Animals. When the animal can be

of the country. If you are practicing in a part of the country where

observed for 10 days, rabies prophylaxis is generally not required



Bites, scratches, and saliva exposures from wild carnivores (especially racoon, skunk, fox and bat) require prophylaxis



Bites by rodents (rats, mice, squirrels) and lagomorphs

rabies is endemic, it is important to recognize the risks that it poses. Bites by domestic animals that can be observed do not require rabies prophylaxis. If the animal can be observed for seven to ten days and the animal does not get sick within that time frame, then we can be assured that the animal does not have rabies. Often the public health authorities will take over and make follow-up phone calls to make sure the animal remains healthy.

(rabbits) are usually considered no risk Where we really have to worry much more are with bites and even scratches because often there is saliva on the paws of rabid animals and it is in the saliva that the rabies virus resides. Especially wild carnivores like raccoons, skunks, foxes and bats. They require rabies prophylaxis. Bites by rodents and lagomorphs, that is rabbits, are usually no risk. So many people will come in and say my child was bitten by a mouse or by a rat and, rabies is not a concern in those cases. Mostly wild carnivores or even sick domestic animals can have rabies.

10

Rabies Once the decision is made to offer postexposure immunization,



Postexposure Immunization

we do both passive immunization and active immunization.

•

Rabies Immune Globulin (RIG) 20 IU/kg. Half in wound

Rabies immune globulin 20 IU/kg is administered half in the

and half IM (separate from human diploid cell vaccine

wound and half given intramuscularly. The human diploid cell

below)

vaccine is given intramuscularly, but not in the gluteal region

•

Human Diploid Cell Vaccine (HDCV). 1 cc IM (not gluteal) given on days 1, 3, 7, 14, and 28

because some treatment failures have been noted with a gluteal administration of the human diploid cell vaccine. The rabies virus is taken up by the nerves and it is transported retrograde to the brain. So children who have bites on the face by potentially rabid animals need to be dealt with a little differently because there is less retrograde transport time when it starts so close to the brain. In cases like that, immunization should take place even if the animal can be observed because you would not want to wait the seven to ten days to determine if the animal is rabid. Retrograde transport of the virus to the brain for facial wounds may have already taken place.

Nonpoisonous snakes generally have an oval-shaped head and a round pupil and most poisonous snakes are in the pit viper family where they have a triangular head and elliptical pupils. They look much more evil.

11

Poisonous Snake Bites The coral snake is a poisonous snake with a different kind of



Identify snake if possible.

venom that is not a pit viper. If you want to remember, "Red on

•

Nonpoisonous: These snakes have an oval head and

yellow, kill a fellow." that will help you identify a coral snake

round pupil

from some of the others. The water snake has a tendency to bite

•

Pit Vipers: These snakes have a triangular head and elliptical pupil

•

Coral Snake: Black-yellow-red-yellow band pattern. "red on yellow, kill a fellow"

but you can see that the head is not triangular and his pupil is round. The copperhead has a triangular shape and an elliptical pupil. It is a member of the pit viper family, which is a venomous or poisonous snake. Some pit viper bites can be potentially lethal, especially for a child. The milk snake coloring can easily be mistaken for a coral snake, but the red is not adjacent to the yellow.

12

Management of Poisonous Snake Bites

Management of poisonous snake bites. The typical pit viper bite is extremely painful, causes inflammation, and local intravascular

     

coagulation at the site of the bite. In the field we want to manage

Support Airway, Breathing, and Circulation.

"airway, breathing and circulation." We want to minimize the

Immobilize the extremity below level of the heart.

distribution of the venom. Not all pit viper bites involve the

Place a wide constriction band proximal to the bite. Avoid

injection of venom. So there are dry bites where there will be a

prolonged full vascular occlusion.

bite but there will really be no venom reaction. But we don't want

Transport to hospital.

to take a chance that a venom reaction will develop. We want to

General wound care

immobilize below the level of the heart. A wide, constricting band

Laboratory Evaluation: ABG. CBC, CBC, coagulation

is placed proximal to the bite to minimize the venous return and

profile, type and screen, electrolytes, BUN, creatinine

the lymphatic return and minimize dissemination of the venom. Certainly a very tight, localized band can cause a tourniqueting effect and cause vascular insufficiency and one wants to avoid that. And rapid transport to a hospital. Venomous snake bites can cause a necrotic reaction and a lot of swelling of the foot.

Once they reach your office or the Emergency Department, we need to do general wound care, consider tetanus and all of the other things. We want to observe and see if there is much of a venom reaction locally. Laboratory evaluation should include an ABG, a CBC, a coagulation profile because the local intravascular coagulation can cause a consumptive coagulopathy and you can get a prolonged coagulation profile. Type and screen is recommended. And then for children who have really systemic effects from the venom, you may want to check electrolytes, BUN and creatinine.

The decision to give antivenin therapy needs to be approached with the help of your poison control center. There are some people who have treated snake bites who feel that more people die from complications of antivenin therapy than from the snake bite itself. This is highly allergenic stuff. And for severe snake bites, the risk-benefit probably favors administering antivenin therapy. But for every poisonous snake bite, we don't need to give antivenin therapy and risk those complications. Furthermore, a test dose is given for those who are candidates to receive the antivenin therapy and see if there is an allergic type reaction. If a bite has occurred, but the local reaction does not seem severe enough to warrant antivenin therapy, one need not give a test dose of antivenin and one can withhold the antivenin therapy and observe for four to six hours to see if the local reaction progresses.

Coral snake bites cause much less local reaction, just some local

13

Spider Bites

redness. But the venom of a coral snake is different and causes a more systemic effect. The bite itself is not as painful and causes cramping, muscle weakness. So there is more of a systemic,



Brown Recluse

neurologic response to the venom of the coral snake than the

•

more local response to the venom from pit vipers.

•

Violin shape on back. Wound care of local necrosis. Débride if necrosis is greater than 2 cm.

•

Consider antibiotic prophylaxis.

•

Dapsone is contraindicated in children.

Spiders. There are really two in the United States to be concerned about. It is interesting that the brown recluse spider, has a venom that causes local necrosis. In these cases, we really only need to provide local wound care and significant debridement if there is a large area of necrosis that looks greater than 2 cm. Antibiotic prophylaxis. And although dapsone is used in adults with brown recluse spider bites, it is not recommended in children because it is not particularly effective.

This black widow spider a is much more insidious type of bite because the bite of a black widow spider is painless. Hours later, a child can develop the more neurologic type symptoms. The venom causes generalized pain, muscle stiffness and nausea. In very severe black widow spider bites, in young children in particular, cardiovascular collapse can occur and there are reports of fatalities. There is antivenin available if you know it is a black widow spider bite. For the muscle stiffness, diazepam and calcium gluconate are recommended.

14

Spider Bites--Black Widow Minor burns. First aid for minor burns involves preventing any

   

Generalized pain, muscle stiffness and nausea occur 1-8

further burning, running the burn under cold water. These are

hours after painless bite

things to tell the family when they call you on the telephone about

Cardiovascular collapse is more likely in children

a child with a burn. A burn is a wound and it can be tetanus prone

Latrodectus antivenin

so you need to consider tetanus prophylaxis. If there are large

Consider calcium gluconate and diazepam for cramps

bullae that are ruptured, you want to debride that devitalized tissue. The easiest way to debride most second degree burns is by rubbing with some sterile gauze. Unruptured bullae should be left intact. In that case, you essentially have a sterile, biological dressing at least for a day or two while the burn itself can start to heal. And so leave unruptured bullae intact.

15

Minor Burns We want to dress with an antibiotic cream, again to reduce the

    

First Aid

burn colonization. We are not going to sterilize the burn but

Tetanus prophylaxis

reduce the numbers of organisms and reduce the likelihood of

Débride dead tissue, but leave unruptured bullae intact

developing infection. We usually use Silvadene cream but

Dress with antibiotic ointment or cream

bacitracin can be used. Parents should change the dressing once

The parent should change dressing once or twice daily

or twice a day and observe for signs of infection. If the burn is

and observe for signs of infection



Larger burns (>2%), facial burns, and burns over joints should be referred to a plastic surgeon



Burns of the buttocks are often a sign of child abuse

really greater than 2% or in a cosmetically important area, over joints, or anything else about the burn that you are worried about, you may want to have them follow up with a plastic surgeon or a burn specialist. Be particularly aware that burns of the buttocks are seldom accidental. The toddler toilet-trained who soils himself may be punished by having his buttocks put under scalding hot water. If you see burns of the buttocks, you need to be very suspicious that is an abusive injury.

16

Seizures - Management Seizures are relatively common. Simple febrile seizures usually



Initial management of seizures -

stop before we see them although sometimes they start in our

•

ABC-Dextrose

waiting room so we do have occasion to observe them. Families

•

Antipyretics if febrile

think the child is dying and even physicians who have seen lots

•

Anticonvulsants

of seizures get very nervous when the child is seizing in front of

1.

seizures > 10 minutes

2.

seizures associated with significant oxygen desaturation

3.

Diazepam, 0.2 mg/kg/dose or

4.

Lorazepam, 0.1 mg/kg/dose IV, slowly. Repeat in 5 minutes if seizure activity continues.

5.

us. If the child is having a seizure, but is adequately oxygenated and has adequate glucose, there is no reason to take drastic measures that can cause complications. We can observe that seizure for a brief period of time. We want to try to maintain an airway. Make sure breathing and circulation are okay. Check the dextrose. If it is a febrile seizure, antipyretics can function as anticonvulsants.

Diazepam, 0.5 mg/kg/dose, rectally if vascular access is unavailable

Anticonvulsants. Most kids who have seized at home and arrived at the Emergency Department have been seizing for more than 10 minutes. If they start seizing in our waiting room, we will watch them for a bit. Seizures associated with significant desaturation should be treated immediately with anticonvulsants. Diazepam or Lorazepam are our first anticonvulsants of choice. Diazepam may have a slightly faster onset, Lorazepam has a longer duration of action. It is not just the total dose of benzodiazepine that is given that is associated with apnea, but the rapidity with which it is infused. So we infuse these things slowly. When a child is having seizure, oxygen and dextrose and the benzodiazepine is given slowly. Rectal Diazepam is very useful for kids with seizure disorders for parents to administer at home or in cases where vascular access is difficult. One or 2 cm past the anal verge, 0.5 mg/kg has a relatively rapid onset and can be used.

17

Gastrointestinal Decontamination-Emesis

GI decontamination. Ipecac is first aid in the home, followed with some fluid. Vomiting almost always occurs with ipecac, but if it



 

doesn't, one need not remove ipecac from the stomach. In

Ipecac is first aid in the home

children with anorexia nervosa who chronically abuse ipecac, a

- Infants 10 mL

cardiomyopathy was demonstrated. But a single dose of ipecac

- Children 15 mL

for a toddler who has ingested something is not going to have any

- Adolescents 30 mL

cardiac toxicity even if the child doesn't vomit.

Follow ipecac with 8 oz fluid If vomiting does not occur (rare), ipecac does not need to be removed from the stomach

18

GI Decontamination--Gastric Lavage Gastric lavage. If you want to get large pill fragments, one needs

   

Large-bore orogastric tube necessary to retrieve pill

to use a large-bore orogastric tube. Often, intubation is necessary

fragments

to use a tube large enough to get pill fragments. The left side

Left side down to delay gastric emptying

down will delay gastric emptying and that is the way proper

Use isotonic fluid until clear

gastric lavage is conducted. Isotonic fluid is given until it is clear.

Rarely more effective than charcoal alone

It is rarely more effective than charcoal alone and so most of us use very little lavage and will give charcoal. Occasionally there will be a child who refuses to drink the charcoal and if we are putting an NG-tube down to administer charcoal, we may do a little bit of lavage but it is not usually more effective than the charcoal alone.

19

GI Decontamination--Activated Charcoal

Charcoal binds most large molecules nonspecifically. We usually give 1 gm/kg either p.o. or ng. The first dose should be with a

 

 



cathartic, sorbitol. And there is an unfortunate problem of

Nonspecific binding of most poisons

children vomiting the charcoal. Some of the charcoal usually

Activated charcoal alone is as effective as gastric empty-

stays down, but removing the tube may prevent some of the

ing (lavage or emesis) followed by charcoal in most

vomiting. Repeated doses of charcoal increase the clearance for

situations

drugs that undergo enterohepatic recirculation. So drugs are

Give 1 g/kg po/ng with cathartic

absorbed, re-excreted in the bile, they have a second pass through

Repeated doses of charcoal increase clearance for drugs

the gut where the charcoal can bind them. Other drugs can be

that undergo enterohepatic recirculation and those that

dialyzed across the GI mucosa by creating a column of charcoal

can be dialyzed across the GI mucosa

from the stomach to the anus. So in certain cases, repetitive doses

Repeated doses of charcoal should not include cathartic

of charcoal can be given. We don't want to give a cathartic with every dose of charcoal because of problems with diarrhea.

Phenobarbital is a molecule that is not highly protein bound that is being dialyzed across the gut mucosa. So repetitive dose activated charcoal for many drugs is very useful.

20

GI Decontamination -- Whole Bowel Irrigation

For drugs like iron, or for lithium, or some of the alcohols, which tend to be small molecules that don't bind to charcoal or for the



 

slow release preparations which can agglutinate in the gut, we can

Drugs not bound by charcoal (lithium, iron, alcohols) and

flush them through the absorptive portion of the gut by using

slow release preparations can be removed by whole bowel

whole bowel irrigation, 500 cc/hour for toddlers and that almost

irrigation with polyethylene glycol solutions

always needs to be given Ng. Some older kids will drink a

Toddlers 500 cc/hr po/ng

liter/hour but most of them need to get the fluid ng. Golytely, a

Adolescents 1 liter/hr po/ng

balanced electrolyte solution, can be given in huge volumes without there being fluid and electrolyte shifts of any significance. Paint chips in the gut can be removed by whole bowel irrigation. Whole bowel irrigation is another very effective technique for gastrointestinal decontamination particularly when charcoal is ineffective.

21