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Background and Objectives: Identifying international differences in the management of acute pediatric poisonings may help improve the quality of care. The objective of this study was to assess the international variation and appropriateness of gastrointestinal decontamination (GID) procedures performed in children and adolescents who present with acute poisonings to emergency departments., Methods: This was an international, multicenter, cross-sectional prospective study including children <18 years with poisoning exposures presenting to 105 emergency departments in 20 countries from 8 global regions belonging to the Pediatric Emergency Research Networks. Data collection started between January and September 2013 and continued for 1 year. The appropriateness of GID procedures performed was analyzed using the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists' recommendations. Multivariate logistic regression was performed to identify independent risk factors for performing GID procedures., Results: We included 1688 patients, 338 of whom (20.0%, 95% confidence interval 18.1%-22.0%) underwent the following GID procedures: activated charcoal (166, 49.1%), activated charcoal and gastric lavage (122, 36.1%), gastric lavage (47, 13.9%), and ipecac (3, 0.9%). In 155 (45.8%, 40.5%-51.2%), the GID procedure was considered appropriate, with significant differences between regions. Independent risk factors for GID procedures included age, toxin category, mechanism of poisoning, absence of symptoms, and the region where the intoxication occurred ( P < .001)., Conclusions: Globally, there are substantial differences in the use and appropriateness of GID procedures in the management of pediatric poisonings. International best practices need to be better implemented., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

There has been considerable publicity about the lack of benefit and potential dangers of syrup of ipecac. In November 2003, the American Academy of Pediatrics recommended against its use. Pharmacies in Houston, Texas were surveyed by telephone before (survey 1) and after (survey 2) the American Academy of Pediatrics' recommendation to determine whether ipecac availability changed. There were 126 pharmacies interviewed at survey 1, and 128 interviewed at survey 2. Pharmacies in survey 1 were more likely than those in survey 2 to sell ipecac (79% versus 64%, P < .01) and to have it in stock (75% versus 48%, P < .001). Pharmacies mostly stored ipecac on the shelves (67%, survey 1; 59%, survey 2, P = .27). Although syrup of ipecac availability has declined significantly, it is still available in more than 50% of pharmacies. Health care providers should advise against its use and advocate that pharmacies remove it.

Objective: To describe the frequency of alternative medication use in bulimia nervosa (BN), and to review available nonprescription emetic (ipecac) and laxative products and their potential toxicities., Method: Survey data were collected from 39 consecutive treatment-seeking patients with BN or subthreshold BN. Survey data of the available nonprescription and herbal products from local retail stores were also collected. Toxicology information was reviewed on these agents from MEDLINE and herbal textbooks., Results: Ipecac use occurred in 18% of the 39 patients. Laxatives had been used at some point to control weight or "get rid of food" by 67% of the patients. Of these, 31% had abused laxatives during the month prior to evaluation. In the product survey, 248 laxative-containing products were identified., Conclusion: There are numerous laxative products readily available to patients, and many of them have significant associated toxicities. Patients with BN tend to endorse high rates of laxative use. While ipecac is used infrequently, it can have deleterious consequences. Patients with BN should be screened for use of both ipecac and laxatives and should be educated about the potential consequences associated with the misuse of these agents.

Objective: To investigate how poisons centres advise on management of common drug poisonings and compare advice on gut decontamination with the EAPCCT/AACT Position Statements., Methods: An interactive questionnaire was sent to 14 poisons centres asking about working practices, "top 20" enquiries in 2002, and management of 4 specific drug poisonings., Results: Replies were received from centres in 11 countries. Annual telephone enquiry numbers varied from 620 (Sri Lanka) to over 50,000 (Germany for 2000). Recommendations for gut decontamination for acetaminophen poisoning were: activated charcoal (AC) alone (5 centres); gastric lavage (GL) alone (1); AC and/or GL (3); AC, GL and/or ipecac (2). Only 40% (4/10) recommended AC and 50% (3/6) GL within 1 hour. Intervention doses for gut decontamination ranged from 100-200 mg/kg (nine centres) and for "high-risk" groups 75-100 mg/kg (3). Plasma concentration for N-acetylcysteine (NAC) treatment ranged from 150 mg/L (four centres) to 200 mg/L (6) at 4 hours. Results were similarly varied for three other common drug poisons (benzodiazepines, amitriptyline, and paroxetine)., Conclusions: Most poisons centres have protocols that differ in terms of gut decontamination, timing, and intervention doses. Many centres recommend charcoal or gastric lavage after the 1-hour limit proposed in the Position Statements. There is scope for rationalization of approaches to the management of common poisons.

Overall, no conclusive data support the use of gastric decontamination in the routine management of the poisoned patient. Studies of asymptomatic patients suggest that no treatment is required, and, given the complications that have been reported, this may be a reasonable approach to' most patients. Even in symptomatic patients, the only demonstrable benefit was found in a post-hoc subgroup analysis and involved an outcome of questionable clinical importance. Given these data, it would be easy to conclude that GI decontamination has no role in the management of the poisoned patient. This conclusion is valid when considering poisoned patients as a group, but all poisoned patients are not the same. Patients with trivial ingestion do well without treatment, and their greatest risk is an iatrogenic complication. Even patients with more serious ingestions usually have good outcomes with supportive care alone. It is no longer sufficient to justify GL or forced administration of AC with the supposition that "the patient could have taken something bad." However,there are some overdoses where limiting the systemic absorption of the poison may limit the toxic effects and prevent serious toxicity. After careful consideration of the risks, GI decontamination should be targeted at patients who, in the opinion of the treating physician, have a potentially life-threatening exposure.

The use of gastric emptying techniques, including ipecac-induced emesis, in the management of poisoned patients has declined significantly in recent years. Historically, poison centers used ipecac syrup in two ways. Ipecac syrup was administered to patients prior to referral to the emergency department in attempts to start the gastric emptying process as early as possible. Additionally, poison centers used ipecac syrup in attempts to keep patients from requiring referral to medical facilities. In these situations, ipecac syrup was administered in the home and poison center staff performed follow-up telephone calls to gauge progress and outcome. Studies to determine the effectiveness of ipecac syrup demonstrate that it induces vomiting in a high percentage of people to whom it is administered and that it decreases the gastrointestinal absorption of ingested substances in a time-dependent fashion. However, the effectiveness of ipecac syrup in affecting patient outcome has not been studied in adequate clinical trials. Its effectiveness in preventing drug absorption has only been documented for a limited number of substances and is substantially reduced if it is given more than 30-90 minutes following ingestion of the toxic material. There are potentially significant contraindications, adverse effects and related problems associated with the use of ipecac syrup. It is the consensus of the panel that the circumstances in which ipecac-induced emesis is the appropriate or desired method of gastric decontamination are rare. The panel concluded that the use of ipecac syrup might have an acceptable benefit-to-risk ratio in rare situations in which: there is no contraindication to the use of ipecac syrup; and there is substantial risk of serious toxicity to the victim; and there is no alternative therapy available or effective to decrease gastrointestinal absorption (e.g., activated charcoal); and there will be a delay of greater than 1 hour before the patient will arrive at an emergency medical facility and ipecac syrup can be administered within 30-90 minutes of the ingestion; and ipecac syrup administration will not adversely affect more definitive treatment that might be provided at a hospital. In such circumstances, the administration of ipecac syrup should occur only in response to a specific recommendation from a poison center, emergency department physician, or other qualified medical personnel. The panel decided not to address the issue of whether ipecac should remain a nonprescription, over-the-counter product. The panel does not support the routine stocking of ipecac in all households with young children but was unable to reach consensus on which households with young children might benefit from stocking ipecac. Instead, the panel concluded that individual practitioners and poison control centers are best able to determine the particular patient population, geographic and other variables that might influence the decision to recommend having ipecac on hand.

Syrup of ipecac should not be administered routinely in the management of poisoned patients. In experimental studies the amount of marker removed by ipecac was highly variable and diminished with time. There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and its routine administration in the emergency department should be abandoned. There are insufficient data to support or exclude ipecac administration soon after poison ingestion. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. Ipecac should not be administered to a patient who has a decreased level or impending loss of consciousness or who has ingested a corrosive substance or hydrocarbon with high aspiration potential. A review of the literature since the preparation of the 1997 Ipecac Syrup Position Statement revealed no new evidence that would require a revision of the conclusions of that Statement.

Introduction: The home administration of ipecac syrup remains a recommendation in some guidelines for the management of specific pediatric poisonings. A common challenge for poison specialists is how to approach the situation when ipecac syrup is indicated but not kept in the home. This study examines whether or not ipecac syrup can be administered and produce timely emesis in this situation., Methods: Over a 6-month period, a prospective observational study was undertaken to determine if ipecac syrup can be administered in a timely manner when it is indicated but not available in the home. Cases where ipecac syrup was indicated but not kept in the home were included if parents stated that they could obtain ipecac within 15 minutes. Timely administration and the onset of emesis were defined as < 30 min and < 60 min, respectively., Results: During our study 14,603 human exposures were evaluated; ipecac syrup was recommended by a poison specialist in 75 cases, and 25 of these were included in our study. Ages ranged from 1 to 6 years. The mean time to administration of ipecac from exposure time was 40 min (SD +/- 14 min). Administration of ipecac syrup occurred in < 30 min in 20% of the cases. The mean time to first emesis from exposure was 58 min (SD +/- 13). Initial emesis occurred in < 60 min in 36% of the cases., Conclusions: Ipecac syrup was rarely recommended by our center and was frequently unavailable when it was recommended. Ipecac syrup often could not be administered in a timely manner because it was not kept in the home. Parents of pediatric patients who have a significant ingestion should not be referred to purchase ipecac syrup.

Syrup of ipecac (SI) has been used medicinally since the 1500s; however, little is known about the pharmacokinetics in humans of SI's active ingredients, emetine and cephaeline. The objective of this study was to evaluate the rate of absorption and the rate of elimination of emetine and cephaeline. Ten healthy, adult, human volunteers between 18 and 45 years of age who were of ideal body weight (body mass index 20-25) completed this study. After an overnight fast, 30 mL SI were ingested. Blood samples were collected 30, 45, 60, 90, 120, 150, and 180 minutes post-ingestion and urine was collected throughout the study period. Plasma and urine concentrations of emetine and cephaeline were measured by reverse-phase HPLC with fluorescence detection. In virtually all subjects, emetine and cephaeline were detected within 5-10 minutes of dosing with the time to maximum concentration being approximately 20 minutes. The mean areas under the concentration-time curve (AUC) for both emetine and cephaeline were similar; however, the ratio of mean cephaeline maximum concentration (Cmax) to emetine Cmax was approximately 1.5. Four of the ten subjects exhibited a type of concentration-time profile in which the levels of cephaeline were substantially higher than those of emetine and the levels of cephaeline were substantially higher than noted for the other six subjects. In these remaining six subjects, the levels of emetine and cephaeline were lower than 10 ng/mL at all time-points. An initial elimination phase was noted in some subjects but not in others. Individuals in whom an initial elimination phase was not observed also exhibited low levels of both alkaloids as compared with the other subjects suggestive of a slower distribution phase. Less than 0. 15% of the administered emetine and cephaeline was recovered in the urine at 3 hours. No relationship between vomiting episodes and peak concentrations of emetine or cephaeline was found. Administration of SI results in rapid appearance and disappearance of emetine and cephaeline in plasma becoming almost undetectable at 3 hours. Very little of either alkaloid is eliminated in the urine within this time period, suggesting extensive distribution. The length of time that an administered dose of SI can result in the detection of emetine and/or cephaeline in the urine has not been determined; future studies in humans are required.

The management of acute poisoning remains an important part of accident and emergency (A&E) care. Three gastric decontamination procedures have been widely used: gastric lavage, ipecac, and activated charcoal. Their role has recently been reviewed and position statements developed by working groups of the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. These have important implications for A&E, as they indicate that activated charcoal is now the agent of choice for most poisons, but than in most situations it is probably only effective if given within an hour of overdose. Ipecac is effectively obsolete and gastric lavage has a narrow range of indications, principally for potentially serious amounts of agents not adsorbed by charcoal. Protocols for care of overdose patients should be modified accordingly.

Ipecac, an over-the-counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated with serious cardiac toxicity; however, the dose effect has not been well established. We present a patient with anorexia and bulimia nervosa who ingested ipecac chronically and developed the characteristic manifestations of ipecac toxicity. Unexpectedly, her induced left ventricular dysfunction returned to normal after only 10 days of withholding the drug. This finding, in contrast with the findings of other reports, establishes that ipecac cardiomyopathy can be readily reversible. The cumulative experience thus far, nonetheless, provides no discernible pattern of the effect of ipecac on the myocardium. Thus, in the continuum of poisoning, the point at which the myocardium becomes irreversibly damaged is undetermined. With continued abuse, potentially lethal outcome, and limited experience with ipecac cardiotoxicity, further investigation and perhaps heightened restriction of the drug are warranted.

We examined the effects of small ingestions of sustained release calcium channel blockers (SR-CCBs) in young children and characterized current recommendations regarding monitoring after a suspected ingestion. A 2-part study was performed of pediatric calcium channel blocker (CCB) ingestion: first a telephone survey of 33 randomly selected Poison Control Centers (PCCs) from around the US concerning their recommended management of a small ingestion of sustained release calcium channel blocker in a child, and then a 5-y retrospective review of local cases of CCB ingestions in children under 4 y-of-age. The number of hours of medical observation recommended by the PCCs varied from > or = 24 h (n = 15, 45%) to < 6 h (n = 6, 18%). The retrospective chart review revealed that 19 of 29 local cases involved a SR-CCB, and 6 of these were thought to have ingested only 1 tablet. Observation time varied from > 24 h to < 6 h in the 17 cases seen in an emergency department. No symptoms or vital sign abnormalities were reported in any case. Recommendations regarding duration of observation varied from < 6 h to 24 h. Ingestion of a few SR-CCB tablets was not associated with symptoms, suggesting that admission and 24-h monitoring may not be necessary under those circumstances.

Objective: To determine the decrease of drug absorption when syrup of ipecac is administered at various times within one hour of drug ingestion., Methods: Ten healthy human volunteers were recruited for a four-limbed randomized crossover study. The three experimental limbs consisted of administration of 30 mL syrup of ipecac, at 5, 30, or 60 minutes after ingestion of 3900 mg acetaminophen as 12 x 325 mg tablets with 250 mL room temperature water. The fourth limb served as control. Blood samples were drawn at 0, 0.5, 1.0, 2.0, 3.0, 4.0, 6.0, and 8.0 hours after analgesic ingestion for serum acetaminophen concentration determination by high-performance liquid chromatography. Repeated measures ANOVA and Tukey's HSD tests were used for group comparisons., Results: The area under the serum concentration vs time curve was (mean +/- SD) 206 +/- 48, 67 +/- 37, 183 +/- 78, and 162 +/- 47 mg/L for control, 5, 30, and 60 minutes, respectively. This corresponds to decreases in bioavailability of 67, 11, and 21%. Only the 5-minute group differed significantly from control (p < 0.05). Sedation was observed as a significant adverse effect of ipecac administration., Conclusions: Our data do not support benefit from ipecac administration at 30 minutes and beyond. Our data suggest that benefit is lost at some point between 5 and 30 minutes. The sedative effect of ipecac may confound the observation of patients who have ingested sedative hypnotic agents.

In 1990, the American Association of Poison Control Centers identified that for the first time activated charcoal (AC) use had surpassed that of syrup of ipecac. As nurses are given the primary responsibility for AC administration, it was important to determine how AC was being administered, as well as nursing attitudes towards AC that have an impact on patient care. Surveys were mailed to the Emergency Departments (EDs) of 60 hospitals served by the Pittsburgh Poison Center (PPC); 6 nurses/ED, 2 from each shift, were asked to respond. Forty-four EDs responded (73.3%) providing 237 surveys. Eighty-two percent of nurses stated they disliked administering AC for the following reasons: Patients did not like AC (64.4%); AC soiled clothing (54.7%); and AC took too long to give (35.5%). Prior to administration, 70.9% of the nurses responded that they shook the AC a minimum of 20 times; 9.3% commented that AC still failed to resuspend. Specific administration techniques included attempts to mask the appearance the the AC (67.1%) and attempts to increase AC's palatability by adding a flavoring agent (37.6%) or by using AC with sorbitol instead of aqueous AC (25.7%). Of note was that the flavoring agents used were those known to decrease AC's ability to adsorb toxins. As the majority of problems with AC involved its poor resuspendibility and palatability, an AC fact sheet was developed and mailed to EDs to provide suggestions on AC resuspension and means of enhancing patient acceptance without compromising AC's adsorptive capacity. By surveying nursing attitudes toward AC and the administration techniques being utilized, the PPC was able to identify specific problems and address nursing concerns in a way that positively impacts patient care.

Serotonin receptor (5-HT3) antagonists provide effective antiemetic therapy in cancer patients receiving emetogenic chemotherapy, such as cisplatin. Animal studies have shown that 5-HT3 receptor antagonists also have antiemetic activity in ipecac-induced emesis. The authors investigated the antiemetic activity of zatosetron maleate, a 5-HT3 receptor antagonist, on ipecac-induced emesis in dogs and healthy men. They also evaluated the effect of ipecac administration on serotonin release and metabolism by measuring urinary 5-hydroxyindoleacetic acid (5-HIAA) excretion in healthy men. In separate randomized, placebo-controlled trials, 20 dogs received zatosetron intravenously and eight healthy men received zatosetron (50 mg) orally, followed by ipecac syrup. In both trials, emetic response to ipecac was recorded, including the number and time of vomits and retches. Zatosetron treatment inhibited and delayed ipecac-induced emesis in both groups. In dogs, zatosetron inhibited ipecac-induced emesis in a dose-dependent manner with a 100-micrograms/kg dose producing complete inhibition. In men, zatosetron administration resulted in fewer emetic episodes after ipecac than had occurred with placebo administration (P = .03); vomiting was completely inhibited by zatosetron. In men, ipecac administration did not affect the urinary 5-HIAA/creatinine ratio (mg/g) or 5-HIAA excretion rate (microgram/hour). Our study demonstrates that zatosetron has similar efficacy on ipecac-induced emesis in healthy men, as has been shown previously with other 5-HT3 receptor antagonists in chemotherapy-induced emesis in cancer patients. We did not observe the increase of urinary 5-HIAA in our study with ipecac-induced emesis, however, as has been described previously in cisplatin-induced emesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To review available information about various methods for reducing gastrointestinal absorption of a poison or drug., Data Sources: Articles on overdose and accidental poisoning generated by the Australian Medlars Service and concentrating on the period between 1985 and 1990 were surveyed. Earlier studies were included if relevant., Study Selection and Data Extraction: English language articles with an emphasis on studies using objective methods to measure individual and comparative efficacy of gastrointestinal decontamination techniques were selected. A total of 65 articles were reviewed., Data Synthesis: Gastric emptying procedures (gastric lavage or emesis caused by syrup of ipecac) are only effective if performed within one hour of drug ingestion. Gastric lavage is superior to syrup of ipecac. Oral administration of activated charcoal is more effective than either gastric emptying procedure, and is recommended for most cases of poisoning. Cathartics (sorbitol) can be used with activated charcoal. Whole bowel lavage with polyethylene glycol is indicated in selected cases of potentially lethal overdose where the toxic substance cannot be absorbed by charcoal and has passed the pylorus., Conclusions: Children--syrup of ipecac can be given at home to children older than 12 months. Most children who reach hospital can be treated by charcoal alone. ADULTS--Most patients are managed with supportive care and, in the absence of contraindications, a single dose of activated charcoal if seen within four hours of ingestion of the poison or drug. Gastric lavage is used if the patient presents within one hour of ingestion and has clinical features of toxicity.

Study Objectives: To determine the effect of syrup of ipecac (SOI) on time to receive and retention of activated charcoal (AC) and on total ED time., Design: During a two-year period, patients were enrolled in a prospective, randomized, unblinded, controlled trial., Setting: All patients were recruited and studied in a pediatric emergency department., Participants: Seventy children less than 6 years old (mean age, 2.4 +/- 0.2 years) who presented with mild-to-moderate acute oral ingestions., Interventions: Group 1 received SOI before AC. Group 2 received only AC., Measurements and Main Results: Group 1 patients took significantly longer to receive AC than group 2 from the time of ED arrival (2.6 +/- 0.1 vs 0.9 +/- 0.1 hours, P less than .0001). Group 1 children were significantly more likely to vomit AC than were group 2 children (18 of 32 vs six of 38, P less than .001). Patients receiving SOI who were subsequently discharged spent significantly more time in the ED than those receiving only AC (4.1 +/- 0.2 vs 3.4 +/- 0.2 hours, P less than .05)., Conclusions: Ipecac delays the administration of AC, hinders its retention, and prolongs ED time in pediatric ingestion patients. These data support the recommendation that AC alone should be the gastrointestinal decontamination method of choice for the mild-to-moderate pediatric ingestion patient presenting to an ED.

The diagnosis and management of acute poisoning episodes in adolescents and young adults with anorexia nervosa are complicated by their underlying psychopathologic conditions. We investigated 23 consecutive cases of poisoning in 21 patients with anorexia nervosa reported to the Massachusetts Poison Center, Boston, during a 13-month period. All were intentional self-poisonings. Agents involved most often were psychotherapeutic drugs, cathartics, and/or analgesics. Potentially life-threatening drugs were often implicated in the poisoning. Diagnosis was complicated by purposefully deceptive information from patients and the presence of unsuspected toxins. Treatment was complicated by long delays to presentation for medical care and by underlying metabolic abnormalities. Decontamination efforts were complicated by the patients' prior use of emetics and cathartics. Seventeen patients required hospitalization; 4 patients suffered a complicated hospital course and a fifth patient died.

A prospective study was conducted to determine if the emetic effects of syrup of ipecac are preserved when activated charcoal is administered prior to emesis. Ten overdose patients who fulfilled the entrance criteria for the study were administered 60 mL syrup of ipecac by a nasogastric tube followed immediately by 500 mL of tap water. Ten minutes after the ipecac was administered, an aqueous slurry of 50 g activated charcoal diluted to 500 mL was instilled down the nasogastric tube and the tube was removed. Emetic response and time to emesis were recorded. Thirty minutes after emesis subsided, a second dose of 50 g activated charcoal (with sorbitol) was administered orally. Emetic responses were noted in all ten patients. The patients averaged 3.7 emetic episodes. Emesis commenced in an average of 13.8 minutes from the start of ipecac administration and concluded in an average of 45.9 minutes. These results in patients are similar to those observed in a previously reported volunteer group similarly treated. This protocol allows early administration of activated charcoal while preserving the emetic properties of syrup of ipecac in the patients treated.

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.

A controlled prospective study to evaluate the efficacy of expired ipecac syrup was conducted at two regional poison control centers in New England. During a 6-month period, 200 study patients treated with expired ipecac syrup and 200 control patients treated with unexpired ipecac syrup were evaluated. There were no statistical differences between the control and study groups in patient characteristics (age and sex) and product characteristics (general class, emetic potential, pretreatment, previously opened bottles, and manufacturer). In both control and study groups, emesis occurred in 100% of cases with 90% of patients vomiting with the first dose. The mean time to emesis was 24.7 minutes and 24.8 minutes in the study and control groups, respectively. Expired preparations ranged from 1 month to greater than 4 years postexpiration, with the duration of expiration not altering the mean time to emesis. Mean time to emesis between the two groups was also not affected by manufacturer, pretreatment with milk, or whether the ipecac syrup bottle was previously opened. We conclude that expired ipecac syrup (up to 4 years postexpiration date) is an effective emetic.

A prospective study was conducted to determine if children less than one year of age developed any complications from syrup of ipecac-induced emesis. All patients in the study were derived from cases received by the poison center. Syrup of ipecac (10 ml) was administered with clear fluids to 24 children less than twelve months of age (mean age 8.7 months; median age 9.0 months; range 3.0-12.0). The average time for the onset of emesis was 26.10 minutes. All children vomited with a single dose of syrup of ipecac. No adverse sequelae such as aspiration or prolonged episodes of emesis were observed. Contrary to the popular belief that emesis may be contraindicated in children less than twelve months of age, we believe that emesis can be safely induced in the home setting in these young children.

A prospective study was conducted to determine whether 30 ml of syrup of ipecac would produce a more rapid emesis than 15 ml in pediatric poisoned victims over twelve months of age. Data from 100 patients, where 15 ml of syrup of ipecac was administered, revealed an average time for emesis to occur of 25.82 minutes. Data from an additional 100 patients in which 30 ml of ipecac syrup was administered shows emesis to occur in 15.76 minutes. Clinically, six patients had repeated episodes of vomiting with 30 ml of ipecac; however, all were completely asymptomatic 60 minutes after ipecac administration. The difference of 10.06 minutes is statistically significant. Another aspect of the study evaluated whether the administration of clear liquids prior to or following ipecac substantially effected the onset of emesis. No differences were noted.

The rates at which 15- and 30-mL doses of syrup of ipecac induced emesis within 30 minutes were evaluated in pediatric patients treated for accidental poisoning. A two-year prospective study was conducted to collect data on 4306 pediatric patients (aged one to six years) who received syrup of ipecac to treat accidental poisoning. Patients received either 15-mL (during 1983) or 30-mL (during 1984) doses of syrup of ipecac and 120-240 mL of water or clear liquid. Time of administration and time of the first episode of emesis were reported by the person administering the syrup of ipecac; the difference between these times was recorded as the time to emesis. Successful emesis was defined as emesis within 30 minutes after ipecac administration, while failure was defined as emesis occurring more than 30 minutes after administration. Success and failure rates were compared using chi-square analysis. Syrup of ipecac 15 mL was administered to 1905 patients, resulting in a failure-to-produce-emesis rate of 8.82% (168 patients). Syrup of ipecac 30 mL was administered to 2401 patients, resulting in a 0.08% failure rate (two patients). A repeat dose of ipecac syrup in the 15-mL group yielded a 99.74% success rate, which was not significantly different from the 99.96% success rate after a single dose of 30 mL. Although syrup of ipecac dosing in pediatric patients is controversial, our data suggest that increasing the standard pediatric dose from 15 to 30 mL significantly reduces the emesis failure rate.

Ipecac syrup administration at home, following advice by a poison center, was evaluated with respect to the availability of ipecac syrup, length of storage time, compliance with recommended procedures for administration, and time for emetic response. In a three-month period, staff pharmacists of the center completed a survey from when they advised 60 callers to administer ipecac syrup at home. Two follow-up phone calls were made to collect additional data. Fifty-five callers provided adequate data for analysis. Ipecac syrup was available at home for 36%, from a pharmacy for 53%, and from a neighbor for 11% of the callers. Compliances with the recommended doses of ipecac syrup and fluids (+/- S.D.) were 92 +/- 20% and 71 +/- 29%, respectively. Following one dose of ipecac syrup, 86% vomited in 19 +/- 8 minutes; after a second dose, 13% responded in 34 +/- 21 minutes after the first dose. By comparison with those who had ipecac syrup at home, there was an insignificant delay in administration when it was obtained from a neighbor; a significant delay (p less than 0.005) occurred when it was obtained by a pharmacy. The onset of emesis did not correlate with the length of time the ipecac syrup had been stored at home. The findings support the use of ipecac syrup at home based on ready availability, adequate compliance, and rapid emetic response.

Twelve adult volunteers were given 24 81-mg aspirin tablets and were randomly assigned into the following treatment groups: (1) control aspirin, (2) 30 mL of ipecac repeated if vomiting not induced, (3) 60 g of activated charcoal per 15 g of magnesium sulfate (MgSO4), and (4) ipecac repeated if needed, followed by activated charcoal/MgSO4 given 1 1/2 hours after the last vomiting episode. All treatments began 60 minutes following aspirin ingestion. Urine was collected for 48 hours for percent total salicylate excretion. Mean +/- SD recovery of salicylate from urine was as follows: aspirin, 96.3% +/- 7.5%; ipecac 70.3% +/- 11.8%, activated charcoal/MgSO4, 56.4% +/- 12%; and ipecac and activated charcoal/MgSO4, 72.4% +/- 14.1%. Ten subjects completed the study. In group 4, eight of ten subjects vomited the activated charcoal/MgSO4 immediately, making statistical analysis impossible. Analysis revealed that activated charcoal/MgSO4 significantly lowered the absorption of aspirin compared with the control and ipecac-treated groups. Furthermore, ipecac significantly lowered aspirin absorption compared with the control group. We conclude that activated charcoal/MgSO4 used alone is superior to the other treatment modalities at inhibiting the absorption of multiple aspirin tablets.

Previous studies have shown that ipecac-induced emesis, even if instituted very early, removes only a mean of 28% to 45% of an ingested tracer. Because vomiting is an ancient reflex that occurs in mammals, reptiles, and other animals, we speculated that, in humans, maintaining a sitting rather than a horizontal posture during induced emesis might decrease the efficacy of gastric emptying. To test this hypothesis, 20 normal fasting adult subjects underwent induced emesis in the knee-chest position on one day and in the sitting position on another. Twenty-five 100-micrograms tablets of cyanocobalamin were ingested as a tracer along with 250 mL tap water. Ten minutes after tracer ingestion, 30 mL ipecac syrup and 640 mL tap water were swallowed. All resulting vomitus was homogenized, frozen, and later assayed for cobalt using atomic absorption spectrophotometry. There was no difference in mean tracer recovery with the two positions: knee-chest, 47.2% v sitting, 46.9% (paired t test, P greater than .95). Analysis of cobalt recovery for all 40 episodes of emesis revealed a mean of 51.2 +/- 23.7 (SD) micrograms out of 108.7 micrograms total cobalt ingested (95% Cl, 43.6 to 58.7 micrograms). This represented 47.1% of the administered tracer dose (95% Cl, 40.1% to 54.0%). Even if initiated only ten minutes after an ingestion, ipecac-induced emesis removes an average of less than half of an ingested tracer dose, with a high degree of intersubject variability. Horizontal patient positioning does not appear to improve the efficacy of this procedure.

The results of a study to assess the level of consumer information about the action and uses of Ipecacuanha Syrup (Emetic) Australian Pharmaceutical Formulary (APF) are reported. Of 40 community pharmacies selected at random from the 321 pharmacies in the Perth metropolitan area, four were unable to supply the syrup. Dosage information provided on the labels of branded products was, for the most part, comprehensive and in line with APF recommendations. Syrup samples dispensed under pharmacy labels provided much less detailed dose information and no information on contraindications on the labels. Counselling by pharmacists was mostly adequate, but information provided by pharmacy assistants was much less detailed. The active alkaloid content of about 77% of the samples of ipecacuanha syrup was within +/- 12% of the target concentration; the remainder had only 56%-58% of the required alkaloid concentration, which indicates a need for more stringent quality control.