First aid interventions by laypeople for acute oral poisoning.

BACKGROUND: Oral poisoning is a major cause of mortality and disability worldwide, with estimates of over 100,000 deaths due to unintentional poisoning each year and an overrepresentation of children below five years of age. Any effective intervention that laypeople can apply to limit or delay uptake or to evacuate, dilute or neutralize the poison before professional help arrives may limit toxicity and save lives. OBJECTIVES: To assess the effects of pre-hospital interventions (alone or in combination) for treating acute oral poisoning, available to and feasible for laypeople before the arrival of professional help. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, ISI Web of Science, International Pharmaceutical Abstracts, and three clinical trials registries to 11 May 2017, and we also carried out reference checking and citation searching. SELECTION CRITERIA: We included randomized controlled trials comparing interventions (alone or in combination) that are feasible in a pre-hospital setting for treating acute oral poisoning patients, including but potentially not limited to activated charcoal (AC), emetics, cathartics, diluents, neutralizing agents and body positioning. DATA COLLECTION AND ANALYSIS: Two reviewers independently performed study selection, data collection and assessment. Primary outcomes of this review were incidence of mortality and adverse events, plus incidence and severity of symptoms of poisoning. Secondary outcomes were duration of symptoms of poisoning, drug absorption, and incidence of hospitalization and ICU admission. MAIN RESULTS: We included 24 trials involving 7099 participants. Using the Cochrane 'Risk of bias' tool, we assessed no study as being at low risk of bias for all domains. Many studies were poorly reported, so the risk of selection and detection biases were often unclear. Most studies reported important outcomes incompletely, and we judged them to be at high risk of reporting bias.All but one study enrolled oral poisoning patients in an emergency department; the remaining study was conducted in a pre-hospital setting. Fourteen studies included multiple toxic syndromes or did not specify, while the other studies specifically investigated paracetamol (2 studies), carbamazepine (2 studies), tricyclic antidepressant (2 studies), yellow oleander (2 studies), benzodiazepine (1 study), or toxic berry intoxication (1 study). Eighteen trials investigated the effects of activated charcoal (AC), administered as a single dose (SDAC) or in multiple doses (MDAC), alone or in combination with other first aid interventions (a cathartic) and/or hospital treatments. Six studies investigated syrup of ipecac plus other first aid interventions (SDAC + cathartic) versus ipecac alone. The collected evidence was mostly of low to very low certainty, often downgraded for indirectness, risk of bias or imprecision due to low numbers of events.First aid interventions that limit or delay the absorption of the poison in the bodyWe are uncertain about the effect of SDAC compared to no intervention on the incidence of adverse events in general (zero events in both treatment groups; 1 study, 451 participants) or vomiting specifically (Peto odds ratio (OR) 4.17, 95% confidence interval (CI) 0.30 to 57.26, 1 study, 25 participants), ICU admission (Peto OR 7.77, 95% CI 0.15 to 391.93, 1 study, 451 participants) and clinical deterioration (zero events in both treatment groups; 1 study, 451 participants) in participants with mixed types or paracetamol poisoning, as all evidence for these outcomes was of very low certainty. No studies assessed SDAC for mortality, duration of symptoms, drug absorption or hospitalization.Only one study compared SDAC to syrup of ipecac in participants with mixed types of poisoning, providing very low-certainty evidence. Therefore we are uncertain about the effects on Glasgow Coma Scale scores (mean difference (MD) -0.15, 95% CI -0.43 to 0.13, 1 study, 34 participants) or incidence of adverse events (risk ratio (RR) 1.24, 95% CI 0.26 to 5.83, 1 study, 34 participants). No information was available concerning mortality, duration of symptoms, drug absorption, hospitalization or ICU admission.This review also considered the added value of SDAC or MDAC to hospital interventions, which mostly included gastric lavage. No included studies investigated the use of body positioning in oral poisoning patients.First aid interventions that evacuate the poison from the gastrointestinal tractWe found one study comparing ipecac versus no intervention in toxic berry ingestion in a pre-hospital setting. Low-certainty evidence suggests there may be an increase in the incidence of adverse events, but the study did not report incidence of mortality, incidence or duration of symptoms of poisoning, drug absorption, hospitalization or ICU admission (103 participants).In addition, we also considered the added value of syrup of ipecac to SDAC plus a cathartic and the added value of a cathartic to SDAC.No studies used cathartics as an individual intervention.First aid interventions that neutralize or dilute the poison No included studies investigated the neutralization or dilution of the poison in oral poisoning patients.The review also considered combinations of different first aid interventions. AUTHORS' CONCLUSIONS: The studies included in this review provided mostly low- or very low-certainty evidence about the use of first aid interventions for acute oral poisoning. A key limitation was the fact that only one included study actually took place in a pre-hospital setting, which undermines our confidence in the applicability of these results to this setting. Thus, the amount of evidence collected was insufficient to draw any conclusions.

Caracterização e avaliação morfológica da parte aérea de acessos de Psychotria ipecacuanha (Brot. ) Stokes (IPECA) / Caracterización y evaluación morfológica de partes aéreas de accesiones de Psychotria ipecacuanha (Brot. ) Stokes (IPECA) / Characterization and morphological evaluation of aerial parts of accessions of Psychotria ipecacuanha (Brot. ) Stokes (IPECA)

Introduction: The species Psychotria ipecacuana (Brotero) Stokes, Rubiaceae, commonly known as ipeca, ipecacuanha or poaia, is under threat of genetic erosion and in danger of extinction. Objectives: Identify and evaluate the morphological characters of accessions of Psychotria ipecacuana and identify their descriptors. Methods: A study was conducted of 17 accessions of Psychotria ipecacuana preserved in vivo at EMBRAPA Eastern Amazonia for 19 morphological characters of the aerial parts of the plant, thirteen qualitative and six quantitative. Of this total, twelve were subjected to multivariant analysis. Principal component analysis was used to select the descriptors. Results: Accessions of Psychotria ipecacuana fluctuated for most characters, and seven were qualitative and nonvariable. Two characters were considered redundant and ten were selected as descriptors. Genetic dissimilarity ranged from 0.19 to 0.77 with a mean value of 0.55, and could be separated into two groups with various subgroups and six different groups by the UPGMA and Tocher methods, respectively. The characters plant height and first branch height were the main contributors to the discrepancy between the accessions. Conclusions: Accessions of Psychotria ipecacuana display great morphological variation in the aerial part of the plant, with ten characters selected as descriptors for the species. These data about the species had never been published before, and they constitute the basis for management at the germplasm bank when selecting characters of interest for improvement programs as well as to provide key information facilitating the identification of specimens from natural or planted ecosystems(AU)

Introducción: la especie Psychotria ipecacuana (Brotero) Stokes, Rubiaceae, popularmente conocida como ipeca, ipecacuanha o poaia, se ve amenazada por la erosión genética y en peligro de extinción. Objetivos: identificar y evaluar accesos del Banco Activo de Germoplasma de Psychotria ipecacuana por caracteres morfológicos, e identificar los descriptores. Métodos: se estudiaron 17 accesiones de Psychotria ipecacuana, conservado in vivo en Embrapa Amazonia Oriental, para 19 caracteres morfológicos de la parte aérea de la planta, siendo trece cualitativo y seis cuantitativo. De este total doce fueron sometidos a análisis multivariante. La selección de descriptores se llevó a cabo mediante el análisis de componentes principales. Resultados: los accesos de Psychotria ipecacuana fluctuaron para la mayoría de los caracteres, sendo siete variables cualitativas y no variables. Dos caracteres se consideraron redundante y diez seleccionados como descriptores. La disimilitud genética varió desde 0,19 hasta 0,77 con una media de 0,55 y se dejó separar en dos grupos con diversos subgrupos y seis grupos diferentes por métodos UPGMA y Tocher, respectivamente. Los caracteres altura de las plantas y altura de la primera rama fueron los principales contribuyentes a la discrepancia entre los accesos. Conclusiones: los accesos de Psychotria ipecacuana tienen una amplia variación morfológica de la parte aérea de la planta con diez caracteres fueran considerados descriptores para esta especie. Estos datos son inéditos para la especie y forman la base para la gestión de banco de germoplasma, en la selección de caracteres de interés para los programas de mejoramiento y para proporcionar información clave que facilitará la identificación de especímenes en los ecosistemas naturales o plantados(AU)

Introdução: a espécie Psychotria ipecacuanha (Brotero) Stokes, Rubiaceae, conhecida popularmente como ipeca, ipecacuanha ou poaia, encontra-se ameaçada de erosão genética e em vias de extinção. Objetivos: caracterizar e avaliar acessos do Banco Ativo de Germoplasma de Psychotria ipecacuanha por caracteres morfológicos, e identificar descritores. Métodos: foram estudados 17 acessos de Psychotria ipecacuanha, conservados in vivo na Embrapa Amazônia Oriental para 19 caracteres morfológicos da parte aérea da planta, sendo treze qualitativos e seis quantitativos. Desse total doze foram submetidos às análises multivariadas. A seleção dos descritores foi realizada pela análise de componentes principais. Resultados: os acessos de Psychotria ipecacuanha apresentaram variações para boa parte dos caracteres, sendo sete qualitativos não variáveis. Dois caracteres foram considerados redundantes e dez selecionados como descritores. As dissimilaridades genéticas variaram de 0,19 a 0,77 com média de 0,55 e permitiram separar os acessos em dois com vários subgrupos e seis grupos divergentes pelos métodos UPGMA e de Tocher, respectivamente. Os caracteres Altura da planta e Altura da primeira ramificação foram os que mais contribuíram para a divergência entre os acessos. Conclusões: os acessos de Psychotria ipecacuanha possuem ampla variação morfológica para a parte aérea da planta com dez caracteres sendo considerados descritores para essa espécie. Estas informações são inéditas para a espécie e servirão de base para o manejo do banco de germoplasma, na seleção de indivíduos de interesse dos programas de melhoramento e para fornecer informações fundamentais que facilitarão a identificação de espécimes em ecossistemas nativos ou plantados(AU)

Caracterização e avaliação morfológica da parte aérea de acessos de Psychotria ipecacuanha (Brot. ) Stokes (IPECA) / Characterization and morphological evaluation of aerial parts of accessions of Psychotria ipecacuanha (Brot. ) Stokes (IPECA)

Introduction: The species Psychotria ipecacuana (Brotero) Stokes, Rubiaceae, commonly known as ipeca, ipecacuanha or poaia, is under threat of genetic erosion and in danger of extinction. Objectives: Identify and evaluate the morphological characters of accessions of Psychotria ipecacuana and identify their descriptors. Methods: A study was conducted of 17 accessions of Psychotria ipecacuana preserved in vivo at EMBRAPA Eastern Amazonia for 19 morphological characters of the aerial parts of the plant, thirteen qualitative and six quantitative. Of this total, twelve were subjected to multivariant analysis. Principal component analysis was used to select the descriptors. Results: Accessions of Psychotria ipecacuana fluctuated for most characters, and seven were qualitative and nonvariable. Two characters were considered redundant and ten were selected as descriptors. Genetic dissimilarity ranged from 0.19 to 0.77 with a mean value of 0.55, and could be separated into two groups with various subgroups and six different groups by the UPGMA and Tocher methods, respectively. The characters plant height and first branch height were the main contributors to the discrepancy between the accessions. Conclusions: Accessions of Psychotria ipecacuana display great morphological variation in the aerial part of the plant, with ten characters selected as descriptors for the species. These data about the species had never been published before, and they constitute the basis for management at the germplasm bank when selecting characters of interest for improvement programs as well as to provide key information facilitating the identification of specimens from natural or planted ecosystems(AU)

Introducción: la especie Psychotria ipecacuana (Brotero) Stokes, Rubiaceae, popularmente conocida como ipeca, ipecacuanha o poaia, se ve amenazada por la erosión genética y en peligro de extinción. Objetivos: identificar y evaluar accesos del Banco Activo de Germoplasma de Psychotria ipecacuana por caracteres morfológicos, e identificar los descriptores. Métodos: se estudiaron 17 accesiones de Psychotria ipecacuana, conservado in vivo en Embrapa Amazonia Oriental, para 19 caracteres morfológicos de la parte aérea de la planta, siendo trece cualitativo y seis cuantitativo. De este total doce fueron sometidos a análisis multivariante. La selección de descriptores se llevó a cabo mediante el análisis de componentes principales. Resultados: los accesos de Psychotria ipecacuana fluctuaron para la mayoría de los caracteres, sendo siete variables cualitativas y no variables. Dos caracteres se consideraron redundante y diez seleccionados como descriptores. La disimilitud genética varió desde 0,19 hasta 0,77 con una media de 0,55 y se dejó separar en dos grupos con diversos subgrupos y seis grupos diferentes por métodos UPGMA y Tocher, respectivamente. Los caracteres altura de las plantas y altura de la primera rama fueron los principales contribuyentes a la discrepancia entre los accesos. Conclusiones: los accesos de Psychotria ipecacuana tienen una amplia variación morfológica de la parte aérea de la planta con diez caracteres fueran considerados descriptores para esta especie. Estos datos son inéditos para la especie y forman la base para la gestión de banco de germoplasma, en la selección de caracteres de interés para los programas de mejoramiento y para proporcionar información clave que facilitará la identificación de especímenes en los ecosistemas naturales o plantados(AU)

Introdução: a espécie Psychotria ipecacuanha (Brotero) Stokes, Rubiaceae, conhecida popularmente como ipeca, ipecacuanha ou poaia, encontra-se ameaçada de erosão genética e em vias de extinção. Objetivos: caracterizar e avaliar acessos do Banco Ativo de Germoplasma de Psychotria ipecacuanha por caracteres morfológicos, e identificar descritores. Métodos: foram estudados 17 acessos de Psychotria ipecacuanha, conservados in vivo na Embrapa Amazônia Oriental para 19 caracteres morfológicos da parte aérea da planta, sendo treze qualitativos e seis quantitativos. Desse total doze foram submetidos às análises multivariadas. A seleção dos descritores foi realizada pela análise de componentes principais. Resultados: os acessos de Psychotria ipecacuanha apresentaram variações para boa parte dos caracteres, sendo sete qualitativos não variáveis. Dois caracteres foram considerados redundantes e dez selecionados como descritores. As dissimilaridades genéticas variaram de 0,19 a 0,77 com média de 0,55 e permitiram separar os acessos em dois com vários subgrupos e seis grupos divergentes pelos métodos UPGMA e de Tocher, respectivamente. Os caracteres Altura da planta e Altura da primeira ramificação foram os que mais contribuíram para a divergência entre os acessos. Conclusões: os acessos de Psychotria ipecacuanha possuem ampla variação morfológica para a parte aérea da planta com dez caracteres sendo considerados descritores para essa espécie. Estas informações são inéditas para a espécie e servirão de base para o manejo do banco de germoplasma, na seleção de indivíduos de interesse dos programas de melhoramento e para fornecer informações fundamentais que facilitarão a identificação de espécimes em ecossistemas nativos ou plantados(AU)

Position paper update: ipecac syrup for gastrointestinal decontamination.

CONTEXT: An update of the first position paper on ipecac syrup from 1997 was published by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists in 2004. The aims of this paper are to briefly summarize the content of the 2004 Position Paper and to present any new data. METHODS: A systematic review of the literature from the year 2003 forward. RESULTS: The literature search yielded a limited number of meaningful articles, and there remains no convincing evidence from clinical studies that ipecac improves the outcome of poisoned patients. Furthermore, the availability of ipecac is rapidly diminishing. CONCLUSIONS: The routine administration of ipecac at the site of ingestion or in the emergency department should definitely be avoided. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. There is not sufficient evidence to warrant any change in the previous ipecac position papers. There are, however, insufficient data to support or exclude ipecac administration soon after ingestion of some specific poisons in rare situations.

Effects on a Poison Center's (PC) triage and follow-up after implementing the no Ipecac use policy.

For years, The American Academy of Pediatrics (AAP) had supported home use of syrup of Ipecac. However, due to mounting evidence that Ipecac use did not improve outcome nor reduce Emergency Department (ED) referrals, the AAP in November of 2003 issued a statement that Ipecac not be used for the home management of poison ingestion. To determine if the cessation of the use of Ipecac for home ingestions is associated with an increased number of follow-up calls, an increased time of observation at home and an increase in the number of ED referrals for care by poison center staff were administered. Fifty randomly selected pediatric (<6 years) cases that received Ipecac ("Ipecac" group) from January 1, 2003 to October 31, 2003 were selected for study. Up to two controls ("no Ipecac" group) were matched by age, amount ingested, and by toxin. Controls were selected from the 2004-2006 time period (Ipecac no longer in use). Fifty "Ipecac" cases and 84 "no Ipecac" controls were analyzed. The groups had no significant differences with respect to percent symptomatic, median time post-ingestion, mean age, and distribution of toxin categories (e.g., antidepressants, beta blockers, etc.). The "no Ipecac" group had nearly ten times the odds of ED referral compared to the "Ipecac" group, (OR = 9.9, 95%CI 3.3-32.2). The mean total hours of follow-up was not significantly different between the groups (diff = -1.1, t = -1.8, p = 0.07). The mean number of follow-up calls was significantly less in the "no Ipecac" group (diff = -1.4 calls, t = -6.8, p < 0.001). Toxicology consults were greater in the "no Ipecac" group (chi (2 )= 4.05, p = 0.04); however, consults were not associated with ED referral. For the time period from 2004 to 2006, the "no Ipecac" policy resulted in an increase in ED referrals at our center. While prior studies have shown that not using Ipecac did not affect clinical outcome, our research suggested that it may have initially influenced triaging outcome. Since the use of Ipecac by centers was once a commonly used home remedy for some ingestions (albeit without rigorously established efficacy), poison center personnel had to transition to the "no Ipecac" policy. Although our referrals increased during a transitional period of time, referral rates have since stabilized and returned to baseline.

The outcome of North American pediatric unintentional mushroom ingestions with various decontamination treatments: an analysis of 14 years of TESS data.

The optimum empiric decontamination therapy for unintentional pediatric mushroom ingestion is not known. We sought to determine case outcomes for unintentional mushroom ingestions in children by decontamination therapies utilized. The 1992-2005 American Association of Poison Control Centers Toxic Exposure Surveillance System was queried for cases of unintentional acute mushroom ingestions in children age <6 years. Cases were excluded if outcome was unknown, if exposure was coded as unrelated to the symptoms, or if there was co-ingestion of a non-mycoid substance. The treatment subgroups analyzed were ipecac, single-dose activated charcoal, and no gastric decontamination. 82,330 cases met the inclusion criteria with 22,454 cases excluded. There were 16 cases with major effects and no deaths. There were 57,531 cases in the three treatment subgroups. There was a significantly smaller percentage of cases with moderate or major outcomes in the ipecac subgroup compared to the no decontamination subgroup. There was a significantly greater percentage of cases with moderate or major outcomes in the activated charcoal compared to the no decontamination subgroup. If decontamination therapy is being performed, and this data suggests it may not be necessary, syrup of ipecac could still be considered an effective option.

Responding to pediatric poisoning.

Make sure you know how to act quickly if a child ingests a toxic substance and what to teach parents to prevent accidental poisonings.

Gastrointestinal decontamination of the poisoned patient.

Gastrointestinal decontamination has been a historically accepted modality in the emergency management of oral intoxicants. Theoretically, gastric and whole-bowel emptying procedures hinder absorption, remove toxic substances, prevent clinical deterioration, and hasten recovery. This article presents a current overview of gastrointestinal decontamination. It challenges the accepted precepts of gut decontamination and assesses the utility of syrup of ipecac-induced emesis, orogastric lavage, single-dose-activated charcoal, cathartics, and whole-bowel irrigation.

Five common toxins ingested by dogs and cats.

When a dog or cat ingests a common household toxin, rapid decontamination is critical. This article provides treatment recommendations for some of the most common toxicoses in dogs and cats, along with a summary table for quick reference.

Ipecacuanha: the South American vomiting root.

The story of ipecacuanha, derived from the plant Cephaelis, is a fascinating one. It was discovered in Brazil in the 1600s and then transported to Paris in the latter part of the same century. It was used there by the physician Helvetius on various members of the French royal court to treat the flux (dysentery) with some success. Later, in the eighteenth century, it was taken up by the physician and privateer Thomas Dover and became, with opium, a fundamental constituent of his celebrated powder, which was used widely to treat fevers and agues for the next 200 years. Progress was then delayed until the early 1800s when the School of Chemistry at Paris established that the dried root of ipecac contained two powerful alkaloids, emetine and cephaeline, that consistently caused vomiting and diarrhoea. The discovery of the pathogenic amoeba, Entamoeba histolytica, in the latter part of the nineteenth century, allowed a distinction to be made between the two main forms of dysentery (amoebic and bacillary). Emetine was shown to be active against the amoebic form of dysentery but ineffective against that caused by bacteria. Ipecacuanha, its root and the pure alkaloid emetine have now been abandoned on the grounds of toxicity. They have been replaced by safer, more effective compounds. Nevertheless, they deserve an honoured place in the history of medicine, especially in the search for an effective treatment for amoebic dysentery.

Pediatric toxicology.

Pediatric patients present unique concerns in the field of medical toxicology. First, there are medicines that are potentially dangerous to small children, even when they are exposed to very small amounts. Clinicians should be wary of these drugs even when young patients present with accidental ingestions of apparently insignificant amounts. Next, over-the-counter laxatives and syrup of ipecac, although not commonly considered abused substances, may be misused in both the setting of Munchausen's syndrome by proxy and in adolescents who have eating disorders. Their use should be considered in any gastrointestinal illness of uncertain origin. Finally, as the use of syrup of ipecac at home now has been discouraged by many, some have explored using activated charcoal at home as a new method of prehospital gastrointestinal decontamination. The literature examining activated charcoal and its use in this capacity is discussed.