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PubMed1986

Death due to chronic syrup of ipecac use in a patient with bulimia.

A 17-year-old girl presented with malaise, weakness, palpitations, dysphagia, myalgias, and weight loss of 1 month's duration. Within 24 hours of admission to the hospital, she had hypotension unresponsive to medical management, intractable congestive heart failure, and arrhythmias; she died. Several empty bottles of syrup of ipecac were later found among her belongings. Syrup of ipecac is commonly used to induce emesis in patients who had ingested toxic substances. The chief pharmacologic property of this agent is due to its alkaloid component, emetine. There have been many previous reports of death due to emetine poisoning in patients receiving ipecac fluid extract and in those treated for amoebic dysentery. However, the literature cites only three case reports of fatalities secondary to chronic ipecac use as a means of losing weight. This is the first report of a death due to chronic ipecac use in an adolescent patient with bulimia. Emetine persists in the body for long periods, and in patients who have ingested it chronically, emetine is extremely toxic, specifically to cardiac smooth and skeletal muscles. With an increased awareness of the importance of weight control in the adolescent age group, the physician must carefully evaluate these patients for the use of emetics.

Adolescent↗
PubMed1986

Expired ipecac syrup efficacy.

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.

Child, Preschool↗
PubMed1978

Rapid emesis from high-dose ipecac syrup in adults and children intoxicated with antiemetics or other drugs.

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.

Adolescent↗
PubMed1988

Intentional ipecac poisoning in children.

Ipecac (emetine) is a safe emetic for emergency home use. Its ready availability also provides the potential for child abuse and chronic self-induced emesis. The chronic administration of Ipecac can result in unusual symptom complexes such as chronic diarrhea and vomiting, muscle weakness, colitis, cardiomyopathy, fever, edema, or electrolyte disturbances. We describe patients who were intentionally poisoned and who demonstrated these symptoms. Because of the widespread use of ipecac for therapy in acute accidental poisonings, toxicology laboratories may not look for or report the presence of this drug in their routine screens. This may delay the recognition of chronic ipecac poisoning in patients.

Child Abuse↗
PubMed1988

Syrup of ipecac. The case for distribution from physicians' offices.

Data from a nationally representative sample of household interviews were analyzed to examine public preparedness for childhood poisoning episodes. Eighty-eight percent (61% to 77% in nonwhite groups) of respondents from households with children younger than 10 years had heard of poison control centers and 70% (50% to 57% in nonwhites) stated that they had the telephone number of such a center. In contrast only 25% stated they had syrup of ipecac in their home. Among blacks and Hispanics this proportion was 9%. To explore possible reasons for this we telephoned a sample of 65 physicians listed in the greater Washington, DC, telephone directory as providers of care for infants and children. Of the 45 (69%) who agreed to be interviewed, 73% informed their patients about poison control centers and 53% provided the appropriate telephone number. Although 78% believed parents should have ipecac in the house, only three (7%) of 45 actually dispensed ipecac to parents. We conclude that ipecac is not widely available in the homes of American children. By regularly dispensing it in the course of pediatric care, physicians could largely remedy this deficiency.

Attitude of Health Personnel↗
PubMed1981

The effect of carbonated beverages on ipecac-induced emesis.

To determine the effect of carbonated beverages on syrup of ipecac, 24 pediatric patients were randomly administered six ounces of water or a carbonated beverage with syrup of ipecac. Changes in the abdominal girth, the volume of emesis, and time of emesis were monitored in all patients. In the carbonated beverage group a significant difference (P less than 0.05) was observed between the baseline and 10-min post-ipecac administration abdominal girth measurements. The time of emesis and volume of emesis were not significantly different in the water or carbonated beverage groups. We conclude that carbonated beverage administration does not alter the effectiveness of syrup of ipecac.

Abdomen↗
PubMed1989

Superiority of activated charcoal alone compared with ipecac and activated charcoal in the treatment of acute toxic ingestions.

A prospective, randomized clinical trial compared the clinical effectiveness of syrup of ipecac and activated charcoal to that of activated charcoal alone in the treatment of acute toxic ingestions. Two hundred adult patients with mild to moderate oral overdoses were entered into the trial. Patients receiving only activated charcoal were discharged from the emergency department in significantly (P less than or equal to .05) less time than those receiving both syrup of ipecac and activated charcoal (6.0 +/- 0.3 vs 6.8 +/- 0.2 hours, respectively). The percentage of patients requiring nonpsychiatric hospitalizations was not significantly different between the two groups (11.2% vs 14.0%, respectively). For the hospitalized patients, the length of time spent in the ICU and in the hospital was not statistically different between the two groups. A complication rate of 5.4% was found with the ipecac and activated charcoal treatment compared with a 0.9% complication rate in the activated charcoal group (P less than or equal to .05). Three episodes of aspiration pneumonitis occurred after administration of ipecac and activated charcoal, while no episodes of aspiration were noted after treatment with only activated charcoal. Together, these data are consistent with the recommendation that ED treatment with activated charcoal alone be the gastrointestinal decontamination procedure of choice for the routine mildly-to-moderately orally poisoned adult patient.

Adult↗
PubMed1989

Efficacy of charcoal cathartic versus ipecac in reducing serum acetaminophen in a simulated overdose.

The traditional role of gastric emptying as the initial step in the management of the poisoned patient has recently been questioned; immediate activated charcoal administration has been recommended by some. In the setting of acetaminophen overdose, ipecac-induced emesis may interfere with subsequent oral antidotal therapy. Therefore, we conducted a study to compare the efficacy of initial therapy with ipecac with therapy with activated charcoal-cathartic in a simulated acetaminophen overdosage. Ten healthy volunteers participated in a randomized, crossover trial. Subjects ingested 3.0 g acetaminophen, followed by either no intervention, 30 mL syrup of ipecac, or 50 g activated charcoal-sorbitol solution at one hour. Serial acetaminophen levels were determined at intervals over eight hours. Both interventions significantly reduced the area under the curve compared with control (P less than .05). When comparing ipecac with activated charcoal-cathartic, no significant difference was noted among these groups.

Acetaminophen↗
PubMed1992

Ipecac abuse--danger.

Ipecac abuse must be considered when working with individuals at risk, particularly those with eating disorders. Medical complications such as myopathy and gastrointestinal and other toxic effects can occur with ipecac abuse, the gravity of which must not be underestimated. Education about ipecac abuse and toxicity is extremely important. Discontinuation of ipecac use usually results in recovery from the harmful effects. College healthcare professionals can play an important role in the education and treatment of this potentially hazardous method of weight control.

Bulimia↗
PubMed1991

Hemorrhagic colitis and pseudomelanosis coli in ipecac ingestion by proxy.

This report describes a toddler with chronic diarrhea, vomiting, and hypotonia due to surreptitious administration of syrup of ipecac by his mother (Munchausen's syndrome by proxy). Several features of this case distinguish it from previous reports of chronic ipecac ingestion in childhood: the development of grossly bloody stools; radiologic, endoscopic, and biopsy evidence of a chronic moderate colitis resembling ulcerative colitis; and the histologic finding of pseudomelanosis coli, providing an important clue to toxic ingestion. The significance and possible mechanism for genesis of pseudomelanosis coli is discussed. This case emphasizes the variability in presentation and difficulty in diagnosing long-term ipecac ingestion by proxy. Ipecac toxicity should be considered in children with unexplained colitis and vomiting.

Biopsy↗
PubMed1987

Gastric rupture and death caused by ipecac syrup.

We have reported a fatal complication of a therapeutic dose of ipecac syrup administered in a hospital emergency room. This child received 15 ml of ipecac syrup shortly after ingesting one to five tablets of chlorpheniramine maleate (4 mg). A prolonged course of vomiting (more than 24 hours) eventually resulted in gastric rupture and death. While the use of ipecac is both efficacious and safe in the overwhelming majority of cases, there have been documented fatalities after appropriate doses. For this reason, ongoing education for physicians is important; education of parents is also warranted since wide-scale distribution to families is the accepted standard. Because most patients stop vomiting within two to three hours after ipecac administration, we recommend that children with persistent vomiting should be observed in a medical facility, where electrolyte levels can be measured and fluids can be replaced if necessary.

Child, Preschool↗
PubMed1990

Efficacy of emetic and United State pharmacopoeia ipecac syrup in prevention of drug absorption.

The efficacy of both the emetic syrup prepared in the previous report and the United States Pharmacopoeia (USP) ipecac syrup concerning the prevention of drug absorption was investigated in 4 beagle dogs using a randomized and cross-over design. In order to control the intragastric pH of the beagle dogs, the administration of pentagastrin or hydrochloric acid (HCl)-glycine buffer (pH 1.5) was tested. The intragastric pH changed from 7.2 to 1.8 with the intramuscular administration of pentagastrin, but the primary emesis occurred more slowly. On the other hand, the HCl-glycine buffer (pH 1.5) gave the appropriate emesis. Therefore, the HCl-glycine buffer (pH 1.5) was used to control the intragastric pH of the beagle dogs. Acetaminophen (AcA), salicylic acid (SA) and kanamycin (KM) as markers were administered orally after conditioning the intragastric pH at 1.5. The emetic syrup or the USP ipecac syrup was then administered. The recovery rate of AcA and KM from vomit was 42-65%. The emetic syrup and the USP ipecac syrup significantly reduced the absorption of AcA from the calculation of pharmacokinetic parameters compared to the control syrup. It was observed that the absorption of cephaeline (CP) in the emetic syrup was less than that of CP in the USP ipecac syrup.

Absorption↗
PubMed1984

Activated charcoal and syrup of ipecac in prevention of cimetidine and pindolol absorption in man after administration of metoclopramide as an antiemetic agent.

The effects of activated charcoal and ipecac syrup by mouth on cimetidine and pindolol absorption were studied in seven subjects, who had ingested 20 mg metoclopramide 1 h earlier, and compared with the adsorption capacity of charcoal in vitro. Activated charcoal, 50 g, given 5 min after 400 mg cimetidine + 10 mg pindolol, reduced their absorption by 99% or more, based on AUC0-48h and the 48-h urinary excretion of the drugs. Syrup of ipecac caused emesis on each occasion. On the average, ipecac reduced the absorption of cimetidine and pindolol by 75% and 60%, respectively. Based on studies in vitro it seems probable that the adsorbing capacity of charcoal for cimetidine but not for pindolol will be saturated if 50 g charcoal is given after an overdose of about 100 fold the therapeutic dose. Because the use of ipecac allowed an absorption of the drugs at least 30 fold that allowed by charcoal, the immediate administration of activated charcoal, without preceding lavage or emesis, should be considered in such poisonings where the adsorption capacity of high charcoal doses will not be saturated.

Administration, Oral↗
PubMedDate not supplied

Determination of chlorpheniramine maleate and tincture ipecac in dosage form by liquid chromatography with ultraviolet detection.

A procedure was developed and validated for measuring chlorpheniramine maleate and tincture ipecac (as emetine hydrochloride) by reversed-phase liquid chromatography with methanol-10 mM sodium heptanesulfonate (20 + 30) as the mobile phase; the pH was adjusted to 4 with acetic acid, and the flow rate was at 1.5 mL/min, with ultraviolet detection at 254 nm. Propyl paraben was used as the internal standard. The standard curves were linear (r = 0.998 and 0.9998) for both chlorpheniramine maleate and emetine hydrochloride over the ranges of 5-100 and 0.1-40 microg/mL, respectively. The mean recoveries +/- standard deviation were 101.37 +/- 2.77% for chlorpheniramine maleate and 98.8 +/- 1.47% for emetine hydrochloride. The proposed method was applied to the determination of chlorpheniramine maleate alone in tablet and syrup dosage forms. The method also was applied to the determination of the emetine content of ipecac liquid extract and tincture ipecac; the results were compared with those of the method of the British Pharmacopoeia. The proposed method was applied successfully to the simultaneous determination of chlorpheniramine maleate and tincture ipecac, as emetine hydrochloride, in syrup dosage form. Both drugs and the internal standard were separated from all interfering components in < 5 min. The proposed method is simple, specific, and economical, when compared with other published methods that determine each component alone.

Chlorpheniramine↗
PubMed1988

Ipecac-induced emesis and gastric lavage are equally unpleasant.

It has been widely held that gastric lavage is more unpleasant than ipecac-induced emesis. In fact, patients are occasionally threatened with large rubber tubes in order to persuade them to drink ipecac. To confirm that this assumption exists, we asked 41 emergency physicians and nurses who had never personally undergone either procedure to estimate the discomfort of each using a 10 cm unsegmented visual analog scale. This "naive" group thought that gastric lavage would be significantly more unpleasant than ipecac-induced emesis (mean scores: lavage = 6.46, emesis = 4.94; P less than .001, paired t-test). Using the same methods, we asked 16 health professionals who had undergone both procedures as part of another study to score the recalled unpleasantness of each procedure. Among these who had actually experienced both, there was no significant difference between the mean scores for lavage (4.09) and emesis (4.62) (P greater than 0.5, paired t-test). The mean score difference (lavage minus emesis) for the "naive" group was significantly greater than for the experimental group (1.52 vs -.53, P less than .001, unpaired t-test). Among normal volunteers, ipecac-induced emesis and gastric lavage are equally unpleasant gastric emptying procedures.

Gastric Lavage↗
PubMed1988

Intentional ipecac poisoning: Munchausen syndrome by proxy.

The intentional poisoning of two children with ipecac by their mothers is described. Intractable vomiting and diarrhea were the initial symptoms in both patients. In addition, one patient had clinical and laboratory evidence of skeletal and cardiac myopathy. Both children were subjected to extensive and invasive diagnostic evaluations before the correct diagnosis of chronic ipecac poisoning was made. These cases illustrate the toxic effects of ipecac ingestion and serve to alert physicians to child abuse by ipecac poisoning.

Child↗
PubMed1985

Reversible ipecac myopathy.

The abuse of ipecac syrup for three years resulted in painless, nonfatigable, chiefly proximal weakness in a 27-year-old woman. Electromyography (EMG) and a muscle biopsy revealed features of a myopathy similar to those previously reported in experimental emetine myopathy. Clinical weakness and EMG abnormalities improved after discontinuation of ipecac administration. A direct toxic action of ipecac (acting through its active alkaloid, emetine hydrochloride) on muscle fibers seemed to be responsible for the weakness in this patient.

Adult↗
PubMed1986

Ipecac-induced emesis versus gastric lavage: a controlled study in normal adults.

Ipecac-induced emesis and gastric lavage are the two procedures most widely used to evacuate the stomachs of patients who have ingested poisons. To resolve a long-standing controversy over the relative efficacy of these two methods, the authors carried out a controlled study in which they administered 25 100-micrograms tablets of cyanocobalamin (vitamin B12) to 18 fasting normal adult volunteers on two separate days. On one day, each subject had emesis induced with 30 ml of ipecac syrup followed by 1,000 ml of tap water; on another day, each underwent gastric aspiration and lavage with a 1.1-cm orogastric tube using 3 l of fluid. Both procedures were begun 10 minutes after the ingestion. The recovered vomitus or gastric washings from each procedure were then analyzed for elemental cobalt using atomic absorption spectrophotometry. The mean rate of recovery of the ingested tracer with ipecac-induced emesis was only 28%, whereas gastric lavage resulted in retrieval of 45% (paired t-test, P less than 0.005). In this study, carefully performed gastric lavage was the more effective method of gastric evacuation of tablets in the adult subject.

Adult↗