Is placing a victim in the left lateral decubitus position an effective first aid intervention for acute oral poisoning? A systematic review

Abstract

Introduction: In acute oral poisoning, any first aid intervention that limits or delays the uptake of the ingested substance, and which can be performed by bystanders as first responders, might assist in reducing morbidity if a toxic substance has been ingested. The current recommendation by the International Federation of Red Cross/Red Crescent Societies is to place a victim in the left lateral decubitus position.

Objective: The aim of this PRISMA compliant systematic review is to assess whether the current recommendation by the International Federation of Red Cross/Red Crescent Societies decreases or delays the absorption of an orally ingested poison.

Methods: The Cochrane Library, MEDLINE, Embase, CINAHL and ISI Web of Science were searched in April 2018 for (quasi) randomized controlled trials investigating different body positions that are feasible in a pre-hospital setting by non-healthcare professionals. Data concerning study identification, study design, population, intervention and comparison, outcome measures and study quality were independently extracted and tabulated from the included studies by two reviewers, using a standardized and piloted data extraction form. The same two authors assessed the risk of bias in the included studies independently, using Cochrane’s tool for assessing risk of bias. The GRADE approach was used to judge the certainty of evidence.

Results: A total of 4991 citations were identified. After removal of 1313 duplicates, the titles and abstracts of 3678 references were screened using the predefined selection criteria. This screening yielded 35 potentially relevant articles which were assessed for eligibility using their full text. Twenty-four papers were excluded as they did not meet the selection criteria; nine studies reported in 10 papers were included with a total of 72 participants. All selected studies were performed in a controlled setting using healthy volunteers in a cross-over design. No studies involved poisoned patients. In four studies, the participants ingested paracetamol as a test drug. In five other studies, the following pharmaceuticals were ingested: sodium salicylate, midazolam, nifedipine combined with paracetamol, amoxicillin or slow release theophylline. Drugs were ingested after a period of fasting which varied between 2 h and 9 h. Different body positions were tested: left lateral position, right lateral position, bed rest during the day, supine position, prone position or upright position, standing or remaining ambulatory. In two studies, it was shown that the left lateral position (with or without 20% head down tilt) resulted in a statistically significant decrease of paracetamol AUC and C_max compared to the right lateral position (with or without 20% head up tilt), sitting and prone position. In two further studies, a statistically significant difference in paracetamol AUC and C_max between bed rest or the left lateral position and ambulation could not be demonstrated. In another study, it was shown that lying on the left side resulted in a statistically significant decrease of nifedipine and its nitropyridine metabolite AUC and C_max, and a statistically significant increase of paracetamol, nifedipine and nitropyridine metabolite T_max compared to lying on the right side or standing. One study looked at the effect of remaining strictly supine compared to remaining ambulant on the uptake of oral midazolam 15 mg. It was shown that remaining strictly supine resulted in a statistically significant decrease of C_max compared to remaining ambulant. Overall, evidence was of very low certainty due to limitations in study design, imprecision due to limited sample size and lack of data and indirectness.

Conclusions: The identified studies provide evidence of very low certainty. However, based on the evidence that the left lateral decubitus position may be effective in decreasing the absorption of several drugs, the simplicity of the intervention and the generally low perceived risk of this intervention, the recommendation of the first aid guidelines of the International Federation of Red Cross and Red Crescent Societies can remain unchanged.

KEYWORDS::

• Poisoning
• body position
• first aid
• laypeople
• drug absorption
• drug overdose

Disclosure statement

No potential conflict of interest was reported by the authors.