Dosage recommendations for activated charcoal-sorbitol treatment

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.

Approach to the poisoned patient

Routine poison management involves the following: (1) stabilization, (2) toxidrome recognition, (3) decontamination, (4) antidote administration, (5) enhanced elimination of toxin, and (6) supportive care. Stabilization involves airway, ventilation, and circulation support. In the patient with altered mental status, oxygen, naloxone, glucose, and thiamine should be administered. Symptom complexes that relate to specific classifications of toxins are referred to as toxidromes. Emesis by means of syrup of ipecac is rarely used for in-hospital gastric decontamination. Activated charcoal is a useful adsorbent for gastric decontamination. Whole bowel irrigation is useful for iron, lead, and lithium poisoning and for the body packer phenomenon. Enhancement of elimination may involve multiple doses of activated charcoal, hemodialysis, or charcoal hemoperfusion.

Small-bowel obstruction secondary to activated charcoal and adhesions

Gastrointestinal obstruction is a rare complication of multiple-dose administration of activated charcoal. Previous reports deal only with obstruction after ingestion of drugs that impair gastrointestinal motility. This patient developed a small-bowel obstruction associated with the administration of multiple doses of activated charcoal (350 g, total) for treatment of theophylline toxicity. This patient also had low-grade, previously asymptomatic adhesions at the ileocecal valve. A 4.5 x 5 x 3-cm aggregate of charcoal was surgically removed from the distal ileum.

Effect of saline cathartics on gastrointestinal transit time of activated charcoal

The effects of saline cathartics on the gastrointestinal transit time of activated charcoal were investigated in six healthy volunteers. The study shows that the mean gastrointestinal transit times of charcoal alone were 29.3 h and 24.4, 15.4, 17.3 and 17.5 h with sodium chloride, sodium sulphate, magnesium sulphate alone and Andrew's Liver Salt respectively. Some volunteers complained of slight abdominal discomfort in all the phases except the Andrew's Liver Salt phase.

Pediatric gastrointestinal decontamination in acute toxin ingestion

The appropriate implementation of the various modalities of gastrointestinal (GI) decontamination is critical in the management of the pediatric patient who is examined in the emergency department or private office after an acute ingestion. Gastrointestinal decontamination includes gastric lavage, syrup of ipecac, activated charcoal, and whole bowel irrigation. Clinical studies have delineated the role and efficacy of these procedures. Trends in GI decontamination place less emphasis on ipecac and gastric lavage and more emphasis on activated charcoal alone in the patient with a mild overdose. Gastric lavage is indicated in serious ingestion and is most effective if done soon after the exposure. Whole bowel irrigation is the newest addition and has important clinical use in the treatment of serious iron ingestions as well as in older adolescent cocaine body suffers and packers. Indications and contraindications of the various forms of GI decontamination are discussed and relevant clinical studies are reviewed.

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

In a prospective study, 174 families were interviewed over the telephone to find out whether the treatment of their child's poisoning with medical charcoal was successfully completed. The majority (103; 59.2%) of the families had no charcoal at home. The mean delay in administration for those who had to obtain charcoal was 41.6 min; significantly longer than the 24.5 min taken for those who had charcoal at home (P < 0.001). The treatment succeeded in all but five of the 102 patients given charcoal at home. Thus for mild poisoning in young children, the administration of activated charcoal at home, under the guidance of a Poison Information Centre, could be a rapid and safe first-aid treatment. Presently the widespread unavailability of charcoal in the home in Finland causes an unnecessary delay in treatment that could be of clinical importance.

Drug overdose — reducing the load

OBJECTIVE

To review available information about various methods for reducing gastrointestinal absorption of a poison or drug.

DATA SOURCES

Articles on overdose and accidental poisoning generated by the Australian Medlars Service and concentrating on the period between 1985 and 1990 were surveyed. Earlier studies were included if relevant.

STUDY SELECTION AND DATA EXTRACTION

English language articles with an emphasis on studies using objective methods to measure individual and comparative efficacy of gastrointestinal decontamination techniques were selected. A total of 65 articles were reviewed.

DATA SYNTHESIS

Gastric emptying procedures (gastric lavage or emesis caused by syrup of ipecac) are only effective if performed within one hour of drug ingestion. Gastric lavage is superior to syrup of ipecac. Oral administration of activated charcoal is more effective than either gastric emptying procedure, and is recommended for most cases of poisoning. Cathartics (sorbitol) can be used with activated charcoal. Whole bowel lavage with polyethylene glycol is indicated in selected cases of potentially lethal overdose where the toxic substance cannot be absorbed by charcoal and has passed the pylorus.

CONCLUSIONS

Children--syrup of ipecac can be given at home to children older than 12 months. Most children who reach hospital can be treated by charcoal alone. ADULTS--Most patients are managed with supportive care and, in the absence of contraindications, a single dose of activated charcoal if seen within four hours of ingestion of the poison or drug. Gastric lavage is used if the patient presents within one hour of ingestion and has clinical features of toxicity.

Acute sulfasalazine overdose

Sulfasalazine (salicylazosulfapyridine, Azulfidine) has been widely used over the last half century for inflammatory bowel diseases, but overdose has not been reported. A 23 year-old male ingested 25 g of sulfasalazine in a suicide attempt. He underwent prompt treatment and survived with no ill-effects.

The effect of activated charcoal on phenytoin pharmacokinetics

STUDY OBJECTIVES

To examine the effect of administration of oral activated charcoal with or without sorbitol on the elimination of phenytoin.

SETTING

Emergency department of a rural teaching institution.

TYPE OF PARTICIPANTS

Eight normal volunteers.

INTERVENTIONS

Subjects received 15 mg/kg phenytoin as an IV infusion. During the first phase of the study, oral activated charcoal was administered to a total dose of 140 g over a ten-hour period. During the second phase of the study, phenytoin alone was administered.

MEASUREMENTS AND MAIN RESULTS

Administration of activated charcoal resulted in a significant decrease in the area under the curve 0-inf (p = .008) and in total body clearance (P = .008). No difference in the effect on phenytoin pharmacokinetic parameters was noted when the charcoal was administered with or without sorbitol, but fewer gastrointestinal adverse effects were noted without sorbitol treatment.

CONCLUSION

Oral activated charcoal was shown to affect phenytoin pharmacokinetic parameters. Further pharmacokinetic/pharmacodynamic studies are warranted to determine if activated charcoal results in a faster recovery from phenytoin toxicity.

Gastrointestinal transit times of a charcoal/sorbitol slurry in overdose patients

Gut decontamination with a slurry of activated charcoal and sorbitol is one of the methods presently available to decrease total body burden of ingested drug. This one year retrospective audit of patients presenting with a history of recent toxic ingestion was designed to determine the time to stool of a charcoal/sorbitol slurry (CSS) when used for differing ingestants. A total of 69 patients received a CSS. 50.7% took less than 6 hours for their first charcoal stool, while 26.1% had emesis of the CSS within 30 minutes of administration. Ingestion of drugs which may increase gastrointestinal transit time (i.e. opioids, cyclic antidepressants) correlated with prolonged time to stool despite treatment with the CSS. Though a prospective, controlled study needs to be performed, variation in dosage of the CSS may be appropriate in select patient groups to offset the effects of the ingestant on bowel motility.

Interaction of microcystin-LR with SuperChar: water decontamination and therapy

Activated charcoal (SuperChar) has been recommended for therapeutic use against poisoning by several toxic agents, but it has not been tested against microcystin-LR toxicosis. Microcystin-LR, a cyclic heptapeptide isolated from fresh water blue-green algae, has been shown to be a potent hepatotoxin in animals and in man. Studies were performed to determine the degree of in vitro adsorption of microcystin-LR to SuperChar and to assess the efficacy of SuperChar as a therapeutic agent against microcystin-LR in vivo. Scatchard analysis of the in vitro data showed that microcystin-LR bound to SuperChar with a maximum binding capacity of 0.692 mM toxin/g SuperChar with a dissociation constant of 0.016 mM. The adsorption characteristics of microcystin-LR by SuperChar was applied successfully to the decontamination of water samples spiked with microcystin-LR. While an oral (po) dose of toxin mixed with SuperChar (0.31-0.36 g/kg) modulated the toxicity, an oral pretreatment with SuperChar did not prevent lethality induced by an oral or intraperitoneal (ip) dose of microcystin-LR in mice.

Toxicodynamic approach to management of the poisoned patient

We recommend a toxicodynamic approach to the management of the poisoned patient. We define the period between ingestion and onset of toxic manifestations (clinical or laboratory) as the preclinical phase, during which the management of the patient necessarily depends solely on the history of ingestion and the predicted toxicity. In the toxic phase during which the patient shows clinical or laboratory evidence of toxicity, the history, clinical status (signs, symptoms, drug levels, laboratory parameters), and toxicodynamics should guide the therapy. In the resolution phase, when the patient shows clinical improvement and declining drug levels, treatment should be based on clinical status. Gastrointestinal decontamination is critical in the first two phases and may be of value during the resolution phase until the body drug burden declines to safe levels. We recommend an aggressive approach to gastrointestinal decontamination, especially in the preclinical phase. With a history of a potentially toxic ingestion of an absorbable drug, an observation period until passage of a charcoal-laden stool should be achieved before discharge of the patient.

Sorbitol catharsis does not enhance efficacy of charcoal in a simulated acetaminophen overdose

The use of a 70% sorbitol solution has recently been advocated as an adjunct to activated charcoal. This results in rapid and profuse catharsis that could possibly cause fluid and electrolyte imbalance. An investigation was undertaken to determine if sorbitol catharsis enhanced the antidotal efficacy of activated charcoal. Eight healthy volunteers participated in a randomized, crossover trial. Subjects ingested 3 g of acetaminophen followed by either no intervention, 50 g of plain activated charcoal at one hour, or 50 g activated charcoal-sorbitol solution at one hour. Serial acetaminophen levels were determined at intervals over eight hours and side effects noted. Both interventions significantly reduced the area under the curve versus control (P less than .05). The addition of sorbitol did not enhance the efficacy of activated charcoal but did increase the side effects noted. Sorbitol has not been proven effective in enhancing drug removal and has side effects that can be significant in a poisoned patient. Current data do not warrant its use, and further investigations should be carried out with other ingested drugs.

Oral activated charcoal in the treatment of intoxications. Role of single and repeated doses

Activated charcoal has an ability to adsorb a wide variety of substances. This property can be applied to prevent the gastrointestinal absorption of various drugs and toxins and to increase their elimination, even after systemic absorption. Single doses of oral activated charcoal effectively prevent the gastrointestinal absorption of most drugs and toxins present in the stomach at the time of charcoal administration. Known exceptions are alcohols, cyanide, and metals such as iron and lithium. In general, activated charcoal is more effective than gastric emptying. However, if the amount of drug or poison ingested is very large or if its affinity to charcoal is poor, the adsorption capacity of activated charcoal can be saturated. In such cases properly performed gastric emptying is likely to be more effective than charcoal alone. Repeated dosing with oral activated charcoal enhances the elimination of many toxicologically significant agents, e.g. aspirin, carbamazepine, dapsone, dextropropoxyphene, cardiac glycosides, meprobamate, phenobarbitone, phenytoin and theophylline. It also accelerates the elimination of many industrial and environmental intoxicants. In acute intoxications 50 to 100g activated charcoal should be administered to adult patients (to children, about 1 g/kg) as soon as possible. The exceptions are patients poisoned with caustic alkalis or acids which will immediately cause local tissue damages. To avoid delays in charcoal administration, activated charcoal should be a part of first-aid kits both at home and at work. The 'blind' administration of charcoal neither prevents later gastric emptying nor does it cause serious adverse effects provided that pulmonary aspiration in obtunded patients is prevented. In severe acute poisonings oral activated charcoal should be administered repeatedly, e.g. 20 to 50g at intervals of 4 to 6 hours, until recovery or until plasma drug concentrations have fallen to non-toxic levels. In addition to increasing the elimination of many drugs and toxins even after their systemic absorption, repeated doses of charcoal also reduce the risk of desorbing from the charcoal-toxin complex as the complex passes through the gastrointestinal tract. Charcoal will not increase the elimination of all substances taken. However, as the drug history in acute intoxications is often unreliable, repeated doses of oral activated charcoal in severe intoxications seem to be justified unless the toxicological laboratory has identified the causative agent as not being prone to adsorption by charcoal. The role of repeated doses of oral activated charcoal in chronic intoxication has not been clearly defined.(ABSTRACT TRUNCATED AT 400 WORDS)

Repetitive doses of activated charcoal in the treatment of poisoning

Activated charcoal has found a renewed role in the management of overdosed patients. Routinely administered to reduce the gastrointestinal (GI) absorption of many drugs, growing evidence indicates that repeated doses of charcoal also may enhance drug elimination. Some drugs are excreted into the bile or gastric fluids (phencyclidine, digoxin) and are reabsorbed. Other drugs (theophylline, phenobarbital) can diffuse from the plasma into the lumen of the GI tract. Activated charcoal is administered at regular intervals to sequester these toxins in the GI tract, eventually causing their excretion in feces. This article reviews the evidence for the safety and efficacy of repetitive charcoal therapy. While supportive management remains the mainstay of therapy in poisoned patients, activated charcoal is inexpensive, effective, simple to administer, and may obviate the need for more invasive methods of toxin removal.