Single-dose oral activated charcoal in the treatment of the self-poisoned patient: a prospective, randomized, controlled trial

The Role of Activated Charcoal in Prehospital Care

Background

Administration of a single-dose activated charcoal (SDAC) is an effective method used for gastric decontamination and for other types of poisoning and overdose. This is only true when given within the first hour of poison ingestion as the effectivity of SDAC reduces over time. In addition, generally, not all patients are able to avail treatment within the specified period. Hence, multi-dose activated charcoal is regarded as a solution to a delayed process, although, no proof outweighs the use of SDAC.

Objective

This study aimed to review and assess the adequacy of the past and current use of AC. The author also aimed to offer recommendations believed to be the best method to consider for prehospital care.

Methods

The author conducted 6,337 online literature searches for this review, wherein seven papers met eligibility criteria for inclusion and analysis.

Results

In this review, routine administration of AC in poisoning was found not related to the duration of hospital stay nor any other subsequent outcomes following poison ingestion. Further, this review did not establish that administration of AC could improve patient's clinical outcome. Further research and clinical trials is required to determine the efficacy of this therapy to appropriate patients in the prehospital setting.

Conclusion

Activated charcoal can be used to treat highly acute to life-threatening poisoning if it is administered within the first hour of ingestion. Further studies would be necessary to investigate if this would affect clinical outcome..

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.

Activated Charcoal and Poisoning: Is It Really Effective?

BACKGROUND

This study aims to compare the poisoned patients who could not be administered activated charcoal because of its unavailability with the poisoned patients who were administered charcoal in the later period and to reveal the results about its effectiveness.

STUDY QUESTION

Is the use of activated charcoal effective against poisoning caused by oral medication?

STUDY DESIGN

This retrospective cohort study with historical control was planned at a tertiary hospital. Patients older than 18 years were admitted to the emergency department because of oral drug poisoning during the study periods. A total of 1159 patients who were not given activated charcoal and 877 patients who were given activated charcoal were included in this study.

MEASURES AND OUTCOMES

The frequency of clinical findings secondary to the drug taken, the frequency of antidote use, the frequency of intubation, and the hospitalization length were determined as clinical outcome parameters.

RESULTS

There was no statistically significant difference in the development of central nervous system findings, cardiovascular system findings, frequency of intubation, and blood gas disorders, as well as the length of hospitalization periods according to the activated charcoal application. Hepatobiliary system findings and electrolyte disturbances were found to be less common in patients given activated charcoal. The frequency of tachycardia, speech impairment, coma, and respiratory acidosis was found to be statistically higher in patients who were administered activated charcoal. The hospitalization period of the patients who were given activated charcoal was longer in patients with drug findings; however, there was no difference in the hospitalization periods of the patients who were given an antidote.

CONCLUSIONS

The use of activated charcoal in poisoned patients may not provide sufficient clinical benefits. However, clinical studies with strong evidence levels are needed to determine activated charcoal's clinical efficacy, which is still used as a universal antidote.

Management of pharmaceutical and recreational drug poisoning

BACKGROUND

Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis.

METHODS

A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature.

CONCLUSIONS

The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.

Antidotes in Poisoning

Introduction

Antidotes are agents that negate the effect of a poison or toxin. Antidotes mediate its effect either by preventing the absorption of the toxin, by binding and neutralizing the poison, antagonizing its end-organ effect, or by inhibition of conversion of the toxin to more toxic metabolites. Antidote administration may not only result in the reduction of free or active toxin level, but also in the mitigation of end-organ effects of the toxin by mechanisms that include competitive inhibition, receptor blockade or direct antagonism of the toxin.

Mechanism of action of antidotes

Reduction in free toxin level can be achieved by specific and non-specific agents that bind to the toxin. The most commonly used non-specific binding agent is activated charcoal. Specific binders include chelating agents, bioscavenger therapy and immunotherapy. In some situations, enhanced elimination can be achieved by urinary alkalization or hemadsorption. Competitive inhibition of enzymes (e.g. ethanol for methanol poisoning), enhancement of enzyme function (e.g. oximes for organophosphorus poisoning) and competitive receptor blockade (e.g. naloxone, flumazenil) are other mechanisms by which antidotes act. Drugs such as N-acetyl cysteine and sodium thiocyanate reduce the formation of toxic metabolites in paracetamol and cyanide poisoning respectively. Drugs such as atropine and magnesium are used to counteract the end-organ effects in organophosphorus poisoning. Vitamins such as vitamin K, folic acid and pyridoxine are used to antagonise the effects of warfarin, methotrexate and INH respectively in the setting of toxicity or overdose. This review provides an overview of the role of antidotes in poisoning.

How to cite this article

Chacko B, Peter JV. Antidotes in Poisoning. Indian J Crit Care Med 2019;23(Suppl 4):S241-S249.

First aid interventions by laypeople for acute oral poisoning

BACKGROUND

Oral poisoning is a major cause of mortality and disability worldwide, with estimates of over 100,000 deaths due to unintentional poisoning each year and an overrepresentation of children below five years of age. Any effective intervention that laypeople can apply to limit or delay uptake or to evacuate, dilute or neutralize the poison before professional help arrives may limit toxicity and save lives.

OBJECTIVES

To assess the effects of pre-hospital interventions (alone or in combination) for treating acute oral poisoning, available to and feasible for laypeople before the arrival of professional help.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, ISI Web of Science, International Pharmaceutical Abstracts, and three clinical trials registries to 11 May 2017, and we also carried out reference checking and citation searching.

SELECTION CRITERIA

We included randomized controlled trials comparing interventions (alone or in combination) that are feasible in a pre-hospital setting for treating acute oral poisoning patients, including but potentially not limited to activated charcoal (AC), emetics, cathartics, diluents, neutralizing agents and body positioning.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed study selection, data collection and assessment. Primary outcomes of this review were incidence of mortality and adverse events, plus incidence and severity of symptoms of poisoning. Secondary outcomes were duration of symptoms of poisoning, drug absorption, and incidence of hospitalization and ICU admission.

MAIN RESULTS

We included 24 trials involving 7099 participants. Using the Cochrane 'Risk of bias' tool, we assessed no study as being at low risk of bias for all domains. Many studies were poorly reported, so the risk of selection and detection biases were often unclear. Most studies reported important outcomes incompletely, and we judged them to be at high risk of reporting bias.All but one study enrolled oral poisoning patients in an emergency department; the remaining study was conducted in a pre-hospital setting. Fourteen studies included multiple toxic syndromes or did not specify, while the other studies specifically investigated paracetamol (2 studies), carbamazepine (2 studies), tricyclic antidepressant (2 studies), yellow oleander (2 studies), benzodiazepine (1 study), or toxic berry intoxication (1 study). Eighteen trials investigated the effects of activated charcoal (AC), administered as a single dose (SDAC) or in multiple doses (MDAC), alone or in combination with other first aid interventions (a cathartic) and/or hospital treatments. Six studies investigated syrup of ipecac plus other first aid interventions (SDAC + cathartic) versus ipecac alone. The collected evidence was mostly of low to very low certainty, often downgraded for indirectness, risk of bias or imprecision due to low numbers of events.First aid interventions that limit or delay the absorption of the poison in the bodyWe are uncertain about the effect of SDAC compared to no intervention on the incidence of adverse events in general (zero events in both treatment groups; 1 study, 451 participants) or vomiting specifically (Peto odds ratio (OR) 4.17, 95% confidence interval (CI) 0.30 to 57.26, 1 study, 25 participants), ICU admission (Peto OR 7.77, 95% CI 0.15 to 391.93, 1 study, 451 participants) and clinical deterioration (zero events in both treatment groups; 1 study, 451 participants) in participants with mixed types or paracetamol poisoning, as all evidence for these outcomes was of very low certainty. No studies assessed SDAC for mortality, duration of symptoms, drug absorption or hospitalization.Only one study compared SDAC to syrup of ipecac in participants with mixed types of poisoning, providing very low-certainty evidence. Therefore we are uncertain about the effects on Glasgow Coma Scale scores (mean difference (MD) -0.15, 95% CI -0.43 to 0.13, 1 study, 34 participants) or incidence of adverse events (risk ratio (RR) 1.24, 95% CI 0.26 to 5.83, 1 study, 34 participants). No information was available concerning mortality, duration of symptoms, drug absorption, hospitalization or ICU admission.This review also considered the added value of SDAC or MDAC to hospital interventions, which mostly included gastric lavage. No included studies investigated the use of body positioning in oral poisoning patients.First aid interventions that evacuate the poison from the gastrointestinal tractWe found one study comparing ipecac versus no intervention in toxic berry ingestion in a pre-hospital setting. Low-certainty evidence suggests there may be an increase in the incidence of adverse events, but the study did not report incidence of mortality, incidence or duration of symptoms of poisoning, drug absorption, hospitalization or ICU admission (103 participants).In addition, we also considered the added value of syrup of ipecac to SDAC plus a cathartic and the added value of a cathartic to SDAC.No studies used cathartics as an individual intervention.First aid interventions that neutralize or dilute the poison No included studies investigated the neutralization or dilution of the poison in oral poisoning patients.The review also considered combinations of different first aid interventions.

AUTHORS' CONCLUSIONS

The studies included in this review provided mostly low- or very low-certainty evidence about the use of first aid interventions for acute oral poisoning. A key limitation was the fact that only one included study actually took place in a pre-hospital setting, which undermines our confidence in the applicability of these results to this setting. Thus, the amount of evidence collected was insufficient to draw any conclusions.

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.

Single dose activated charcoal for gut decontamination: Application by medical non-professionals -a prospective study on availability and practicability

Context

Oral activated charcoal (AC) for toxin absorption should be applied as soon as possible. Extra-hospital AC-application on site by medical laypersons with pre-emptive obtained AC may save time, but may be inferior to AC-application by medical professionals.

Objective

1) Availability and incidence of pre-emptive stockpiling of AC on site in the German region Bavaria 2) time saved by AC-stockpiling and application on site, 3) quality of AC-application defined by completeness of the applied AC-dose, time needed, incidence of side-effects in lay-care and in professional-care, considering confounding variables: AC-formulation/powder/tablets, recommended AC-dose, patient’s age.

Method

telephone-interviews in cases with AC-recommendation by a Poison Information Centre (PIC). Lay-care was suggested according to risk-assessment by PIC. Ingestion sites were classified as either apt for AC-stockpiling or not apt.

Results

1) availability: In Bavaria only 20%–22% of eligible cases had AC on-hand, 2) time-saving was at least 14 min. 3) Lay-care/professional-care or patient’s age had no significant influence on the completeness of the applied AC-dose, which was higher with AC as powder but negatively correlated with the recommended AC-dose. No significant difference was seen with time needed for application and incidence of side-effects.

Conclusion

pre-emptive AC-stocking should be encouraged.

A retrospective review of the prehospital use of activated charcoal

OBJECTIVE

We studied the complications and timing implications of prehospital activated charcoal (PAC). Appropriateness of PAC administration was also evaluated.

METHODS

We retrospectively reviewed prehospital records over 32 months for overdose cases, where PAC was administered. Cases were assessed for amount and type of ingestant, clinical findings, timing of PAC, timing of transport and arrival into the emergency department (ED), and complications. Encounter duration in cases of PAC was compared with that, for all cases during the study period, where an overdose patient who did not receive activated charcoal was transported.

RESULTS

Two thousand eight hundred forty-five total cases were identified. In 441 cases, PAC was given; and complications could be assessed. Two hundred eighty-one of these had complete information regarding timing of ingestion, activated charcoal administration, and transport. The average time between overdose and PAC was 49.8 minutes (range, 7-199 minutes; median, 41.0 minutes; SD, 30.4 minutes). Complications included emesis (7%), declining mental status (4%), declining blood pressure (0.4%), and declining oxygen saturation (0.4%). Four hundred seventeen cases of PAC had documentation of timing of emergency medical service (EMS) arrival on scene and arrival at the ED. Average EMS encounter time was 29 minutes (range, 10-53 minutes; median, 27.9 minutes). Two thousand forty-four poisoning patients were transported who did not receive PAC. The average EMS encounter time for this group was 28.1 minutes (range, 4-82 minutes; median, 27.3 minutes), not significantly different (P =.114).

CONCLUSIONS

Prehospital activated charcoal did not appear to markedly delay transport or arrival of overdose patients into the ED and was generally safe.

Indications for single-dose activated charcoal administration in acute overdose

PURPOSE OF REVIEW

Gastrointestinal decontamination in overdose patients remains a controversial problem in emergency medicine. There has been a significant decrease in the use of single-dose activated charcoal (SDAC) in recent years based on little new evidence and possibly because the overall mortality in overdose patients is low.

RECENT FINDINGS

Human volunteer studies suggest SDAC is effective and this effect occurs for up to 4 h after ingestion, but the magnitude of the reduction in area under the curve (AUC) decreases over time. Two randomized controlled trials including one recent large study did not find SDAC to be beneficial. Pharmacokinetic and pharmacodynamic studies of specific drugs in overdose suggest that for most drugs SDAC decreases drug exposure, but this does not translate to clinical benefit in all cases. The administration of SDAC is a low-risk intervention.

SUMMARY

Although SDAC is unlikely to be beneficial in many overdose patients, for some subgroups with severe poisoning, the benefits will outweigh the low risk of administration. The use of SDAC should be based on the potential toxicity of the drug ingested and the potential benefit of SDAC balanced against the willingness of the patient to take SDAC and the low risk of administration.

Does prearrival communication from a poison center to an emergency department decrease time to activated charcoal for pediatric poisoning?

OBJECTIVE

A poison center plays an important role in directing appropriate care, which is critical in reducing morbidity due to poisoning. Activated charcoal (AC) is one intervention for some poisonings. This study examined whether children with a poisoning who were preannounced by a poison center received AC earlier than patients without a referral.

METHODS

A retrospective review of AC administration in children aged 0 to 18 years in a pediatric emergency department (ED) from 2000 to 2006 was performed. Abstracted covariates were poison center referral status, age, sex, acuity, disposition, transportation mode, triage time, and time of AC administration. Analysis of variance controlling for covariates tested the equality of mean time intervals between the groups with and without a poison center referral.

RESULTS

Three hundred fifty-one cases met the inclusion criteria. One hundred thirty-five (39%) were male. Eighty cases (23%) had a poison center referral. Time from triage to charcoal administration for patients with a poison center referral was a mean of 59 (SD, 34) minutes. Time for the group without a referral was a mean of 71 (SD, 43) minutes (P = 0.0036).

CONCLUSIONS

Advanced communication from a poison center was associated with earlier administration of AC in the ED for this population. Nevertheless, the duration to charcoal administration was frequently suboptimal. Triage and prehospital practices should be reexamined to improve timeliness of AC when indicated and consider exclusion of administration if beyond an appropriate time frame. Advanced notification should be the paradigm for all poison centers, and early response protocols for poison center referrals should be used by EDs.

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.

Gastrointestinal decontamination of the poisoned patient

Gastrointestinal decontamination has been a historically accepted modality in the emergency management of oral intoxicants. Theoretically, gastric and whole-bowel emptying procedures hinder absorption, remove toxic substances, prevent clinical deterioration, and hasten recovery. This article presents a current overview of gastrointestinal decontamination. It challenges the accepted precepts of gut decontamination and assesses the utility of syrup of ipecac-induced emesis, orogastric lavage, single-dose-activated charcoal, cathartics, and whole-bowel irrigation.

Study protocol: a randomised controlled trial of multiple and single dose activated charcoal for acute self-poisoning

BACKGROUND

The case fatality for intentional self-poisoning in rural Asia is 10-30 times higher than in the West, mostly due to the use of highly toxic poisons. Activated charcoal is a widely available intervention that may - if given early - bind to poisons in the stomach and prevent their absorption. Current guidelines recommend giving a single dose of charcoal (SDAC) if patients arrive within an hour of ingestion. Multiple doses (MDAC) may increase poison elimination at a later time by interrupting any enterohepatic or enterovascular circulations. The effectiveness of SDAC or MDAC is unknown. Since most patients present to hospital after one hour, we considered MDAC to have a higher likelihood of clinical benefit and set up a study to compare MDAC with no charcoal. A third arm of SDAC was added to help determine whether any benefit noted from MDAC resulted from the first dose or all doses.

METHODS/DESIGN

We set up a randomised controlled trial assessing the effectiveness of superactivated charcoal in unselected adult self-poisoning patients admitted to the adult medical wards of three Sri Lankan secondary hospitals. Patients were randomised to standard treatment or standard treatment plus either a single 50 g dose of superactivated charcoal dissolved in 300 ml of water or six doses every four hours. All patients with a history of poison ingestion were approached concerning the study and written informed consent taken from each patient, or their relative (for unconscious patients or those <16 yrs), recruited to the study. The exclusion criteria were: age under 14 yrs; prior treatment with activated charcoal during this poisoning episode; pregnancy; ingestion of a corrosive or hydrocarbon; requirement for oral medication; inability of the medical staff to intubate the patient with a Glasgow Coma Score <13; presentation >72 hrs post-ingestion, and previous recruitment. The primary outcome was in-hospital mortality; secondary outcomes included the occurrence of serious complications (need for intubation, time requiring assisted ventilation, fits, cardiac dysrhythmias). Analysis will be on an intention-to-treat basis; the effects of reported time to treatment after poisoning and status on admission will also be assessed.

DISCUSSION

This trial will provide important information on the effectiveness of both single and multiple dose activated charcoal in the forms of poisoning commonly seen in rural Asia. If charcoal is found to be effective, it should be possible to make it widely available across rural Asia in an affordable formulation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02920054.

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.

Use of single-dose activated charcoal among Canadian pediatric emergency physicians

OBJECTIVE

Gastric decontamination with single-dose activated charcoal (SDAC) is a mainstay in emergency department (ED) treatment of ingestions. Guidelines updated in 2005 encourage practitioners to use SDAC only in toxic ingestions presenting within 1 hour. Despite these guidelines, adult studies demonstrate a significant lack of consensus. This study examined the proposed use of SDAC for gastric decontamination in common pediatric ingestion scenarios by emergency physicians working in Canadian pediatric EDs.

METHODS

A standardized survey consisting of 5 clinical scenarios was mailed to all physicians with a primary clinical appointment to the ED at 9 Canadian children's hospitals.

RESULTS

One hundred thirty-one physicians were surveyed, and 95 (72%) responded. The majority of respondents were pediatricians (68.1%) with a mean of 15.0 years of experience (SD, 6.8 years). Of those surveyed; 91 (97.8%) would use SDAC for a toxic ingestion presenting in less than 1 hour; 35 (36.8%) would use SDAC for a toxic ingestion presenting after 3 hours; 61 (64.9%) would use SDAC for a nontoxic exploratory ingestion presenting in less than 1 hour; and 29 (30.5%) would use SDAC for a mildly symptomatic intentional ingestion presenting at an unknown time. Eleven (11.7%) would use SDAC for an ingestion of a substance that does not adsorb to SDAC.

CONCLUSIONS

There is variation in the use of SDAC among emergency physicians working in Canadian pediatric EDs. This variation suggests that optimal management is not clear and that continued education and research are required.

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.

Prehospital activated charcoal: the way forward

OBJECTIVES

Single dose activated charcoal (SDAC) may be an effective method of gastric decontamination when administered to patients within an hour of drug overdose. However, few patients who may benefit from this treatment attend an emergency department within this timeframe. The authors sought to determine the current attitudes of ambulance NHS trusts to recent recommendations that the administration of SDAC should be considered as a prehospital therapy.

METHODS

A postal questionnaire was used to determine the current level of use of prehospital activated charcoal by ambulance NHS trusts, the incidence of associated complications, and barriers preventing the routine use of prehospital SDAC.

RESULTS

A completed questionnaire was returned by 36 of the 39 ambulance NHS trusts in the UK (response rate 92%). Currently none of the trusts that responded to the questionnaire provides prehospital SDAC as an intervention. The most common barriers to the provision of prehospital SDAC are the current lack of evidence in the medical literature proving it is effective in improving patient outcome and the lack of a recognised protocol for its administration. Other issues included concerns regarding potential complications, ambulance turnaround times, lack of availability of SDAC, and lack of funding.

CONCLUSIONS

A lack of published evidence proving efficacy remains the most important factor in preventing the routine administration of SDAC to appropriate patients in the prehospital environment. Further research in this setting is required to determine the usefulness of this therapy.

A randomized clinical trial of activated charcoal for the routine management of oral drug overdose

BACKGROUND

Activated charcoal (AC) is commonly used for the routine management of oral drug overdose.

AIM

To determine whether the routine use of activated charcoal has an effect on patient outcomes.

DESIGN

Randomized controlled unblinded trial.

METHODS

We recruited all adult patients presenting with an oral overdose at The Canberra Hospital, excluding only transfers, late presenters, those who had ingested drugs not adsorbed by activated charcoal or where administration was contraindicated, and very serious ingestions (at the discretion of the admitting physician). Patients were randomized to either activated charcoal or no decontamination.

RESULTS

The trial recruited 327 patients over 16 months. Of 411 presentations, four refused consent, 27 were protocol violations and 53 were excluded from the trial. Only seven were excluded due to the severity of their ingestion. The most common substances ingested were benzodiazepines, paracetamol and selective serotonin reuptake inhibitor antidepressants. More than 80% of patients presented within 4 h following ingestion. There were no differences between AC and no decontamination in terms of length of stay (AC 6.75 h, IQR 4-14 vs. controls 5.5 h, IQR 3-12; p=0.11) or secondary outcomes including vomiting, mortality and intensive care admission.

DISCUSSION

Routine administration of charcoal following oral overdose did not significantly influence length of stay or other patient outcomes following oral drug overdose. There were few adverse events. This does not exclude a role in patients who present shortly after ingestion of highly lethal drugs.

Single‐Dose Activated Charcoal‐Backup and Reassess

Single-dose activated charcoal (SDAC) is frequently administered to poisoned patients. The assumption is that toxin absorption is prevented and that toxicity (as defined by morbidity and mortality) of the poisoning is decreased. Yet there is no evidence that SDAC improves outcome. Risks of this procedure have not been determined. The reported adverse events following SDAC administration are reviewed and risk:benefit ratio for this procedure is discussed.

Activated charcoal is effective but equilibrium dialysis is ineffective in removing oleander leaf extract and oleandrin from human serum: monitoring the effect by measuring apparent digoxin concentration

Accidental poisoning from oleander leaf or oleander tea can be life threatening. The authors studied the effectiveness of activated charcoal and equilibrium dialysis in removing oleander leaf extract and commercially available oleandrin as well as oleandrigenin, the active components of oleander plant, from human serum. Oleander leaf extract was prepared in distilled water and drug-free serum was supplemented with the extract. Then serum was treated with activated charcoal at room temperature and an aliquot was removed at 0 minutes, 10 minutes, 20 minutes, and finally 30 minutes to study the presence of oleander extract by measuring the apparent digoxin concentration using the FPIA for digoxin. The authors observed effective removal of oleander extract by activated charcoal. When the authors supplemented other drug-free serum pools with pure oleandrin or oleandrigenin and then subsequently treated them with activated charcoal, the authors observed complete removal of digoxin-like immunoreactivity at the end of 30 minutes' treatment. When drug-free serum pool supplemented with either oleander leaf extract, oleandrin, or oleandrigenin was passed through a small column packed with activated charcoal, the authors observed almost no apparent digoxin concentration following the passage through the column indicating that activated charcoal is very effective in removing oleander from human serum in vitro. In contrast, when serum pools containing either oleander leaf extract or oleandrin were subjected to equilibrium dialysis against phosphate buffer at pH 7.4, the authors observed no significant reduction in apparent digoxin concentration even after 24 hours. The authors conclude that activated charcoal is effective but equilibrium dialysis is ineffective in removing oleander leaf extract from human serum.