Incidence of aspiration pneumonia in intubated patients receiving activated charcoal

Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit

Poisoning and its aftermath are globally observed and acknowledged concerns. India has a large burden of "self-harm/suicides" with 12.4/per 100,000 population committing suicide. Consumption of poisonous substances is the second most common mode of self-harm in India. Patients present to both public and private institutions in a critically ill state. The Indian Society of Critical Care Medicine (ISCCM) and Indian College of Critical Care Medicine (ICCCM) decided to address common and contentious issues related to poisoning by developing a position statement that is expected to be appropriate in the Indian scenario by the constitution of an "expert group" to provide a "set of statements" aimed at addressing the common issues faced by intensivists in their practice in managing such patients. The structured approach, framework, and process adopted in developing the position statement on the approach to poisoning have been detailed in this statement. The formation of an expert advisory panel was followed by a literature search, and multiple sessions of consensus-building exercises to reach the current statement presented below. The statement consists of relevant questions with possible answers thereof. Each answer was further weighed against the data and evidence available in the literature. Recommendations were made using a simplified score to make the statement qualitatively meaningful.

How to cite this article

Rungta N, Ray B, Bhalla A, DP Samaddar, Paul G, Prasad S, et al. Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S217-S232.

Lung injury caused by aspiration of organophosphorus insecticide and gastric contents in pigs

INTRODUCTION

Patients who require mechanical ventilation after self-poisoning with ingested organophosphorus (OP) insecticides often die. Aspiration of stomach contents may contribute to lung injury and lethality. This study was designed to assess the severity of direct and indirect pulmonary injury created by pulmonary instillation of mixtures of OP insecticide, solvent (Solv) and porcine gastric juice (GJ) compared to controls.

METHODS

Terminally anaesthetised minipigs (groups n = 5) were exposed to sham bronchoscopy or given mixtures (0.5 mL/kg) of: saline, GJ, OP insecticide and GJ (OP + GJ), or Solv and GJ (Solv + GJ), placed into the right lung, and monitored for 48 h. Lung injury was assessed through analysis of bronchoalveolar lavage fluid (BALF), computed tomography and histopathology.

RESULTS

OP + GJ created a direct lung injury consisting of neutrophil infiltration, oedema and haemorrhage, as well as indirect injury to the other lung. OP + GJ directly-injured lung parenchyma had increased concentrations of BALF protein, albumin, IL-6, IL-8 and C-reactive protein (CRP) at 24 h (p < 0.05), and BALF protein, albumin and CRP at 48 h (p < 0.05), when compared with controls. Aspiration of GJ produced similar direct effects to OP + GJ but less indirect lung injury. Lung injury was less severe after Solv + GJ, for combined lung histopathology scores (vs. OP + GJ, p < 0.05) and for the proportion of directly-injured lung that was poorly/non-aerated at 48 h.

CONCLUSION

Pulmonary instillation of OP + GJ created more lung damage than controls or Solv + GJ. In patients with severe OP insecticide poisoning and reduced consciousness, early airway protection is likely to reduce pulmonary damage.

Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose

INTRODUCTION

The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations.

OBJECTIVES

The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal?  Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal.

METHODS

A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations.  One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study.

RESULTS

From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals.

CONCLUSIONS

This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death.  Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.

Endotracheal Intubation in the Pharmaceutical-Poisoned Patient: a Narrative Review of the Literature

INTRODUCTION

Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated.

DISCUSSION

A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm.

CONCLUSIONS

ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations.

Clinical Effects of Activated Charcoal Unavailability on Treatment Outcomes for Oral Drug Poisoned Patients

Background

Activated charcoal is the most frequently and widely used oral decontaminating agent in emergency departments (EDs). However, there is some debate about its clinical benefits and risks. In Korea, activated charcoal with sorbitol was unavailable as of the mid-2015, and our hospital had been unable to use it from September 2015. This study examined the differences of clinical features and outcomes of patients during the periods charcoal was and was not available.

Methods

We retrospectively reviewed the electronic medical records of patients who had visited an urban tertiary academic ED for oral drug poisoning between January 2013 and January 2017.

Results

For the charcoal-available period, 413 patients were identified and for the charcoal-unavailable period, 221. Activated charcoal was used in the treatment of 141 patients (34%) during the available period. The mortality rates during the available and unavailable periods were 1.9 and 0.9%, respectively (p = 0.507). There was also no interperiod difference in the development of aspiration pneumonia (9.9 versus 9.5%, p = 0.864), the endotracheal intubation rate (8.4 versus 7.2%, p = 0.586), and vasopressor use (5.3 versus 5.0%, p = 0.85). Intensive care unit (ICU) admission was higher in the unavailable period (5.8 versus 13.6%, p = 0.001). ICU days were lower in the unavailable period (10 [4.5-19] versus 4 [3-9], p = 0.01). Hospital admission (43.3 versus 29.9%, p = 0.001) was lower in the unavailable period.

Conclusions

In this single center study, there appeared to be no difference in mortality, intubation rates, or vasopressor use between the charcoal-available and charcoal-unavailable periods.

An exploratory study; the therapeutic effects of premixed activated charcoal-sorbitol administration in patients poisoned with organophosphate pesticide

OBJECTIVE

The effects of activated charcoal (AC) mixed with cathartics for gastric decontamination in the management of organophosphate (OP) poisoning remain unknown due to limited clinical evidence. This exploratory study assessed the effectiveness of premixed AC-sorbitol as a treatment for OP poisoning.

MATERIALS AND METHODS

This retrospective observational case study included patients who either did not receive AC-sorbitol or received a single dose of AC-sorbitol within 24 h after OP ingestion. The patients were divided into three groups: no AC-sorbitol treatment, patients who received AC-sorbitol within 1 h of OP ingestion, and patients who received AC-sorbitol more than 1 h after OP ingestion. Mortality, the development of respiratory failure, and the duration of mechanical ventilation were used as outcome measurements for effectiveness, whereas aspiration pneumonia and electrolyte imbalance were employed as safety measurements.

RESULT

Among 262 patients with OP poisoning, 198 were included. Of these, 133 patients did not receive AC-sorbitol, whereas 14 and 51 patients received AC-sorbitol within 1 h or more than 1 h after ingestion, respectively. The time from ingestion to hospital arrival and time from ingestion to administration of atropine and pralidoxime differed among the groups, whereas other characteristics, including age, amount ingested, and type of ingested OP, were similar among the groups. Univariate and multivariate analysis demonstrated that the administration of AC-sorbitol was not associated with outcome measures for effectiveness and did not significantly increase either aspiration pneumonia or electrolyte imbalances during hospitalization.

DISCUSSION AND CONCLUSION

The administration of AC-sorbitol exerted neither beneficial nor harmful effects on the outcomes of OP-poisoned patients regardless of the time from OP ingestion to administration, compared with those of patients who did not receive AC-sorbitol. However, this study enrolled a small number of patients who received AC-sorbitol; further qualified trials with a sufficient number of patients are therefore needed.

The effect of curcumin on lung injuries in a rat model induced by aspirating gastrointestinal decontamination agents

BACKGROUND

Aspiration is one of the most feared complications of gastrointestinal decontamination procedures with nonabsorbed polyethylene glycol (PEG) solution and activated charcoal (AC). We aimed to investigate the protective effects of curcumin (CUR) on lung injury in rats induced by aspiration of these agents.

METHODS

Experimental rats were divided randomly into 6 groups (n = 7): a saline-aspirated control (group I), sterile saline aspirated with CUR treatment (group II), PEG aspirated (group III), PEG aspirated with CUR treatment (group IV), AC aspirated (group V), and AC aspirated with CUR treatment (group VI). After aspiration, treatment groups II, IV, and VI were given 150 mg/kg CUR intraperitoneally once a day for 7 days. After 7 days, the rats were humanely killed, and both the lungs and serum specimens from all groups were evaluated histopathologically, immunohistochemically, and biochemically.

RESULTS

Aspiration of gastrointestinal decontamination agents produced histopathologic changes, elevated levels of malondialdehyde and surfactant protein D, reduced levels of antioxidant enzymes, and increased expression of inflammatory cytokines interleukin-1β and tumor necrosis factor α. Curcumin treatments effectively attenuated the rats' pulmonary inflammation responses (as shown by reduced alveolar damage), decreased serum malondialdehyde and surfactant protein D levels, and inhibited the expressions of tumor necrosis factor α and interleukin-1β.

CONCLUSIONS

Because of its anti-inflammatory effects, CUR treatment may have preventive effects on lung injuries induced by aspirating gastrointestinal decontamination agents.

The role of iNOS inhibitors on lung injury induced by gastrointestinal decontamination agents aspiration

Aspiration is a devastating complication during decontamination procedure in poisoning patients. We have investigated whether S-methylisothiourea protects different pulmonary aspiration gastrointestinal decontamination agent-induced lung injury in rats. Forty-two male Sprague-Dawley rats were assigned to one of six groups (n = 7): normal saline, activated charcoal, polyethylene glycol, normal saline + S-methylisothiourea treated activated charcoal + S-methylisothiourea treated and polyethylene glycol + S-methylisothiourea treated. Normal saline, activated aharcoal and polyethylene glycol were instilled into the lungs. The rats received S-methylisothiourea i.p twice daily for 7 days. Serum surfactant protein D, oxidative stress products and inducible nitric oxide synthase expression in the lung were investigated. The aspiration of activated charcoal significantly increased all histopathological scores (P < 0.01). Only peribronchial inflammatory cell infiltration, alveolar edema, and alveolar histiocytes were increased in the polyethylene glycol groups as compared to the normal saline group (P < 0.05). Pulmonary aspiration increased serum malondialdehyde (P < 0.001), and surfactant protein D (P < 0.05) levels and decreased serum superoxide dismutase levels (P < 0.05). S-methylisothiourea treatment decreased all histopathological scores in the activated charcoal treated S-methylisothiourea group (P < 0.01) and only decreased alveolar edema and alveolar histiocytes in the polyethylene glycol-treated S-methylisothiourea group (P < 0.05). S-methylisothiourea treatment reduced elevated oxidative factors, inducible nitric oxide synthase activity and serum surfactant protein D levels. Our findings showed that S-methylisothiourea may be a protective drug against Activated Charcoal and Polyethylene Glycol-induced lung injury.

Gastrointestinal decontamination in the acutely poisoned patient

Objective

To define the role of gastrointestinal (GI) decontamination of the poisoned patient.

Data Sources

A computer-based PubMed/MEDLINE search of the literature on GI decontamination in the poisoned patient with cross referencing of sources.

Study Selection and Data Extraction

Clinical, animal and in vitro studies were reviewed for clinical relevance to GI decontamination of the poisoned patient.

Data Synthesis

The literature suggests that previously, widely used, aggressive approaches including the use of ipecac syrup, gastric lavage, and cathartics are now rarely recommended. Whole bowel irrigation is still often recommended for slow-release drugs, metals, and patients who "pack" or "stuff" foreign bodies filled with drugs of abuse, but with little quality data to support it. Activated charcoal (AC), single or multiple doses, was also a previous mainstay of GI decontamination, but the utility of AC is now recognized to be limited and more time dependent than previously practiced. These recommendations have resulted in several treatment guidelines that are mostly based on retrospective analysis, animal studies or small case series, and rarely based on randomized clinical trials.

Conclusions

The current literature supports limited use of GI decontamination of the poisoned patient.

The approach to the patient with an unknown overdose

Toxic overdose can present with various clinical signs and symptoms. These may be the only clues to diagnosis when the cause of toxicity is unknown at the time of initial assessment. The prognosis and clinical course of recovery of a patient poisoned by a specific agent depends largely on the quality of care delivered within the first few hours in the emergency setting. Usually the drug or toxin can be quickly identified by a careful history, a directed physical examination, and commonly available laboratory tests. Once the patient has been stabilized, the physician must consider how to minimize the bioavailability of toxin not yet absorbed, which antidotes (if any) to administer, and if other measures to enhance elimination are necessary.

Activated charcoal for pediatric poisonings: the universal antidote?

PURPOSE OF REVIEW

For decades, activated charcoal has been used as a 'universal antidote' for the majority of poisons because of its ability to prevent the absorption of most toxic agents from the gastrointestinal tract and enhance the elimination of some agents already absorbed. This manuscript will review the history of activated charcoal, its indications, contraindications, and the complications associated with its use as reported in the literature.

RECENT FINDINGS

Recent randomized prospective studies, although with small numbers, have shown no difference in length of hospital stay, morbidity, and mortality between groups who received and did not receive activated charcoal. No study has had sufficient numbers to satisfactorily address clinical outcome in patients who received activated charcoal less than 1 h following ingestion.

SUMMARY

If used appropriately, activated charcoal has relatively low morbidity. Due to the lack of definitive studies showing a benefit in clinical outcome, it should not be used routinely in ingestions. AC could be considered for patients with an intact airway who present soon after ingestion of a toxic or life-threatening dose of an adsorbable toxin. The appropriate use of activated charcoal should be determined by the analysis of the relative risks and benefits of its use in each specific clinical scenario.

Lung disease 35 years after aspiration of activated charcoal in combination with pulmonary lymphangioleiomyomatosis. A histological and clinicopathological study with scanning electron microscopic evaluation and element analysis

Activated charcoal provides effective treatment for most toxic ingestions. Accidental aspiration of activated charcoal is rare. Previously, there have been a few single cases reported on charcoal-related pulmonary complications. We describe an unusual case of pulmonary lesions 35 years after accidental aspiration of activated charcoal. The 38-year-old female patient presented with recurrent pneumothorax. A routinely performed chest roentgenogram revealed pulmonary lesions, highly suggestive to lymphangioleiomyomatosis (LAM). Histopathological investigation of the lung tissue demonstrated some features of LAM but showed prominent pneumoconiotic lesions with cystic tissue destruction. The pneumoconiotic reaction was characterized by prominent black deposits accompanied by foreign-body granuloma formation and minimal fibrosis. Scanning electron microscopic investigation of these deposits showed particles measuring up to 300 microm in greatest diameter. Energy-dispersive X-ray spectra of these particles revealed carbon-rich material, presumably charcoal. The aspiration event was confirmed by the clinical history. To our knowledge, this is the first report not only on a long-term follow-up after aspiration of activated charcoal but also on charcoal-related pulmonary lesions in combination with LAM.

The Changing Indications of Gastrointestinal Decontamination in Poisonings

Gastrointestinal (GI) decontamination is commonly used in the treatment of the poisoned patient. Although the practice is widely accepted, the science behind the recommendations is limited. This article describes commonly used techniques for GI decontamination and critically reviews the studies evaluating these treatments.

Gastrointestinal decontamination

Overall, no conclusive data support the use of gastric decontamination in the routine management of the poisoned patient. Studies of asymptomatic patients suggest that no treatment is required, and, given the complications that have been reported, this may be a reasonable approach to' most patients. Even in symptomatic patients, the only demonstrable benefit was found in a post-hoc subgroup analysis and involved an outcome of questionable clinical importance. Given these data, it would be easy to conclude that GI decontamination has no role in the management of the poisoned patient. This conclusion is valid when considering poisoned patients as a group, but all poisoned patients are not the same. Patients with trivial ingestion do well without treatment, and their greatest risk is an iatrogenic complication. Even patients with more serious ingestions usually have good outcomes with supportive care alone. It is no longer sufficient to justify GL or forced administration of AC with the supposition that "the patient could have taken something bad." However,there are some overdoses where limiting the systemic absorption of the poison may limit the toxic effects and prevent serious toxicity. After careful consideration of the risks, GI decontamination should be targeted at patients who, in the opinion of the treating physician, have a potentially life-threatening exposure.

Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes

OBJECTIVE

To characterize the frequency of aspiration pneumonitis in an unselected population of overdose patients and, further, to identify factors that predispose to aspiration pneumonitis and the outcomes of patients with aspiration pneumonitis compared with those without.

DESIGN

Retrospective cohort study.

SETTING

Toxicology unit of a tertiary referral hospital.

PATIENTS

All poisoning admissions.

MEASUREMENTS AND MAIN RESULTS

A total of 71 of 4,562 poisoning admissions to the Hunter Area Toxicology Service between January 1997 and October 2002 had definite aspiration pneumonitis (1.6%; 95% confidence interval, 1.2-2.0). Older age, Glasgow Coma Score of <15, spontaneous emesis, seizures, delayed presentation to hospital, and ingestion of tricyclic antidepressants were associated with an increased risk of aspiration pneumonitis. Paracetamol poisoning and female sex were associated with a decreased risk of aspiration pneumonitis with univariate analysis. Ingestion of alcohol, benzodiazepines, antipsychotics, and administration of activated charcoal were not associated with aspiration pneumonitis. A logistic regression model for predicting aspiration pneumonitis contained seven predictors: age, sex, Glasgow Coma Score of <15 (odds ratio, 3.14; 95% confidence interval, 1.87-5.27), emesis (odds ratio, 4.17; 95% confidence interval, 2.44-7.13), seizure, tricyclic antidepressant ingestion, and time from ingestion to presentation (delay of >24 hrs [odds ratio, 4.42; 95% confidence interval, 2.42-8.10]). The mortality for patients with aspiration pneumonitis was 8.5% compared with 0.4% for those without (odds ratio, 23; 95% confidence interval, 9-60; p <.0001), and they had a significantly higher intensive care unit admission rate. The median length of stay of patients with aspiration pneumonitis was 126 hrs (interquartile range, 62-210 hrs) compared with 14.7 hrs (interquartile range, 7-23 hrs) in patients without (p <.0001).

CONCLUSIONS

Our study has shown a number of risk factors in overdose patients that are associated with aspiration pneumonitis that may allow the early identification of these patients for appropriate observation and management. Patients with aspiration pneumonitis have a significantly increased mortality and length of stay in the hospital.

Does gastric lavage really push poisons beyond the pylorus? A systematic review of the evidence

Classically, treatment of acute self-poisoning involves resuscitation and supportive care, followed by gastric emptying, administration of activated charcoal, and use of specific antidotes. Recently, however, the practice of gastric emptying has fallen out of favor in the West because physicians have recognized its complications and the lack of evidence for clinical benefit from its practice. Authoritative position statements have stated that forced emesis should not be used and that gastric lavage should be used in restricted settings. One commonly cited complication of gastric lavage is propulsion of poison beyond the pyloric sphincter into the small bowel. We have carried out a systematic search for studies addressing this issue and found only 2. The first, a randomized controlled trial of patients presenting to an emergency department, reported propulsion of poison into the small bowel and has been widely cited as showing evidence for such a complication. However, analysis of the data presented in this article shows no significant difference in the number of radio-opaque marker pellets present in the small bowel after gastric lavage, ipecac-induced forced emesis, or no intervention. The second, an observational study using human volunteers, showed significantly less poison in the small bowel after gastric lavage than after no intervention. In conclusion, it seems that no published data support the statement that gastric lavage forces poison into the small bowel.

How accurate are emergency clinicians at interpreting noncontrast computed tomography for suspected renal colic?

OBJECTIVE

To assess the accuracy of emergency physicians and trainees in the interpretation of noncontrast helical computed tomography (NCHCT) for suspected renal colic by examining the interrater reliability between emergency department (ED) clinicians and radiologists.

METHODS

Information was collected prospectively on all ED patients undergoing NCHCT for suspected renal colic over a 12-month period. Emergency physicians and trainees were asked to report the absence or presence of specific renal parameters (renal tract abnormality, calculus, hydroureter, hydronephrosis, perinephric stranding, and renal parenchymal edema) and nonrenal parameters (nonrenal abnormality, free gas, free fluid, and aortic diameter >3 cm). These reports were compared with the formal radiology report, which was used as the reference standard. The sensitivity, specificity, accuracy, and kappa coefficient were calculated for each of the parameters.

RESULTS

Over the 12-month period, 212 patients underwent NCHCT for suspected renal colic, of whom 127 had both ED and formal radiological reporting. There was an excellent degree of interrater reliability between the ED clinicians and the radiologists (kappa > 0.75) for the presence of renal tract abnormality and renal tract calculus. There was intermediate interrater reliability (kappa 0.4-0.75) for nonrenal tract abnormalities, hydroureter, hydronephrosis, and perinephric stranding. Four patients had potentially significant nonrenal abnormalities missed by ED clinicians.

CONCLUSIONS

Emergency clinicians are able to identify renal calculi with a high degree of accuracy but may miss important nonrenal abnormalities. Therefore, all patients without evidence of renal tract calculus on NCHCT must have early and appropriate follow-up.

The frequency of complications associated with the use of multiple-dose activated charcoal

STUDY OBJECTIVE

The objective of this study was to determine the frequency of complications associated with the use of multiple-dose activated charcoal.

METHODS

The study population was drawn from 8 tertiary care hospitals in 4 North American cities. Medical records of all inpatients between March 1993 and March 1998 with a discharge diagnosis of poisoning (International Classification of Diseases, 9th edition, Clinical Modification codes 960-989.9) were reviewed to select patients who had received multiple-dose activated charcoal (defined as > or =2 doses administered within 12 hours). Medical records of patients who received multiple-dose activated charcoal were reviewed for patient demographics and clinical information regarding the occurrence of pulmonary aspiration, gastrointestinal obstruction, hypernatremia, hypermagnesemia, corneal abrasion, and other complications associated with the use of multiple-dose activated charcoal.

RESULTS

We reviewed 6,258 medical records, identifying 878 patients who received multiple-dose activated charcoal. We judged 5 (0.6%; 95% confidence interval [CI] 0.1% to 1.1%) patients to have had clinically significant pulmonary aspiration and none (0%; upper 95% CI 0.3%) to have had gastrointestinal obstruction. None of the patients with pulmonary aspiration died or had residual sequelae recorded. Hypernatremia (peak serum sodium >145 mEq/L [145 mmol/L]) was documented in 53 (6.0%; 95% CI 4.4% to 7.6%) patients, of whom 5 (0.6%; 95% CI 0.1% to 1.1%) had a serum sodium concentration of greater than 155 mEq/L (155 mmol/L). Hypermagnesemia (peak serum magnesium >2.5 mg/dL [1.0 mmol/L]) was documented in 27 (3.1%; 95% CI 2.0% to 4.2%) patients, of whom 3 (0.3%; 95% CI 0.1% to 1.0%) had peak values that were greater than 3.75 mg/dL (1.5 mmol/L). One patient had a corneal abrasion (0.1%; 95% CI 0% to 0.6%). No other complications were identified.

CONCLUSION

Clinically significant complications associated with the use of multiple-dose activated charcoal occur infrequently.

Aspiration pneumonia following severe self-poisoning

PURPOSE

To investigate the risk factors of aspiration pneumonia following severe self-poisoning.

MATERIALS AND METHODS

Patients treated due to severe self-poisoning in the ICU of Oulu University Hospital, Oulu, Finland during 1.11.1989-31.10.2000 were analyzed retrospectively.

RESULTS

28.4% of 257 patients fulfilled the criteria of aspiration pneumonia. An unconscious patient who was not intubated until arrival at the emergency room (ER) had an odds ratio (OR) of 3.34 (CI 1.3-8.7) for aspiration pneumonia. If the patient was intubated at the first contact with health care providers, OR was 1.8 (CI 0.6-5.7). The use of gastric lavage or activated charcoal in the case of a non-intubated unconscious patient led to ORs of 2.7 (CI 0.8-9.3) and 3.7 (CI 1.01-12.5), respectively. The mean length of ICU stay was 0.9 (CI 0.8-0.9) days among patients without aspiration pneumonia and 1.9 (CI 1.3-2.6) days among those with aspiration pneumonia. The mean length of hospital stay was 2.8 (CI 2.5-3.1) days among the patients without aspiration pneumonia and 6.5 (CI 5.3-7.6) days among those with aspiration pneumonia.

CONCLUSION

To avoid aspiration pneumonia intubation of an unconscious patient on scene before arrival at the ER is recommended. The use of gastric lavage and activated charcoal increase the risk of aspiration pneumonia if the patient is unconscious and not intubated. Aspiration pneumonia significantly prolongs the length of ICU and hospital stay.

The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review

Gastrointestinal decontamination has been practiced for hundreds of years; however, only in the past few years have data emerged that demonstrate a clinical benefit in some patients. Because most potentially toxic ingestions involve agents that are not toxic in the quantity consumed, the exact circumstances in which decontamination is beneficial and which methods are most beneficial in those circumstances remain important topics of research. Maximum benefit from decontamination is expected in patients who present soon after the ingestion. Unfortunately, many overdose patients present at least 2 hours after taking a medication, when most of the toxin has been absorbed or has moved well into the intestine, beyond the expected reach of gastrointestinal decontamination. Decontamination probably does not contribute to the outcome of many such patients, especially those without symptoms. However, if absorption has been delayed or gastrointestinal motility has been slowed, activated charcoal may reduce the final amount absorbed. The use of activated charcoal in these cases may be beneficial and is associated with few complications. Therefore, administration of activated charcoal is recommended as soon as possible after emergency department presentation, unless the agent and quantity are known to be nontoxic, the agent is known not to adsorb to activated charcoal, or the delay has been so long that absorption is probably complete. The use of gastric emptying in addition to activated charcoal has generated intense debate. Several large comparative studies have failed to demonstrate a benefit of gastric emptying before activated charcoal. Because complications of such 2-step decontamination include a higher rate of intubation, aspiration, and ICU admission, gastric emptying in addition to activated charcoal cannot be considered the routine approach to patients. However, there are several infrequent circumstances in which the data are inadequate to accurately assess the potential benefit of gastric emptying in addition to activated charcoal: symptomatic patients presenting in the first hour after ingestion, symptomatic patients who have ingested agents that slow gastrointestinal motility, patients taking sustained release medications, and those taking massive or life-threatening amounts of medication. These circumstances represent only a small subset of ingestions. In the absence of convincing data about benefit or lack of benefit of gastric emptying for these patients, individual physicians must act on a personal valuation: Is it better to use a treatment that might have some benefit but definitely has some risk or not to use a treatment that has any risk unless there is proven benefit?

Evaluation of administration of activated charcoal in the home

OBJECTIVE

Activated charcoal (AC) is recognized as the treatment of choice for gastrointestinal decontamination after many ingestions. AC use in the home has been limited by concerns that parents would not administer it properly and that children would refuse to take AC. Previous descriptions of home administration have reported mixed results.

METHODS

This was an 18-month consecutive case series of all patients for whom AC administration was recommended in the home. Data collected included AC availability in the home and/or a local pharmacy, success in administration, amount administered, time after ingestion to AC administration, difficulties in administration, adverse effects, age and gender of patient, substance involved in poisoning, and medical outcome. All cases were followed for at least 3 days after the ingestion. Patients who initially had home AC recommendation but who ultimately were treated in the emergency department (ED) served as a comparison group.

RESULTS

Home administration of AC was recommended in 138 cases. A total of 115 individuals (83%) were treated with AC in the home, with no failures to administer AC. Reasons for failure to manage at home were 1) mother preferred ED (8 cases), 2) could not locate AC (7 cases), 3) pharmacy closed for the night (6 cases) and 4) no home telephone for follow-up (2 cases). Time to AC administration after ingestion was a mean of 38 minutes (+/-18.3) for home treatment and 73 minutes (+/-18.1) for ED treatment. Ninety-five percent of home cases received AC in < or =60 minutes versus 33% for ED management. AC was in the home in 11 cases at the time of recommendation. The amount of AC administered was a mean of 12.1 g (standard deviation: 6.9) and a median of 12 g. Eight children (6.9%) who were treated at home vomited after AC versus 3 (13%) who received ED treatment. No aspirations or complications occurred.

CONCLUSIONS

AC can be administered successfully by the lay public in the home. Home use of AC significantly reduces the time to AC administration.

Pulmonary aspiration and lung injury

Lung injury after aspiration, although very rare, is a feared and potentially devastating sequela after anaesthesia. This paper summarizes the most recent studies in aspiration lung injury focusing on its clinical epidemiology, new insights in its pathophysiology and innovative concepts in its prevention and therapy.