Evaluation of administration of activated charcoal in the home

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.

Current Controversies in Gastrointestinal Decontamination

Most poisonings reported to American poison control centers occur in the home. The most common route of exposure is ingestion, which is responsible for most fatalities. The goal of gastrointestinal decontamination is to prevent absorption of the toxin. Trends in treating poisoned patients have changed over the past few decades in light of a move toward practicing evidence-based medicine. Efficacy and clinical outcome have come into question and have led to position papers published recently regarding syrup of ipecac, gastric lavage, activated charcoal, and whole-bowel irrigation. These different methods of decontamination and the scientific data supporting each one will be reviewed, and the current controversies surrounding each will be discussed.

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.

Activated charcoal administration in a pediatric emergency department

OBJECTIVES

Activated charcoal is the commonest form of gastrointestinal decontamination offered to potentially poisoned children within United States emergency departments. Our aim was to describe this practice with regard to timing, route of administration, use of flavoring agents, and occurrence of adverse events other than vomiting.

METHODS

Descriptive data were prospectively collected from consecutive administrations of single-dose activated charcoal, within an urban, academic pediatric emergency department, over a period of 2.5 years.

RESULTS

Two hundred seventy-five subjects were enrolled. The median time elapsed between ingestion and emergency department arrival was 1.2 hours. Although 55% of children were administered charcoal within 1 hour of emergency department presentation, only 7.8% received charcoal within 1 hour of poisoning exposure. Forty-four percent of children younger than 6 years, 50% of 6-year to 12-year olds, and 89% of 12-year to 18-year olds drank the charcoal voluntarily (P < 0.01). Medical staff chose not to offer charcoal orally to 42 asymptomatic children among the 176 subjects under the age of 6 years. Of the 114 young children offered oral charcoal, 36 (32%) refused or were intolerant. Nurses added flavoring agents to the charcoal in 59% of oral administrations, but this act did not enhance observed palatability. Among children younger than 6 years, the median time from first sip to complete ingestion of charcoal slurry was 15 minutes. One pulmonary aspiration event and a case of constipation were noted.

CONCLUSIONS

Despite published guidelines, children treated in an emergency department rarely received charcoal within 1 hour of ingestion. Gastric tube administration of charcoal varies by age and is partly subjective in its application. We found no evidence that excipient flavoring of charcoal improved success of administration. Pulmonary aspiration of charcoal, although uncommon, should be considered when assessing the risk of therapy. We offer a report of symptomatic constipation from single-dose charcoal.

Risk factors for emesis after therapeutic use of activated charcoal in acutely poisoned children

OBJECTIVES

Vomiting frequently complicates the administration of activated charcoal. The incidence of such vomiting is not defined precisely in the pediatric population. Little is known about the patient-, poison-, or procedure-specific factors that contribute to emesis of charcoal. This study aimed to estimate the incidence of vomiting subsequent to therapeutic administration of charcoal to poisoned children < or =18 years of age and to examine the relative contributions of several risk factors to the occurrence of vomiting.

METHODS

Data were collected on a prospective cohort of 275 consecutive children who were treated with activated charcoal for acute poisoning exposure. The study was set in the emergency department of an urban, tertiary-care children's hospital. Sorbitol content of the charcoal was alternately assigned. Potential risk factors for vomiting were recorded prospectively, and the occurrence of vomiting within 2 hours of charcoal administration was measured.

RESULTS

A total of 56 (20.4%) of 275 patients vomited. Median time to vomiting was 10 minutes. Previous vomiting (relative risk: 3.41; 95% CI: 1.48-7.85) and nasogastric tube administration (relative risk: 2.40; 95% CI: 1.13-5.09) were found to be the most significant independent risk factors for vomiting. The increased risk among children >12 years of age, compared with younger children, approached significance. Sorbitol content, large charcoal volumes, or fast administration rates did not increase vomiting risk significantly.

CONCLUSIONS

One of every 5 children who are given activated charcoal within our pediatric emergency department vomited. Children with previous vomiting or nasogastric tube administration were at highest risk, and these factors should be accounted for in future investigation of antiemetic strategies. Sorbitol content of charcoal was not a significant risk factor for emesis.

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.

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.

Feasibility of prehospital treatment with activated charcoal: Who could we treat, who should we treat?

OBJECTIVES

To investigate the feasibility and potential risk benefit of prehospital administration of activated charcoal.

METHODS

Review of deliberate self poisoning presentations to the emergency department (ED) of a toxicology unit by ambulance over six years. Data were extracted from a standardised prospective database of poisonings. Outcomes included: number of patients attended by ambulance and number arriving in emergency within one hour. Cases were stratified by ingestion type, based on toxicity and sedative activity.

RESULTS

2041 poisoning admissions were included. The median time to ambulance attendance was 1 h 23 min (IQR 37 min-3 h) and to hospital attendance was 2 h 15 min (IQR 1 h 25 min-4 h). In 774 cases (38%) ambulance attendance occurred within one hour, but in only 161 (8%) did ED attendance occur within one hour. Non-sedating, highly toxic substances were ingested in 55 cases, 24 (23 with GCS>14) with ambulance attendance, and five with ED attendance, within one hour. Conversely 439 patients ingested a less toxic, sedative agent, 160 with ambulance attendance, and 32 with ED attendance, within one hour. Limiting decontamination to patients ingesting highly toxic, non-sedating compounds (GCS<14) reduces the proportion requiring treatment to 23 of the 774 (3.0%), an additional 18 patients.

CONCLUSION

More patients could potentially be decontaminated if all patients attended by ambulance within one hour received charcoal. However, this would expose 128 patients with sedative, low risk poisonings to the risk of aspiration, and only treat 18 extra high risk poisonings. This small potential benefit of prehospital charcoal is unlikely to justify the expense in training and protocols required to implement it