Treating Poisonings: Focus on Syrup of Ipecac Syrup of ipecac is the most useful emetic agent in the home treatment ofpoisoning. by Vance A. HoldsclalN, PharmD, and Diane Nykamp, PharmD
Accidental poisonings are the most common reasons for the administration of emetic agents. Two-thirds of all poisonings occur in children less than five years old and usually occur at home with an adult close by.1 An emetic is 'an agent that induces vomiting. Elnetics are usually reserved for the treatlnent of poisonings (accidental and intentional) and work by reducing potentially toxic agents in the stomach. Emetics are only useful if an adequate amount of the ingested substance is in the stomach. Several types of emetic agents are current1y available: syrup of ipecac, salt water, dry mustard water, copper sulfate, zinc sulfate, and apomorphine. In the home setting, syrup of ipecac is considered the most effective emetic agent, especially when the time from ingestion of the poison to administration of the emetic is within 30 minutes to one hour. 2 This discussion will focus primarily on the proper use of ipecac syrup as an . emetic agent in the treatment of poisoning.
Physiology The vomiting process is a reflex that involves both the central nervous system (CNS) and the gastrointestinal (GI) system. The reflex is mediated by a "vomiting center " located within the CNS via the chemoreceptor trigger zone (CTZ) in the medulla and in the gastric mucosa. 3 Centrally acting emetics work by stimulating the CTZ; other agents produce gastric irritation to induce emesis. Vol. NS32, No.7 July 1992/ 567
ED
The vomiting process begins with a deep breath along with a forceful contraction of the diaphragm and abdominal muscles. An increase in the intrathoracic and intraabdominal pressure causes the stomach to become compressed and elevates the esophageal pressure, moving stomach contents into the esophagus and mouth. It is the combination of increased intrathoracic pressure and reverse peristaltic waves that expels vomitus from the esophagus. Normally, in the alert individual, the glottis will close off the trachea and prevent aspiration into the airway.4
Actions and Administration Syrup of ipecac is prepared from ipecac powder, which is derived from the plant Cephaelis ipecacuanha or aculninata. Each 30 mL of ipecac syrup USP has a range of 36.9 mg to 147.1 mg of the total ether-soluble alkaloids (emetine and cephaeline) of ipecac. s Based on the manufacturer's discretion, ipecac may be \prescription or nonprescription. Ipecac produces emesis by direct action on the gastric mucosa and by stimulation of the CTZ.6 Since ipecac does not perform to its full potential when the stomach is empty, the patient should be encouraged to drink the recommended quantity of fluid following ipecac administration. Also, it is recommended that milk products not be used concurrently with syrup of ipecac. 7 It is also imperative that the pharmacist dispense and AMERICAN PHARMACY
administer (if indicated) the syrup form of ipecac and not the fluid extract form. The fluid extract form of ipecac is 14 times more potent than the syrup and may result in severe toxicity or death. 6 The appropriate dose of syrup of ipecac and water intake should be based on the age of the patient. Controversy remains over whether or not to administer syrup of ipecac to a child less than one year old, thus ipecac should only be administered to these children under physician supervision. In children more than one year old, the recommended dose of syrup of ipecac is 15 mL followed by one glass (240 mL) of water. If vomiting does not occur within 20 minutes, the dose should be repeated one time. The initial dose of syrup of ipecac for adolescents and adults is 30 mL immediately followed by 1 glass (240 mL) of water or carbonated beverage, and may be repeated once if necessary. Encourage the patient to walk around; clinical experience indicates that patients who are ambulatory are more likely to vomit more quickly than those who are in a reclining position. 4 Reclining may also increase the chance of aspiration of vomitus. Adverse effects following administration of syrup of ipecac are rare. However, pharmacists should be aware of the possible side effects of this medication. Diarrhea, mild gastrointestinal upset, and CNS depression are side ~ffects that may occur after therapeutic doses. If a dose greater than the recommended dose is administered, ipecac may be cardiotoxic causing bradycardia, atrial fibrillation, and hypotension. s Similar toxicities occur with chronic use, such as is seen in patients with bulimia. Vomiting due to administration of syrup of ipecac can be dangerous , and unwarranted administration of ipecac should be avoided. Ipecac should not be administered to pregnant or lactating women unless under the supervision of a physician. Other contraindications to the use of syrup of ipecac are found in Table 1.
ducing emesis; however, there is evidence that copper sulfate may significantly increase serum copper levels. 4 High copper levels have been associated with jaundice and oliguria. 10 Although not an emetic agent, activated charcoal is an effective adsorbent for most drugs and chemicals and will therefore decrease the absorption of toxic materials in poisonings. Activated charcoal is usually administered after ipecac-induced vomiting ends. Whereas ipecac removes toxic substances from the stomach, activated charcoal adsorbs substances from the gastrointestinal tract. Activated charcoal, however, should not be given in conjunction with ipecac because it will bind and inactivate the ipecac syrupJl The dose of activated charcoal is 30 g in children and 60 g-100 g in adults. However, pharmacists should be aware that poison alert kits usually contain only 10 g of activated charcoal. Another form of treatment in poisoning is the mechanical induction of vomiting by administering fluids and then manually stimulating the gag reflex at the back of the throat with either a blunt object or a finger. Risks associated with mechanical induction of vomiting include perforation of throat tissue and hemorrhage. Mechanically induced emesis is not as effective as the administration of syrup of ipecac. 4 However, mechanical stimulation may be a practical option in an emergency, when appropriate emetic or medical care is not available. Table 1
Contraindications to Syrup of Ipecac Administration
Comparisons with Other Products Syrup of ipecac is considered the most useful emetic agent in the home treatment of poisoning, although other agents ,,{emetic and nonemetic) are effective in decreasing the absorption of the toxic material. Apomorphine, a morphine derivative available only as an injection, has more potent emetic properties than ipecac; however, apomorphine causes more CNS depression, especially respiratory depression. 9 Salt water, an emesis inducer, may be dangerous to use because of its sodium absorption properties. Fatalities have been associated with patients using salt water as an emetic. 4 Studies have also compared the effectiveness of ipecac and copper sulfate (not available as a nonprescription product), an emetic agent .that stimulates the vomiting center by direct gastric irritation. Both agents are comparable in proAMERICAN PHARMACY
July 1992/ 568 Vol. NS32, No.7
Preventing Accidental Poisonings The most effective treatment for poisonings is prevention. The pharmacist should be prepared to educate the public on how poisonings can be avoided. Child-resistant caps and safety packaging of medications have contributed to the decline in poisonings among children. 12 Pharmacists -should also insttuct parents on other methods of poison prevention (see Table 2).
Summary ,The awareness of poison prevention is increasing despite an alarming incidence of accidental and intentional poisonings in the United States. During 1990, 72 poison centers throughout the United States, serving a population of 191.7 million, submitted to the American Association of Poison Control Centers data collection system 1,713,462 cases of poisonings, which included 612 deaths. 13 Emetic agents, when used properly, can reduce the extent and severity of ilnproperly ingested medications, selected household products, and other toxic chemicals. The pharmacist can play a valuable role in distributing information about poison control centers, poison prevention, and appropriate treatment of poisonings. Vance A . Holdsclaw) PharmD) was a student at Mercer University Southern School of Pharmacy) Atlanta) Ga. ) at the time this was written. Diane Nykamp) Ph a rmD) is associate professor ofpharmacy practice at Mercer. Reviewers for this monograph are David S. Wheeler, assistant director ofpharmacy) The Moses H. Cone Memorial Hospital) Greensboro) N c.) Daniel W Teat) PharmD) associate professor and director of admissions and continuing education) Campbell University School of Pharmacy) Buies Creek) N.C. ) and Nicholas G. Popovich) PhD) professor ofpharmacy practice) Purdue University) West Lafayette) Ind. This series is coordinated by the Section of Clinical/PharmacotherapeutiC Practice in the Academy ofPharmacy Practice and Management of the American Pharmaceutical Association. Dennis M. Williams) PharmD) BCPS) is the editor.
References 1. Scottish Rite Children's Medical Center-Poison Control Information. Atlanta, Ga. 2. Schauben JL, Spillane J. Poison emergencies. US Pharm. 1990:37-58. 3. Guyton AC. Textbook of Medical Physiology, 7th ed. Philadelphia: WB Saunders; 1986:803-4. 4. Oderda GM, Korberly BH. Emetic and antiemetic products. In: Handbook of Nonprescription Drugs, 9th ed. Washington, DC: American Pharmaceutical Association; 1990:293-312. 5. Physicians' Desk Reference for Nonprescription Drugs, 9th ed. Oradell, NJ: Medical Economics Co; 1988:624. 6. Drug Facts and Comparisons, 1989 ed. St. Louis: Lippincott Co; 1989:2184. 7. USP-DI Advice for the Patient, 1991 ed. Rockville Md: U.S. Pharmacopeial Convention, Inc; 1991;2:683-4.
Vol. NS32, No.7 July 1992/ 569
8. USP-DI Drug Information for the Health Care Provider, 1991 ed. Rockville Md: U.S. Pharmacopeial Convention, Inc; 1991;1B:1551-3. 9. Klassen CD. Principles of toxicology. In: Gilman AG, Rail TW, Nies AS, et aI., eds. Goodman and Gilman The Pharmacological Basis of Therapeutics, 8th ed. New York: Pergamon Press; 1990:49-61. 10. Oderda GM, Klein-Schwartz W. Clinical toxicology. In: Herfindal ET, Gourley DR, Hart LL, eds. Clinical Pharmacy and Therapeutics, 4th ed. Baltimore: Williams and Wilkins; 1988:1038-51. 11. Lippman W, Rumley W. Medical emergencies. In: Dunagan WC, Ridner ML, eds. Manual of Medical Therapeutics, 26th ed. Boston: Little, Brown, and Co; 1989:482-503. 12. Grogan FJ. The Pharmacist's Prescription. New York: Avon Books; 1987:355. 13. Litovitz TL, Bailey KM, Schmitz BF. The 1990 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1991;9:461-509.
AMERICAN PHARMACY
Accidental poisonings are the most common reasons for the administration of emetic agents. Two-thirds of all poisonings occur in children less than five years old and usually occur at home with an adult close by.1 An emetic is 'an agent that induces vomiting. Elnetics are usually reserved for the treatlnent of poisonings (accidental and intentional) and work by reducing potentially toxic agents in the stomach. Emetics are only useful if an adequate amount of the ingested substance is in the stomach. Several types of emetic agents are current1y available: syrup of ipecac, salt water, dry mustard water, copper sulfate, zinc sulfate, and apomorphine. In the home setting, syrup of ipecac is considered the most effective emetic agent, especially when the time from ingestion of the poison to administration of the emetic is within 30 minutes to one hour. 2 This discussion will focus primarily on the proper use of ipecac syrup as an . emetic agent in the treatment of poisoning.
Physiology The vomiting process is a reflex that involves both the central nervous system (CNS) and the gastrointestinal (GI) system. The reflex is mediated by a "vomiting center " located within the CNS via the chemoreceptor trigger zone (CTZ) in the medulla and in the gastric mucosa. 3 Centrally acting emetics work by stimulating the CTZ; other agents produce gastric irritation to induce emesis. Vol. NS32, No.7 July 1992/ 567
ED
The vomiting process begins with a deep breath along with a forceful contraction of the diaphragm and abdominal muscles. An increase in the intrathoracic and intraabdominal pressure causes the stomach to become compressed and elevates the esophageal pressure, moving stomach contents into the esophagus and mouth. It is the combination of increased intrathoracic pressure and reverse peristaltic waves that expels vomitus from the esophagus. Normally, in the alert individual, the glottis will close off the trachea and prevent aspiration into the airway.4
Actions and Administration Syrup of ipecac is prepared from ipecac powder, which is derived from the plant Cephaelis ipecacuanha or aculninata. Each 30 mL of ipecac syrup USP has a range of 36.9 mg to 147.1 mg of the total ether-soluble alkaloids (emetine and cephaeline) of ipecac. s Based on the manufacturer's discretion, ipecac may be \prescription or nonprescription. Ipecac produces emesis by direct action on the gastric mucosa and by stimulation of the CTZ.6 Since ipecac does not perform to its full potential when the stomach is empty, the patient should be encouraged to drink the recommended quantity of fluid following ipecac administration. Also, it is recommended that milk products not be used concurrently with syrup of ipecac. 7 It is also imperative that the pharmacist dispense and AMERICAN PHARMACY
administer (if indicated) the syrup form of ipecac and not the fluid extract form. The fluid extract form of ipecac is 14 times more potent than the syrup and may result in severe toxicity or death. 6 The appropriate dose of syrup of ipecac and water intake should be based on the age of the patient. Controversy remains over whether or not to administer syrup of ipecac to a child less than one year old, thus ipecac should only be administered to these children under physician supervision. In children more than one year old, the recommended dose of syrup of ipecac is 15 mL followed by one glass (240 mL) of water. If vomiting does not occur within 20 minutes, the dose should be repeated one time. The initial dose of syrup of ipecac for adolescents and adults is 30 mL immediately followed by 1 glass (240 mL) of water or carbonated beverage, and may be repeated once if necessary. Encourage the patient to walk around; clinical experience indicates that patients who are ambulatory are more likely to vomit more quickly than those who are in a reclining position. 4 Reclining may also increase the chance of aspiration of vomitus. Adverse effects following administration of syrup of ipecac are rare. However, pharmacists should be aware of the possible side effects of this medication. Diarrhea, mild gastrointestinal upset, and CNS depression are side ~ffects that may occur after therapeutic doses. If a dose greater than the recommended dose is administered, ipecac may be cardiotoxic causing bradycardia, atrial fibrillation, and hypotension. s Similar toxicities occur with chronic use, such as is seen in patients with bulimia. Vomiting due to administration of syrup of ipecac can be dangerous , and unwarranted administration of ipecac should be avoided. Ipecac should not be administered to pregnant or lactating women unless under the supervision of a physician. Other contraindications to the use of syrup of ipecac are found in Table 1.
ducing emesis; however, there is evidence that copper sulfate may significantly increase serum copper levels. 4 High copper levels have been associated with jaundice and oliguria. 10 Although not an emetic agent, activated charcoal is an effective adsorbent for most drugs and chemicals and will therefore decrease the absorption of toxic materials in poisonings. Activated charcoal is usually administered after ipecac-induced vomiting ends. Whereas ipecac removes toxic substances from the stomach, activated charcoal adsorbs substances from the gastrointestinal tract. Activated charcoal, however, should not be given in conjunction with ipecac because it will bind and inactivate the ipecac syrupJl The dose of activated charcoal is 30 g in children and 60 g-100 g in adults. However, pharmacists should be aware that poison alert kits usually contain only 10 g of activated charcoal. Another form of treatment in poisoning is the mechanical induction of vomiting by administering fluids and then manually stimulating the gag reflex at the back of the throat with either a blunt object or a finger. Risks associated with mechanical induction of vomiting include perforation of throat tissue and hemorrhage. Mechanically induced emesis is not as effective as the administration of syrup of ipecac. 4 However, mechanical stimulation may be a practical option in an emergency, when appropriate emetic or medical care is not available. Table 1
Contraindications to Syrup of Ipecac Administration
Comparisons with Other Products Syrup of ipecac is considered the most useful emetic agent in the home treatment of poisoning, although other agents ,,{emetic and nonemetic) are effective in decreasing the absorption of the toxic material. Apomorphine, a morphine derivative available only as an injection, has more potent emetic properties than ipecac; however, apomorphine causes more CNS depression, especially respiratory depression. 9 Salt water, an emesis inducer, may be dangerous to use because of its sodium absorption properties. Fatalities have been associated with patients using salt water as an emetic. 4 Studies have also compared the effectiveness of ipecac and copper sulfate (not available as a nonprescription product), an emetic agent .that stimulates the vomiting center by direct gastric irritation. Both agents are comparable in proAMERICAN PHARMACY
July 1992/ 568 Vol. NS32, No.7
Preventing Accidental Poisonings The most effective treatment for poisonings is prevention. The pharmacist should be prepared to educate the public on how poisonings can be avoided. Child-resistant caps and safety packaging of medications have contributed to the decline in poisonings among children. 12 Pharmacists -should also insttuct parents on other methods of poison prevention (see Table 2).
Summary ,The awareness of poison prevention is increasing despite an alarming incidence of accidental and intentional poisonings in the United States. During 1990, 72 poison centers throughout the United States, serving a population of 191.7 million, submitted to the American Association of Poison Control Centers data collection system 1,713,462 cases of poisonings, which included 612 deaths. 13 Emetic agents, when used properly, can reduce the extent and severity of ilnproperly ingested medications, selected household products, and other toxic chemicals. The pharmacist can play a valuable role in distributing information about poison control centers, poison prevention, and appropriate treatment of poisonings. Vance A . Holdsclaw) PharmD) was a student at Mercer University Southern School of Pharmacy) Atlanta) Ga. ) at the time this was written. Diane Nykamp) Ph a rmD) is associate professor ofpharmacy practice at Mercer. Reviewers for this monograph are David S. Wheeler, assistant director ofpharmacy) The Moses H. Cone Memorial Hospital) Greensboro) N c.) Daniel W Teat) PharmD) associate professor and director of admissions and continuing education) Campbell University School of Pharmacy) Buies Creek) N.C. ) and Nicholas G. Popovich) PhD) professor ofpharmacy practice) Purdue University) West Lafayette) Ind. This series is coordinated by the Section of Clinical/PharmacotherapeutiC Practice in the Academy ofPharmacy Practice and Management of the American Pharmaceutical Association. Dennis M. Williams) PharmD) BCPS) is the editor.
References 1. Scottish Rite Children's Medical Center-Poison Control Information. Atlanta, Ga. 2. Schauben JL, Spillane J. Poison emergencies. US Pharm. 1990:37-58. 3. Guyton AC. Textbook of Medical Physiology, 7th ed. Philadelphia: WB Saunders; 1986:803-4. 4. Oderda GM, Korberly BH. Emetic and antiemetic products. In: Handbook of Nonprescription Drugs, 9th ed. Washington, DC: American Pharmaceutical Association; 1990:293-312. 5. Physicians' Desk Reference for Nonprescription Drugs, 9th ed. Oradell, NJ: Medical Economics Co; 1988:624. 6. Drug Facts and Comparisons, 1989 ed. St. Louis: Lippincott Co; 1989:2184. 7. USP-DI Advice for the Patient, 1991 ed. Rockville Md: U.S. Pharmacopeial Convention, Inc; 1991;2:683-4.
Vol. NS32, No.7 July 1992/ 569
8. USP-DI Drug Information for the Health Care Provider, 1991 ed. Rockville Md: U.S. Pharmacopeial Convention, Inc; 1991;1B:1551-3. 9. Klassen CD. Principles of toxicology. In: Gilman AG, Rail TW, Nies AS, et aI., eds. Goodman and Gilman The Pharmacological Basis of Therapeutics, 8th ed. New York: Pergamon Press; 1990:49-61. 10. Oderda GM, Klein-Schwartz W. Clinical toxicology. In: Herfindal ET, Gourley DR, Hart LL, eds. Clinical Pharmacy and Therapeutics, 4th ed. Baltimore: Williams and Wilkins; 1988:1038-51. 11. Lippman W, Rumley W. Medical emergencies. In: Dunagan WC, Ridner ML, eds. Manual of Medical Therapeutics, 26th ed. Boston: Little, Brown, and Co; 1989:482-503. 12. Grogan FJ. The Pharmacist's Prescription. New York: Avon Books; 1987:355. 13. Litovitz TL, Bailey KM, Schmitz BF. The 1990 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1991;9:461-509.
AMERICAN PHARMACY
