Gastrointestinal (GI) hemorrhage: The patient who has had GI hemorrhage may present with signs and symptoms of volume loss and a decrease in oxygen-carrying capacity. These symptoms include tachypnea, tachycardia, hypotension, orthostatic changes, decreased hemodynamic filling pressures, decreased urine output, pallor, cold and clammy skin, confusion, anxiety, and somnolence. The patient may also show signs of hematemesis, maroon or tarry stools, or hematochezia. Gastric lavage in GI hemorrhage may be helpful in clearing the stomach of blood and clots to facilitate evaluation of the source of bleeding and to improve visualization of the gastric fundus in preparation for endoscopic treatment.^5,10 The presence of bright red blood in the aspirate could be an indicator for the need for urgent enodoscopy.⁵

 Overdose: The American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists do not recommend the use of gastric lavage in the routine management of poisoned patients because of the limited evidence of improved patient outcomes and potential risks of the procedure.^3,9 However, in specific poisoning cases, gastric lavage could be of some benefit (Level D*). Indications include if lavage is initiated in symptomatic patients within 1 hour (60 minutes) of ingestion of a potentially life-threatening amount of highly toxic substance, if the substance slows GI motility, or if the substance is a sustained-release medication.^3,7–9 Gastric lavage is contraindicated in the use of overdose if the patient has consumed strong corrosives or hydrocarbons (e.g., gasoline, strong acids, or alkali) and if the pills or pill fragments are known to be larger than the opening of the orogastric (OG) tube.^6,9 The administration of activated charcoal (AC) has been used in combination with gastric lavage for specific toxins; however, its use must be approached cautiously because the combination of therapies may result in an increased risk for aspiration.^7,8 It should be noted that the end point of gastric lavage is not clearly defined if particulate cannot be clearly observed; however, the amount of lavage fluid instilled should approximate the amount of fluid returned.^7–9 Gastric lavage after overdose or toxin ingestion has variable efficacy. The amount of toxin or drug recovered depends on variables such as time from ingestion, whether liquid or pills were ingested, specific agent ingested, and size of lavage tube used. Even if lavage is performed close to the time of ingestion, not all the ingested toxin will be recovered and treatment related to effects of the overdose will still be necessary.^6–9

 No. 36 to 40 Fr gastric tube or

 No. 30 English gastric tube

• Perform baseline cardiovascular and neurologic assessments and assess hemodynamic status, cardiac rhythm, and vital signs. Rationale: Passage of the lavage tube may cause changes in heart rate, blood pressure, or vagal stimulation, which can precipitate bradydysrhythmias or other electrocardiographic (ECG) changes, including ST elevation.⁹ In the overdose case, toxic levels of certain classes of drugs can also cause ECG changes.³

• Perform baseline respiratory assessment and pulse oximetry. Rationale: Gastric lavage has been shown to cause changes in oxygen saturation, leading to hypoxia. Patients who are unable to protect the airway should be intubated before gastric lavage.

• Signs and symptoms of major blood loss are as follows:

• Evaluate the patient for a history of esophageal varices, recent GI surgery, coagulopathy, or underlying pathology. Rationale: Varices, recent surgery, coagulopathies, or other contraindications may predispose the patient to complications during lavage tube insertion.

• Obtain baseline coagulation studies, hematocrit and hemoglobin values, basic metabolic panel, renal and liver function tests, and blood type. Rationale: Baseline information is provided so that treatment can be determined and progress can be more accurately monitored.

• Serum toxicology screen, urinalysis, urine toxicology screen, and anion gap (overdose case) are other laboratory tests that also may be monitored. Rationale: Baseline information for diagnosis is provided so that intervention can be made appropriately and patient progress can be more accurately monitored.³

• Obtain arterial blood gas (ABG) values. Rationale: Overdose victims with hypoventilation and patients with GI hemorrhage with significant blood loss or comorbid disease are at risk for hypoxia, hypercapnea, and acid-base disorders.

• Assess adequacy of gag reflex. Rationale: Lack of an adequate gag reflex indicates the need for endotracheal intubation before lavage begins.^6,9,11

• Assess the type of drugs or toxic substances ingested, quantity ingested, and time since ingestion. Use of common toxidromes (classifications of the signs and symptoms that develop with poisoning) can help to identify unknown ingested substances (for the overdose case).³ Rationale: Certain substances may require neutralization before tube evacuation is attempted. A poison control center should be contacted if the practitioner is unsure that lavage is indicated. Side effects can be anticipated if the drugs or toxins that were swallowed and the quantity are known.

• Perform careful skin assessment (overdose case). Rationale: Assessment may give evidence regarding toxin ingested because various drugs can cause cutaneous changes. Changes to look for include diaphoresis, bullae, acneiform rash, flushed appearance, and cyanosis.

• Assess any odors present (overdose case). Rationale: Some toxins have a distinctive odor, which can aid in identification of substance ingested.

• Perform a 12-lead ECG and continuous cardiac monitoring. Rationale: In an overdose case, the drug or toxin ingested may be cardiotoxic. For the patient with a GI hemorrhage, comorbid disease states may increase risk for tissue hypoxia and ischemia.

• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.

• Place the patient on a cardiac monitor, automatic blood pressure cuff, and pulse oximeter. Set up oropharyngeal suction. Rationale: This action allows for close cardiovascular and respiratory system monitoring during the procedure and ensures suction is available for the procedure.

• Establish and maintain intravenous (IV) access. For the patient with GI hemorrhage, place a minimum of two large-bore IVs or provide central access. Rationale: IV access is necessary for emergency IV medication administration and volume resuscitation in the case of GI hemorrhage.⁵

• Position patient in left lateral decubitus position.^7,8 Rationale: This position facilitates passage of the tube into the stomach. The left lateral position is the position of choice to prevent aspiration if the patient should vomit.

• Apply oxygen via nasal prongs or mask as needed. Continue to evaluate the patient for possible need of airway intubation. Rationale: Supplemental oxygen may optimize the patient’s oxygen saturation.