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Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, Chan WL, Smith SW, Olson KR, Gosselin S. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila) 2021; 59:1196-1227. [PMID: 34424785 DOI: 10.1080/15563650.2021.1961144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Lotte C G Hoegberg
- Department of Anesthesiology, The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - E Martin Caravati
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Wui Ling Chan
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Silas W Smith
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kent R Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, California
| | - Sophie Gosselin
- Emergency Department CISSS Montérégie Centre, Greenfield Park, Canada.,Centre antipoison du Québec, Québec, Canada.,Department of Emergency Medicine, McGill Faculty of Medicine, Montreal, Canada
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Abstract
Why has ipecac syrup become less popular in emergency management of poisoning and overdose? When should gastric lavage, activated charcoal, cathartics, or a combination of methods be used? Which patients are candidates for whole-bowel irrigation with polyethylene glycol-electrolyte solution? Drs Harris and Kingston answer these questions and present their recommendations for each of the available management options.
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Affiliation(s)
- C R Harris
- Emergency Medicine Department, St Paul-Ramsey Medical Center, MN 55101
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Benson BE, Hoppu K, Troutman WG, Bedry R, Erdman A, Höjer J, Mégarbane B, Thanacoody R, Caravati EM. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila) 2013; 51:140-6. [PMID: 23418938 DOI: 10.3109/15563650.2013.770154] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- B E Benson
- American Academy of Clinical Toxicology, McLean, VA, USA.
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Abstract
The increasing use of nonsteroidal antiinflammatory drugs (NSAIDs) in small animals has resulted in the development of new and innovative additions to this class of drugs. Examples of NSAIDs now available for use in small animals include aspirin, etodolac, carprofen, ketoprofen, meloxicam, deracoxib, and tepoxalin. The purposes of this article are to review the pathophysiology of prostaglandin synthesis and inhibition, the mechanisms of action, pharmacokinetics, pharmacological effects, and potential adverse reactions of aspirin and the newly released NSAIDs.
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Affiliation(s)
- Stephen L Curry
- Department of Veterinary Medicine and Surgery and the Comparative Orthopaedic Laboratory, College of Veterinary Medicine, University of Missouri, Columbia, Missouri 65211, USA
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Abstract
Decontamination is the removal or reduction of chemical, biologic, or radiologic agents from the patient's skin, mucosa, lungs, and gastrointestinal tract. Decontamination is an important step in decreasing the clinical effects of the agent on the patient, as well as protecting coworkers from exposure. For most agents and the vast majority of scenarios, the removal of clothing and a simple 5- to 6-minute shower with soap and water is sufficient to eliminate the risks to the patient and hospital staff. In rare circumstances, additional steps in decontamination including gastric lavage, broncho-alveolar lavage, surgical removal of wound foreign bodies, and administration of activated charcoal, polyethylene glycol electrolyte solution, and radioisotope binding agents, may be necessary.
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Affiliation(s)
- Marc Houston
- Oregon Health and Science University, CDW-EM, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA
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6
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Abstract
Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. The results of clinical outcome studies in overdose patients are weighed heavily on the side of showing a lack of beneficial effect. Serious risks of the procedure include hypoxia, dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and electrolyte abnormalities, and aspiration pneumonitis. Contraindications include loss of protective airway reflexes (unless the patient is first intubated tracheally), ingestion of a strong acid or alkali, ingestion of a hydrocarbon with a high aspiration potential, or risk of GI hemorrhage due to an underlying medical or surgical condition. A review of the 1997 Gastric Lavage Position Statement revealed no new evidence that would require a revision of the conclusions of the Statement.
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Dargan PI, Wallace CI, Jones AL. An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose. Emerg Med J 2002; 19:206-9. [PMID: 11971828 PMCID: PMC1725844 DOI: 10.1136/emj.19.3.206] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop a flowchart to be used as a tool to guide clinicians step by step through the management of salicylate poisoning. METHODS A comprehensive literature search was carried out. RESULTS The evidence base was used to develop a management flowchart that guides the clinician through the three main steps in caring for the patient with salicylate poisoning: preventing further absorption, assessing the severity of poisoning and, where appropriate, increasing elimination. CONCLUSIONS Salicylate poisoning can result in severe morbidity and mortality and this flowchart provides an evidence based guideline that will guide clinicians through the management of patients presenting to the emergency department with salicylate poisoning.
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Affiliation(s)
- P I Dargan
- National Poisons Information Service, Guy's and St Thomas' NHS Trust, London, UK.
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Hoffman RJ, Osterhoudt KC. Evaluation and management of pediatric poisonings. PEDIATRIC CASE REVIEWS (PRINT) 2002; 2:51-63. [PMID: 12865696 DOI: 10.1097/00132584-200201000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Robert J Hoffman
- Division of Toxicology, Maimonides Medical Center, Brooklyn, NY; and the Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
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9
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Grierson R, Green R, Sitar DS, Tenenbein M. Gastric Lavage for Liquid Poisons. Ann Emerg Med 2000. [DOI: 10.1067/mem.2000.105931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Tucker JR. Indications for, techniques of, complications of, and efficacy of gastric lavage in the treatment of the poisoned child. Curr Opin Pediatr 2000; 12:163-5. [PMID: 10763767 DOI: 10.1097/00008480-200004000-00014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Gastrointestinal decontamination is central to the care of poisoned patients, and gastric lavage is one common method for gastrointestinal decontamination. Gastric lavage in pediatric patients should be limited to children who present shortly after a potentially life-threatening ingestion. The routine use of gastric lavage has recently been questioned because of limited outcome data and increased morbidity. If gastric lavage is deemed necessary, proper positioning of the patient and strict attention to appropriate technique are essential to avert complications.
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Affiliation(s)
- J R Tucker
- University of Connecticut School of Medicine, Division of Pediatric Emergency Medicine, Connecticut Children's Medical Center, Hartford 06106, USA
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Vale JA. Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1998; 35:711-9. [PMID: 9482426 DOI: 10.3109/15563659709162568] [Citation(s) in RCA: 196] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In preparing this Position Statement, all relevant scientific literature was identified and reviewed critically by acknowledged experts using agreed criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not usually considered. A draft Position Statement was then produced and subjected to detailed peer review by an international group of clinical toxicologists chosen by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. The Position Statement went through multiple drafts before being approved by the boards of the two societies and being endorsed by other societies. The Position Statement includes a summary statement for ease of use and is supported by detailed documentation which describes the scientific evidence on which the Statement is based. Gastric lavage should not be employed routinely in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. There is no certain evidence that its use improves clinical outcome and it may cause significant morbidity. Gastric lavage should not be considered unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 minutes of ingestion. Even then, clinical benefit has not been confirmed in controlled studies. Unless a patient is intubated, gastric lavage is contraindicated if airway protective reflexes are lost. It is also contraindicated if a hydrocarbon with high aspiration potential or corrosive substance has been ingested.
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Abstract
The approach to the use of gastrointestinal decontamination procedures in the treatment of ingested toxins has changed in recent years. Many toxicologists and physicians have taken strong positions either for or against the use of emesis, gastric lavage, activated charcoal, or other procedures. What is the scientific basis for these positions? This article reviews and comments on the published studies comparing the effectiveness of these widely used procedures.
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Affiliation(s)
- A S Manoguerra
- San Diego Regional Poison Center, University of California San Diego Medical Center, USA
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Bosse GM, Barefoot JA, Pfeifer MP, Rodgers GC. Comparison of three methods of gut decontamination in tricyclic antidepressant overdose. J Emerg Med 1995; 13:203-9. [PMID: 7775792 DOI: 10.1016/0736-4679(94)00153-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The purpose of this study was to prospectively compare the effectiveness of three different gut decontamination methods in 51 patients presenting to an emergency department with tricyclic antidepressant overdose. Patients were randomized to three treatments; Group 1 received activated charcoal, Group 2 received saline lavage followed by activated charcoal, and Group 3 received activated charcoal followed by saline lavage followed by activated charcoal. Baseline characteristics of the three groups did not differ, including Glasgow Coma Scores, age, and mean tricyclic antidepressant levels. Average length of stay in admitted patients was 93.3 hours in Group 1, 107.2 hours in Group 2, and 66.7 hours in Group 3. Of those admitted to an ICU, average ICU time was 66.9 hours in Group 1, 54.1 hours in Group 2, and 34.4 hours in Group 3. Average duration of sinus tachycardia was 20.8 hours in Group 1, 30.8 hours in Group 2, and 32.2 hours in Group 3. Of those requiring mechanical ventilation, average ventilator time was 43.4 hours in Group 1, 24.1 hours in Group 2, and 17.8 hours in Group 3. No statistically significant difference could be shown with respect to the clinical endpoints noted. There were no deaths in any of the groups. All three methods of gut decontamination had similar clinical outcomes.
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Affiliation(s)
- G M Bosse
- Department of Emergency Medicine, University of Louisville, Kentucky 40292, USA
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15
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Bond GR, Requa RK, Krenzelok EP, Normann SA, Tendler JD, Morris CL, McCoy DJ, Thompson MW, McCarthy T, Roblez J. Influence of time until emesis on the efficacy of decontamination using acetaminophen as a marker in a pediatric population. Ann Emerg Med 1993; 22:1403-7. [PMID: 8103306 DOI: 10.1016/s0196-0644(05)81986-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE To determine the extent of drug removal by emesis at different times after the ingestion of a toxic substance. DESIGN Multicenter retrospective chart review. METHODS Using the American Association of Poison Control Centers' aggregate data base, children who had ingested acetaminophen and who were referred to a health care facility by one of 11 poison centers during a two-year period were identified. Charts of these patients were reviewed to determine the quantity ingested per kilogram of body weight, method of decontamination used, the timing of decontamination, and the serum acetaminophen concentration obtained four hours after ingestion. RESULT Charts of 455 patients met all requirements for inclusion. When emesis occurred within one-half hour after ingestion, mean serum acetaminophen concentration drawn four hours after ingestion was approximately half that in a control group that received no decontamination. Emesis had less impact when it was delayed further and had no demonstrable impact when it occurred more than 90 minutes after ingestion. CONCLUSION Many factors must be considered when deciding if and by what method a given patient should receive decontamination. When delayed gastric emptying is not expected, emesis can at best decrease a toxic burden by half if it occurs early. Medical care givers must continue to scrutinize management practice to ensure that syrup of ipecac is given only in situations in which it is likely to make a difference in outcome and in which it is the most effective agent to achieve this goal.
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Affiliation(s)
- G R Bond
- Samaritan Regional Poison Center, Phoenix, Arizona
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16
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Abstract
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.
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Affiliation(s)
- S Phillips
- Rocky Mountain Poison and Drug Center, Denver General Hospital, University of Colorado Health Sciences Center 80204
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17
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Oderda GM. Gastrointestinal Decontamination. J Pharm Pract 1993. [DOI: 10.1177/089719009300600203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gastrointestinal decontamination plays an important role in the management of poisoned patients. The use of ipecac syrup has declined, and the use of activated charcoal has increased, during the period 1983 to 1991. If an emetic is used, ipecac syrup is the emetic of choice. If gastric emptying is done in an emergency department, gastric lavage is preferred. Recent studies in animals, human volunteers, and poisoned patients suggest that activated charcoal and a cathartic is as effective, or more effective, than ipecac or lavage plus activated charcoal and a cathartic. As such, activated charcoal and a cathartic should be considered the primary decontamination procedures to be used in a hospital.
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Affiliation(s)
- Gary M. Oderda
- College of Pharmacy, University of Utah, Salt Lake City, UT
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Heiser JM, Daya MR, Magnussen AR, Norton RL, Spyker DA, Allen DW, Krasselt W. Massive strychnine intoxication: serial blood levels in a fatal case. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1992; 30:269-83. [PMID: 1588676 DOI: 10.3109/15563659209038638] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A fatal case of strychnine intoxication is reported. The patient expired despite early aggressive management and prevention of metabolic complications. Serial blood levels are reported. In contrast to a previous report describing first order elimination kinetics, our data suggest that strychnine follows Michaelis-Menton elimination kinetics. The case illustrates the rapid, dramatic course of severe strychnine ingestions. A review of the toxicokinetics, mechanism of action and treatment of strychnine intoxication follows.
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Affiliation(s)
- J M Heiser
- Oregon Health Sciences University, Portland
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Krenzelok EP, Lush RM. Container residue after the administration of aqueous activated charcoal products. Am J Emerg Med 1991; 9:144-6. [PMID: 1994942 DOI: 10.1016/0735-6757(91)90176-k] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Commercial aqueous activated charcoal (AC) products may sit in emergency departments, pharmacies, and homes for prolonged periods resulting in the inability to resuspend the AC for patient administration. The potential risk to the patient from not receiving an adequate amount of AC, especially when AC may be the sole means of gastric decontamination, is obvious. To simulate this potential problem, samples of five different aqueous AC products (ActaChar, Actidose, InstaChar, LiquiChar, and SuperChar) were placed into storage for periods of 3 and 12 months. At the end of each study period, samples were agitated and the effluent and container residue were collected, oven-dried, and weighed. With the exception of Actidose, all products retained substantial amounts of AC in the container at both time intervals. These data stress the negative impact of dormant storage on the resuspendability of aqueous activated charcoal products. Furthermore, they suggest the importance of thorough container agitation and rinsing to insure that the patient receives sufficient AC. This is especially important when AC is the sole means of decontamination.
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Affiliation(s)
- E P Krenzelok
- Pittsburgh Poison Center, Children's Hospital of Pittsburgh, PA
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Burton BT, Bayer MJ. Gastric emptying: initial management of the poisoned patient? Ann Emerg Med 1988; 17:762-3. [PMID: 3382084 DOI: 10.1016/s0196-0644(88)80648-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Tenenbein M. In reply. Ann Emerg Med 1988. [DOI: 10.1016/s0196-0644(88)80649-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Danel V, Henry JA, Glucksman E. Activated charcoal, emesis, and gastric lavage in aspirin overdose. BRITISH MEDICAL JOURNAL 1988; 296:1507. [PMID: 2898963 PMCID: PMC2546073 DOI: 10.1136/bmj.296.6635.1507] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- V Danel
- National Poisons Unit, Guy's Hospital, London
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23
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Abstract
Activated charcoal has been used for centuries as antidotal therapy for poisonings. New variations of charcoal therapy have developed over the last two decades. These modifications include multiple-dose activated charcoal (MDAC) therapy, charcoal hemoperfusion, and a new "superactive" charcoal (SAC). Recent literature suggests using initial charcoal therapy instead of ipecac as a first-line antidotal agent for many acute poisonings. The palatability of charcoal slurries has been enhanced by the addition of carboxymethylcellulose, sucrose, saccharin, chocolate syrup, or sorbitol. The new SAC has shown to adsorb 1.7 to 4 times the amount of substance tested compared with other activated charcoal preparations. Multiple-dose activated charcoal therapy has been shown effective in treating phenobarbital, digoxin, digitoxin, theophylline, and dapsone intoxications, among others. The problems associated with charcoal hemoperfusion therapy have been partially alleviated, and it is now alternative therapy for the seriously intoxicated patient.
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Abstract
Gastric lavage has been used to manage toxic ingestions since the early 1800s. The entire realm of gastrointestinal decontamination has been extensively studied for the past 30 years. Recommendations are still evolving and remain controversial. The current indications for lavage are obtundation, unprotected airway, seizures, the need for urgent removal, and the tendency to form concretions. Hydrocarbon management depends on specific toxicity and viscosity. Contraindications for this procedure are insignificant ingestions, prolonged time since ingestion, and caustic poisoning. Proper technique minimizes complications and maximizes toxin removal. Activated charcoal and a cathartic are given after lavage. Complications include nasal trauma, esophageal perforation, tracheal intubation, aspiration, electrolyte imbalance, and hypothermia.
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