Medical charcoal for a child's poisoning at home: availability and success of administration in Finland

Deutschlandweites Vergiftungsspektrum im Kindes- und Jugendalter

Hintergrund Vergiftungen verursachen bei Kindern den Großteil der Notfalleinsätze in Deutschland, die durch präventive Maßnahmen verhindert oder gemildert werden könnten. Daher ist für den Pädiater das Wissen um häufige Intoxikationen essentiell. Die vorliegende Arbeit zeigt allgemeine und epidemiologische Daten zu Vergiftungen sowie einen Überblick über die häufigsten einzelnen Noxen und -kategorien im Kindes- und Jugendalter.

Methoden Retrospektiv wurden Vergiftungsfälle bei Kindern und Jugendlichen aus 6 deutschen Giftnotrufzentralen (2012–2016 und 2002–2016) ausgewertet. Kategorielle Daten sind als Mittelwerte±Standardabweichung, häufigste Noxen nach Punkten angegeben.

Ergebnisse Die Anruferzahl insbesondere der Laien nahm ab 2002 deutlich zu. Zwei Drittel der Fälle traten bei Klein- und Vorschulkindern auf, häufiger bei Jungen (50%) als bei Mädchen (44%), bei Jugendlichen überwiegen weibliche Patienten (>60%). Im Alter<14 Jahre sind Intoxikationen auf Unfälle in Haushalt, Kindertagespflege oder Schulen zurückzuführen (>95%), bei Jugendlichen treten suizidale Intoxikationen und Abusus (13%) in den Vordergrund. 90% der Fälle verlaufen asymptomatisch oder leicht, wobei der Anteil der klinisch symptomatischen Fälle mit dem Alter zunimmt (Jugendliche 13% vs. Säuglinge 1%). Vergiftungen mit Medikamenten stellen bei Jugendlichen die häufigste Gruppe dar, bei Kindern tensidhaltige Reinigungsmittel und Kosmetika, Sanitärreinigungsmittel, Tabak, Knicklicht und Entkalker in Lösung.

Diskussion und Schlussfolgerung Stetig steigende Anruferzahlen von Fachpersonal und Laien veranschaulichen die Bedeutung der Giftnotrufzentralen. Obwohl Vergiftungen bei Kindern und Jugendlichen meist asymptomatisch oder mit leichten Symptomen verlaufen, darf die Relevanz präventiver Maßnahmen v. a. bei Kindern<7 Jahren nicht unterschätzt werden.

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.

Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management

A review of U.S. poison center data for 2004 showed over 12,000 exposures to tricyclic antidepressants (TCAs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce healthcare costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate prehospital triage and management of patients with suspected ingestions of TCAs by 1) describing the manner in which an ingestion of a TCA might be managed, 2) identifying the key decision elements in managing cases of TCA ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of TCAs alone. Co-ingestion of additional substances could require different referral and management recommendations depending on their combined toxicities. This guideline is based on the assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with suspected self-harm or who are the victims of malicious administration of a TCA should be referred to an emergency department immediately (Grade D). 2) Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self-harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by EMS, with close monitoring of clinical status and vital signs en route, should be considered (Grade D). 3) Patients who are symptomatic (e.g., weak, drowsy, dizzy, tremulous, palpitations) after a TCA ingestion should be referred to an emergency department (Grade B). 4) Ingestion of either of the following amounts (whichever is lower) would warrant consideration of referral to an emergency department: an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose. For all TCAs except desipramine, nortriptyline, trimipramine, and protriptyline, this dose is >5 mg/kg. For despiramine it is >2.5 mg/kg; for nortriptyline it is >2.5 mg/kg; for trimipramine it is >2.5 mg/kg; and for protriptyline it is >1 mg/kg. This recommendation applies to both patients who are naïve to the specific TCA and to patients currently taking cyclic antidepressants who take extra doses, in which case the extra doses should be added to the daily dose taken and then compared to the threshold dose for referral to an emergency department (Grades B/C). 5) Do not induce emesis (Grade D). 6) The risk-to-benefit ratio of prehospital activated charcoal for gastrointestinal decontamination in TCA poisoning is unknown. Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grades B/D). 7) For unintentional poisonings, asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the initial call to a poison center is greater than 6 hours. These patients do not need referral to an emergency department facility (Grade C). 8) Follow-up calls to determine the outcome for a TCA ingestions ideally should be made within 4 hours of the initial call to a poison center and then at appropriate intervals thereafter based on the clinical judgment of the poison center staff (Grade D). 9) An ECG or rhythm strip, if available, should be checked during the prehospital assessment of a TCA overdose patient. A wide-complex arrhythmia with a QRS duration longer than 100 msec is an indicator that the patient should be immediately stabilized, given sodium bicarbonate if there is a protocol for its use, and transported to an emergency department (Grade B). 10) Symptomatic patients with TCA poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard ACLS guidelines (Grade D). 11) Administration of sodium bicarbonate might be beneficial for patients with severe or life-threatening TCA toxicity if there is a prehospital protocol for its use (Grades B/D). 12) For TCA-associated convulsions, benzodiazepines are recommended (Grade D). 13) Flumazenil is not recommended for patients with TCA poisoning (Grade D).

Pediatric Toxicology

Pediatric patients present unique concerns in the field of medical toxicology. First, there are medicines that are potentially dangerous to small children, even when they are exposed to very small amounts. Clinicians should be wary of these drugs even when young patients present with accidental ingestions of apparently insignificant amounts. Next, over-the-counter laxatives and syrup of ipecac, although not commonly considered abused substances, may be misused in both the setting of Munchausen's syndrome by proxy and in adolescents who have eating disorders. Their use should be considered in any gastrointestinal illness of uncertain origin. Finally, as the use of syrup of ipecac at home now has been discouraged by many, some have explored using activated charcoal at home as a new method of prehospital gastrointestinal decontamination. The literature examining activated charcoal and its use in this capacity is discussed.

Poison treatment in the home. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention

The ingestion of a potentially poisonous substance by a young child is a common event, with the American Association of Poison Control Centers reporting approximately 1.2 million such events in the United States in 2001. The American Academy of Pediatrics (AAP) has long concerned itself with this issue and has made poison prevention an integral component of its injury prevention initiatives. A key AAP recommendation has been to keep a 1-oz bottle of syrup of ipecac in the home to be used only on the advice of a physician or poison control center. Recently, there has been interest regarding activated charcoal in the home as a poison treatment strategy. After reviewing the evidence, the AAP believes that ipecac should no longer be used routinely as a home treatment strategy, that existing ipecac in the home should be disposed of safely, and that it is premature to recommend the administration of activated charcoal in the home. The first action for a caregiver of a child who may have ingested a toxic substance is to consult with the local poison control center.

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.

Home administration of charcoal: can mothers administer a therapeutic dose?

This study evaluated whether children under 3 years of age would drink a therapeutic dose of activated charcoal (AC) in a simulated home environment. Children 13 to 35 months participated with their mothers. Children were randomly assigned to receive AC mixed with regular cola or with diet cola. Maximum time allowed to drink the AC was 30 min. A therapeutic dose was defined as 1 gm/kg or 15 g (the entire bottle) if the child weighed >15 kg. Fifteen children participated; eight received AC with regular cola; seven received AC with diet cola. Ages ranged from 13 to 30 months (average 19 months; SD 4.5 months). Eleven of 15 (73%) drank <1/2 (60 mL) of the AC. Nine of 15 (60%) drank <1/4 of the AC (30 mL). None of these children ingested a therapeutic dose. Three of the 15 (20%) drank > or =100 mL equaling a therapeutic dose. All three were in the group receiving regular cola; 62.5% (five of the eight) who had AC mixed with regular cola did not drink a therapeutic dose. The potential for failure of home AC administration needs to be considered when making the decision to recommend home stocking of AC. Mixing AC with cola does not ensure successful administration. Diet cola does not appear to be an alternative.

5-Year analysis of mushroom exposures in California

OBJECTIVE

To evaluate outcomes following toxic mushroom ingestions.

DESIGN

Retrospective data analysis.

METHODS

We analyzed American Association of Poison Control Center data for California from 1993 through 1997.

RESULTS

A total of 6,317 exposures occurred during the study period. Most (n = 6,229 [99.7%]) were acute exposures, and the rest (0.3%) were chronic; 87.6% (n = 5,536) were unintentional. Most (n = 4,235 [67.0%]) were in children younger than 6 years, and of these, only 6.0% experienced any clinical effects. The most common symptoms in patients aged 6 years and older were vomiting in 588 patients (28.2%), nausea in 307 patients (14.7%), diarrhea in 263 patients (12.6%), and abdominal pain in 221 patients (10.6%). No effects were seen in 3,131 (49.6% of all patients). Major effects were seen in only 17 patients (0.3%). Only 61 patients (1.0%) were admitted to a critical care unit. Death occurred in a 32-year-old adult who ate foraged mushrooms. Of all patients, 1,375 (21.8%) received no therapy or were observed only.

CONCLUSIONS

Most mushroom exposures were acute and unintentional and occurred in children younger than 6 years. Major toxic reactions or death was uncommon.

Activated charcoal as the sole intervention for treatment after childhood poisoning

Childhood poisonings account for approximately two thirds of all human toxic exposures reported annually to the American Association of Poison Control Centers. Activated charcoal (AC) is the mainstay of decontamination in the emergency department setting. This review focuses on six concepts: 1) description of AC and its method of action, 2) evolution of AC in the gastrointestinal decontamination process, 3) prehospital use of AC, 4) superactivated charcoal, 5) multiple-dose AC, and 6) complications of AC administration. The most recent evolving trends in decontamination of the pediatric patient include trends toward earlier decontamination, either in the home or by paramedics in the field. The newer, "super" activated charcoals, with their greater surface area, may improve compliance of oral administration of AC. Finally, guidelines have been set to limit use of multiple-dose activated charcoal regimens to certain pharmaceuticals only, as well as discouraging cathartic use with charcoal dosing.

Comparison of the palatabilities of standard and superactivated charcoal in toxic ingestions: a randomized trial

OBJECTIVE

To compare the palatabilities of two activated charcoal formulations in patients with potentially toxic ingestions.

METHODS

Prospective double-blinded randomized controlled trial comparing the palatability of standard charcoal [LiquiChar (LC)] with that of a superactivated granulated form [(CharcoAid G (CA)]. Alert adult patients with known or suspected toxic ingestions requiring activated charcoal were randomly assigned to receive 60 g of either LC or CA diluted in a cola beverage to a volume of 340 mL. Standardized forms were used to collect data on patient demographics, time required to drink the charcoal, the remaining volume of activated charcoal, and any adverse reactions. Patients rated the palatability of the activated charcoal on a 100-mm visual analog scale (VAS) with 100 indicating "best imaginable beverage." Telephone follow-up was obtained to identify complications. Student's t-tests or Mann-Whitney U tests were used to compare continuous variables (e.g., VAS, time, age). Fisher's exact tests were used to compare categorical variables. This study had a power of 0.9 to detect a 20-mm difference in the VAS, alpha = 0.05.

RESULTS

There were 60 patients enrolled; 29 drank LC, 31 drank CA. Mean age was 34 years; 68% were female. The groups were similar for age, time from ingestion, ingested agents, time required to drink charcoal, and remaining volume. There were more females in the LC group. Patients receiving CA had significantly higher palatability scores than those receiving LC [35.9 (95% CI = 22.5 to 49.3 mm) vs 19.0 mm (95% CI = 9.3 to 28.6 mm) p = 0.04]. None of the patients aspirated. Of seven patients who vomited, five were given LC (p = 0.25).

CONCLUSIONS

CharcoAid is more palatable to patients with toxic ingestions than the standard nongranulated form. Use of the granular charcoal may improve patient compliance.