There is virtually no indication for the use of emesis in the in-hospital treatment of poisonings. This is primarily because other modalities of decontamination, in particular activated charcoal and whole bowel irrigation are as effective or more effective than using emesis and emesis substantially delays the use of other modalities.
1. When indicated, emesis is best accomplished with the administration of syrup of ipecac.
(still currently available over the counter but may only be available with a prescription in the future.)
2. This is a plant derivative containing the alkaloids emetine (methylcephaeline) and cephaeline
3. Has both a direct effect on the stomach, as well as a central effect
a. Stimulates the chemotactic trigger zone (cephaeline).
4. When ipecac is not available, 30 mL of a mild dishwashing soap (not electric dishwasher detergent) in water is an acceptable alternative for the induction of emesis, though it is less effective than ipecac.
5. Manual stimulation (placing a finger in the back of the throat), other emetics (saline, hydrogen peroxide, and copper sulfate) are less effective and potentially harmful, and thus should not be used in humans.
1. A single dose of ipecac produces emesis in over 90% of patients; mean time to vomit of ~20 minutes.
2. Although the production of emesis is reliable, the amount of drug recovered ranges anywhere from 6-89% this data comes from studies using swallowed tracers in volunteers and overdose patients, and in one case from direct inspection of the stomach with endoscopy.
1. Acute ingestion of a potentially toxic substance still expected to be in the stomach (generally < 1 hr)
2. Protective airway reflex (gag) intact - mental status expected to remain stable
3. May be effective when pills are too large to pass through the ports in a lavage tube (e.g. some extended release preparations, adult iron supplements, etc.)
4. May be useful with substances that bind poorly to charcoal, such as lithium
5. May be useful when removal of 25-30% of the ingested dose may have a significant influence on patient outcome
1. Non-toxic ingestions - emesis should not be used as a method of punishment.
2. Prior significant vomiting - ipecac induced emesis is no better than “natural” emesis, and would not be expected to recover additional material.
3. Any patient who is comatose, seizing, hypotensive, or has lost his/her protective airway reflex.
4. The patient who is presently awake, but may be expected to rapidly deteriorate before emesis has been completed. Examples of this type of ingestion include TCA, beta-blockers, camphor, and many others.
5. Caustic agents may cause additional injury during emesis.
6. Aspiration risk: ingestions of poorly absorbed hydrocarbons.
7. Sharp objects and other foreign body ingestions.
8. Need for rapid administration of oral antidotes, such as NAC, especially approaching 6-8 hours after APAP ingestion.
9. Late in pregnancy
10. Hypertensive crisis or intracranial hypertension.
1. Children under 6 months of age: Contraindicated
2. Children 6 - 12 months: 5-10 mL of ipecac with 15 mL of water/kg body weight
3. Children 1 - 12 years: 15 mL of ipecac with 240 mL of water
4. Adults: 30 mL ipecac with 240-480 mL of water
5. This dose may be repeated in 30 minutes if emesis has not occurred.
1. Intractable vomiting (rare)
4. Myocardial toxicity - associated with extract of ipecac (has 14 times the alkaloidal content of the syrup – production ceased in 1970) or with repeated dosing of syrup as in patients with bulimia.
5. Neuromuscular weakness (seen with chronic abuse in bulimics or with Munchausen’s by Proxy))
6. Mallory-Weiss tear of the esophagus
9. Threatened abortion possibly induced by ipecac
Krenzelok EP, McGuigan M, Lheur P. Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35(7):699-709PMID9482425