Question

• What are the accepted risks associated with recommending having syrup of ipecac in the home?

Clinical Bottom Lines

1. No good data exist to complete a NNH analysis. 
2. Available data suggests that life-threatening intoxication in young children is a rare event at best. 
3. Administration before medical contact poses the largest risk for side effects and inappropriate administration in contraindicated poisonings remains the key point of physician intervention in use of syrup of ipecac.

Summary of Key Evidence

1. About 0.4% of callers over 8 months to one regional poison control center had given ipecac prior to calling.¹ 
2. During that 8 months 5 cases (0.02%) of ipecac ingestion prior to phone contact were contraindicated.  None of these resulted in death or serious morbidity. 
3. Symptoms in follow up were described in 32 patients in the prospective poison control cohort and included lethargy, protracted emesis (>1 hr), and diarrhea.  All are known side effects of ipecac administration.

Additional Comments

• Current recommendations from American Academy of Clinical Toxicology are against syrup of ipecac's use in the emergency department stating that its administration may delay other more life-saving interventions.²
• Randomized controlled trial in adults compared syrup of ipecac and activated charcoal with activated charcoal alone and found no difference in symptoms or need for hospitalization between the two groups.
• Syrup of ipecac is mixture of two alkaloids, emetine & cephaeline, which work at the brainstem's chemoreceptors to trigger nausea.
• Severe side effects of ipecac include cardiac conduction abnormalities (a-fib and bradycardia), hypotension, and myocarditis.  Administrations is linked with increased risk of aspiration.
• Chronic dieting, a risk factor for bulimia, is associated with an 8 increase in relative risk for chronic ipecac administration.³

Citation

1. Young WF, Bivins HG. Evaluation of gastric emptying using radionuclides: gastric lavage versus ipecac-induced emesis. Annals of Emergency Medicine 1993; 22(9):1423-7.
2. Krenzelok EP, McGuigan M, Lheur P. Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centers and Clinical Toxicologists.  Journal of Toxicology - Clinical Toxicology   1997; 35(7):699-709.
3. Story M, Rosenwinkel K, Himes JH, Resnick M, Harris LJ, Blum RW. Demographic and risk factors associated with chronic dieting in adolescents. American Journal of Diseases of Children 1991; 145(9):994-8.

CAT Author: David Myers, MD

CAT Appraisers: John Frohna, MD

Date appraised: November 15, 1999