Container residue after the administration of aqueous activated charcoal products

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.

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.

In vitro adsorption of phenobarbital, chlorpheniramine maleate, and theophylline by four commercially available activated charcoal suspensions

Four commercially available antidotal activated charcoal suspensions (Actidose Aqua, InstaChar, LiquiChar, and CharcoAid 2000) were evaluated with respect to their abilities to adsorb three test drugs in vitro from simulated gastric fluid. Different volumes of each suspension were added to glass vials containing 20 mL of stock solutions of each drug. The vials were shaken for a time more than sufficient to ensure adsorption equilibrium, then the charcoal was removed from the samples by filtration. The filtrates were analyzed by ultraviolet spectroscopy to determine the residual drug concentrations. The product containing a 2000 m2/g charcoal (CharcoAid 2000) adsorbed more drug per unit volume of suspension than did the other three products, which contained 900 m2/g charcoal and which were all similar in performance.

Phenobarbital removal characteristics of three brands of activated charcoals: a system analysis approach

The in vivo phenobarbital removal characteristics of three brands of activated charcoal (Actidose, Charcoaid, Superchar) were studied in normal volunteers using a system analysis approach. The subjects received a 200-mg dose of oral or intravenous phenobarbital followed by a single oral dose of 30 g of one of the three charcoals in a randomized crossover design. The relative merits of the three charcoals in enhancing the removal of oral and intravenous phenobarbital were assessed using a system analysis approach. The removal clearance, time to peak (tp), peak removal clearance (Rmax), percentage of dose removed (PCT infinity), and phenobarbital removal clearance (CLr) were calculated for the oral and intravenous treatments. Superchar had a pulse-like effect, with the shortest tp and the largest Rmax. Actidose and Charcoaid had similar effects, with Actidose inducing slightly greater phenobarbital removal. Superchar has the highest surface area and relative percentage of surface hydroxyl groups, whereas Actidose has the lowest surface area and relative percentage of surface hydroxyl groups of the three charcoals studied. Although correlations between the in vitro and the in vivo phenobarbital adsorption characteristics of the three charcoals may be difficult due to the presence of preservatives and palatibility enhancers in the commercial preparations, it appears that the in vivo effectiveness decreases as the surface area and the concentration of surface hydroxyl groups decrease. The proposed system analysis approach requires fewer assumptions than methods based on compartmental or physiologic approaches and has the advantage of describing the phenobarbital removal in a dynamic manner.

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.

Selection of activated charcoal products for the treatment of poisonings

OBJECTIVE

To determine if differences exist among currently available activated charcoal products, and if an evaluation of risk versus benefit provides a guide to product selection.

DESIGN

National survey by mail.

PARTICIPANTS

US manufacturers of activated charcoal products.

RESULTS

Six companies market activated charcoal products in ready-to-use containers. The products differ in surface area of charcoal, sorbitol content, and packaging (aqueous or powdered form). No significant differences were noted in the cost of 25- to 30-g units or efficacy based on surface area of activated charcoal. The addition of sorbitol to activated charcoal, particularly at high concentrations, increases the incidence of adverse effects, especially in children.

CONCLUSIONS

Although differences do exist among currently marketed activated charcoal products, the clinical significance of these variations is unknown. Based on an evaluation of risks and benefits, any activated charcoal product that does not contain sorbitol appears to be a suitable choice for treating poisoning victims.

Acute poisoning emergencies. Resolving the gastric decontamination controversy

As in all medical emergencies, in acute poisoning the cornerstone of management is good supportive care. Aggressive support of the cardiovascular, respiratory, and central nervous systems, along with appropriate gastric decontamination, greatly reduces morbidity and mortality and improves patient outcome. Ipecac is generally reserved for home use, where it can be given to induce emesis immediately after ingestion of toxins, and it is given only in cases of mild or moderate toxicity. Activated charcoal should replace ipecac in the emergency department for cases of mild or moderate toxicity. Gastric lavage and administration of activated charcoal should be considered in cases with life-threatening potential. A cathartic should be considered after activated charcoal has been administered, but only in cases where it will not have a detrimental effect.