Stomach Wash (Gastric Lavage) - Complete Procedure

Indications

• Patient presents within 3 hours of poison/drug ingestion (most effective window)
• Can still be performed if gastric emptying is delayed (e.g., sustained-release medications)
• Beyond 6-12 hours, still indicated for: salicylates, tricyclics, carbamazepine, barbiturates

Equipment Needed

Pre-Procedure Steps

1. Obtain IV access and attach continuous cardiac monitor and pulse oximeter.
2. Restrain hands of uncooperative patients.
3. Give an IV antiemetic (e.g., promethazine) if needed - avoid sedating dose.
4. Pre-measure the tube: estimate distance from nose/mouth, around the ear, to the mid-epigastrium. Mark this on the tube.
   • Insert to ~50 cm in adults, ~25 cm in children.
5. Larger holes may be cut at the tube tip to accommodate pill fragments.

Patient Positioning

• The left lateral position keeps gastric contents pooled away from the pylorus, preventing them from being pushed into the duodenum.
• The right lateral position must be avoided - it directs contents toward the pylorus and duodenum.
• If the patient is intubated/on a ventilator, supine is acceptable. An awake non-intubated patient should never be lavaged supine.

Step-by-Step Procedure

• Lubricate the tube well with glycerin or Vaseline.
• Pass the tube orally (orogastric route preferred over nasal; nasal route risks mucosal injury and limits tube diameter).
• Use a bite block to prevent tube damage.
• Once the tube enters the pharynx, tuck the chin to the chest to guide the tube into the esophagus.
• Pass gently to avoid pharyngeal injury.

• Auscultate over the epigastrium while instilling air.
• Aspirate gastric contents (confirms position).
• Alternatively, place the open end in a cup of water - if bubbles appear, the tube is in the trachea (reposition immediately).
• X-ray confirmation may be obtained if clinically uncertain.

• Before starting lavage, aspirate all gastric contents by suction, repositioning the tube tip as needed.
• Preserve the first sample for chemical/toxicological analysis.

• Instill 250-300 mL of warm saline (35°C) at a time in adults. Hold the funnel high for gravity-assisted flow.
• In children: use 10-15 mL/kg body weight of warm saline (not plain water - risk of hyponatremia and water intoxication).
• Do not use volumes >300 mL per cycle - larger volumes risk pushing contents into the duodenum.
• Aspirate/siphon the fluid out using the suction bulb or syringe.
• Repeat cycles until the effluent runs clear, colourless, and free of particulate matter.

• Administer activated charcoal slurry (1 g/kg) through the tube before removal - it adsorbs residual toxin.
• Leave a small quantity of specific antidote or activated charcoal in the stomach.
• Clamp the tube before withdrawing it to prevent aspiration of residual fluid.

Contraindications

• Corrosive poisoning (acid/alkali) - risk of perforation (exception: carbolic acid can be lavaged)
• Comatose/unconscious patient without airway protection
• Volatile poisons (risk of inhalation)
• Convulsant poisons

• Depressed airway reflexes (unless intubated)
• Active vomiting
• Abnormal pharyngeal/GI anatomy
• Coagulopathy
• Large pill fragments or sharp foreign bodies
• Low-viscosity hydrocarbons (high aspiration risk)
• More than 60 minutes since ingestion of most toxins
• Infants and neonates

Complications

1. Laryngeal spasm
2. Aspiration pneumonitis (most serious - prevented by correct positioning and airway protection)
3. Perforation of the stomach or esophagus
4. Cardiac effects - sinus bradycardia, ST changes on ECG
5. Hyponatremia/water intoxication (in children if plain water used instead of saline)

• P C Dikshit Textbook of Forensic Medicine and Toxicology, pp. 434-435
• Roberts and Hedges' Clinical Procedures in Emergency Medicine, pp. 997-998
• Pfenninger and Fowler's Procedures for Primary Care, pp. 1416-1417