Quick Q about activated charcoal

[GoldShadow]

A few days ago I was helping out with practicals at my ambulance garage's EMT class, and one of the stations was an overdose; so that got me thinking about activated charcoal and its indications/contraindications.

I was just wondering why it is contraindicated in the ingestion of acids and bases? According to emedicine, caustic substances can burn the lining of the GI tract and docs may have to examine this with an endoscope, and the charcoal makes it difficult to see.

Just curious if that's the only reason or whether there's something else?

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[viostorm]

A few days ago I was helping out with practicals at my ambulance garage's EMT class, and one of the stations was an overdose; so that got me thinking about activated charcoal and its indications/contraindications.

I was just wondering why it is contraindicated in the ingestion of acids and bases? According to emedicine, caustic substances can burn the lining of the GI tract and docs may have to examine this with an endoscope, and the charcoal makes it difficult to see.

Just curious if that's the only reason or whether there's something else?

Severe acids and alkali can ulcerate and perforate the esophagus/GI tract. It would be bad for charcoal to be outside of the GI tract and hanging out in the body.

My feeling on activated charcoal is it should NEVER be used. It has never been shown to change outcome and only makes a mess. It is a left over from the time before evidence based medicine and should be gone.

 

[TerraMedicX]

Severe acids and alkali can ulcerate and perforate the esophagus/GI tract. It would be bad for charcoal to be outside of the GI tract and hanging out in the body.

My feeling on activated charcoal is it should NEVER be used. It has never been shown to change outcome and only makes a mess. It is a left over from the time before evidence based medicine and should be gone.

Could you quote some studies on this? I've never heard that myself, although I wouldn't be entirely surprised. My agency is a real PITA about giving charcoal on overdoses, and I would love to get that changed if it doesn't make any difference.

Nate.

 

[docB]

A few days ago I was helping out with practicals at my ambulance garage's EMT class, and one of the stations was an overdose; so that got me thinking about activated charcoal and its indications/contraindications.

I was just wondering why it is contraindicated in the ingestion of acids and bases? According to emedicine, caustic substances can burn the lining of the GI tract and docs may have to examine this with an endoscope, and the charcoal makes it difficult to see.

Just curious if that's the only reason or whether there's something else?

Another reason not to give AC to people who have ingested Acids, Bases, hydrocarbons and metals (like lithium) is that it doesn't bind any of those substances. Since it doesn't work for those poisons it's not reasonable to expose the patient to the aspiration risk of giving it.

 

[docB]

Could you quote some studies on this? I've never heard that myself, although I wouldn't be entirely surprised. My agency is a real PITA about giving charcoal on overdoses, and I would love to get that changed if it doesn't make any difference.

Nate.

I agree that what I've been hearing over the last year is that we will be moving away from giving AC. It is losing favor in particular for EMS and for patients with any degree of decreased LOC. I have to admit I can't find any recent academic work to back this up. I'll keep looking as I didn't have a lot of time to surf on it today.

 

[GoldShadow]

Ah, thanks for the help docB and viostorm.

So if AC will be phased out, what might replace it, if anything?

 

[ParamedicMan]

I believe that charcoal only binds to organic compounds. Thus, the only thing I could think of as indications would be an overdose (organic pills, not Fe, etc) within 30 minutes ish...

As for acids and strong bases, just give ipecac. I hear they taste better the second time anyways... (Feel the burn)

 

[TerraMedicX]

I believe that charcoal only binds to organic compounds. Thus, the only thing I could think of as indications would be an overdose (organic pills, not Fe, etc) within 30 minutes ish...

As for acids and strong bases, just give ipecac. I hear they taste better the second time anyways... (Feel the burn)

Actually, I believe ipecac is also contraindicated in acid/base ingestion due to the risk of additional damage to the esophagus, mouth and the possibility of aspiration of the caustic substance. Besides...what paramedic in their right mind would actually WANT their patients to vomit!! I believe standard of care for caustic ingestion is gastric lavage through an NG/OG tube.

Nate.

 

[viostorm]

Actually, I believe ipecac is also contraindicated in acid/base ingestion due to the risk of additional damage to the esophagus, mouth and the possibility of aspiration of the caustic substance. Besides...what paramedic in their right mind would actually WANT their patients to vomit!! I believe standard of care for caustic ingestion is gastric lavage through an NG/OG tube.

Nate.

Gastric lavage has not been shown to change outcome either.

I'm too busy on medicine right now or else I'd go for some resources on this stuff.

Agreed on the ipecac, not in acid/base.

 

[docB]

Actually, I believe ipecac is also contraindicated in acid/base ingestion due to the risk of additional damage to the esophagus, mouth and the possibility of aspiration of the caustic substance. Besides...what paramedic in their right mind would actually WANT their patients to vomit!! I believe standard of care for caustic ingestion is gastric lavage through an NG/OG tube.

Nate.

He was kidding. Hence the .

Ok, I talked to one of the tox fellows up at Rocky Mtn PC. He said that the majority of toxicologists have been gravitating toward thinking that AC is probably not as effective as we've always thought and that now there's a push to really study it. Most of the studies from way back that made it seem so useful were done long, long ago and were done in the lab, not in people.

Here are the abstracts of some more recent studies (2002 and 2005) questioning the effectiveness of AC:

Single-Dose Oral Activated Charcoal in the Treatment of
the Self-Poisoned Patient: A Prospective, Randomized,
Controlled Trial
Kevin S. Merigian1* and Kari E. Blaho2

American Journal of Therapeutics 9, 301–308 (2002)

Oral activated charcoal (OAC) is a universally accepted treatment of the overdose patient. Although the benefits of OAC have been suggested, there are no conclusive clinical data indicating that OAC affects outcome in overdose patients. This study was a prospective, randomized, controlled trial to determine the effects of OAC treatment in the self-poisoned adult patient. Adult patients presenting to the emergency department (ED) with a history of oral overdose were assigned to treatment with OAC (50 g) or supportive care only on an even-odd day protocol. Patients did not undergo gastric evacuation procedures in the ED. The outcome measures were clinical deterioration, length of stay in the ED or hospital, and complication rate. Over a 24-month period, 1479 patients were entered into the study. There were no significant differences in outcome parameters between the OAC treatment group and controls when comparing the length of intubation time, length of hospital stay, and the complication rates associated with the overdose. There was a higher incidence of vomiting and longer length of ED stay associated with OAC treatment. The results of this study indicated that oral drug overdose patients do not require gastric evacuation or charcoal administration. OAC provided no additional benefit to supportive care alone, was associated with a higher incidence of vomiting and a longer length of ED stay, and did not improve clinical outcome.

Q J Med doi:10.1093/qjmed/hci102
A randomized clinical trial of activated charcoal for
the routine management of oral drug overdose
G.M. COOPER1, D.G. LE COUTEUR, D. RICHARDSON and N.A. BUCKLEY
From the Pharmacy, University of Canberra, Bruce, 2Centre for Education and Research on Ageing and ANZAC Research Institute, University of Sydney, Concord Repatriation General Hospital, Concord, and Departments of 3Emergency Medicine and 4Clinical Pharmacology and Toxicology, Canberra Clinical School, The Canberra Hospital, Canberra, Australia

Received 23 November 2004 and in revised form 23 June 2005

Summary
Background: Activated charcoal (AC) is commonly
used for the routine management of oral drug overdose.
Aim: To determine whether the routine use of
activated charcoal has an effect on patient
outcomes.
Design: Randomized controlled unblinded trial.
Methods: We recruited all adult patients presenting
with an oral overdose at The Canberra Hospital,
excluding only transfers, late presenters, those
who had ingested drugs not adsorbed by activated
charcoal or where administration was contraindicated,
and very serious ingestions (at the discretion
of the admitting physician). Patients were randomized
to either activated charcoal or no decontamination.
Results: The trial recruited 327 patients over
16 months. Of 411 presentations, four refused
consent, 27 were protocol violations and 53 were
excluded from the trial. Only seven were
excluded due to the severity of their ingestion.
The most common substances ingested were
benzodiazepines, paracetamol and selective
serotonin reuptake inhibitor antidepressants.
More than 80% of patients presented within 4 h
following ingestion. There were no differences
between AC and no decontamination in terms of
length of stay (AC 6.75 h, IQR 4–14 vs. controls
5.5 h, IQR 3–12; p¼0.11) or secondary outcomes
including vomiting, mortality and intensive care
admission.
Discussion: Routine administration of charcoal
following oral overdose did not significantly influence
length of stay or other patient outcomes
following oral drug overdose. There were few
adverse events. This does not exclude a role in
patients who present shortly after ingestion of highly
lethal drugs.

 

[docB]

Could you quote some studies on this? I've never heard that myself, although I wouldn't be entirely surprised. My agency is a real PITA about giving charcoal on overdoses, and I would love to get that changed if it doesn't make any difference.

Nate.

I've been thinking about this post for a few days. This is the way that EMS is going to be in the future. We'll get told things, demand evidence and then make changes (or not) based on the EBM. I want to give you a better answer than just the articles above. But I'm a bit limited on my knowledge of the literature in tox because it's not one of my big interests. So here's what I suggest: If you really want to change the protocols in your system call the poison control center that you are under and ask to talk to one of the toxicologists or fellows. See what the attitude is at your PCC about AC prehospital. Make sure they understand that you're talking about prehospital. If they love AC you're probably screwed until more data emerges. If they think AC is on the way out ask for them to send you what they feel are the relevant studies. See if they'd be willing to present the evidence to the board that sets your protocols. It's slow and boring and the bureaucracy is mind numbing but that's the way to do it. Hopefully as EBM influences EMS more and more EMS boards will become more adaptable.

 

[TerraMedicX]

I've been thinking about this post for a few days. This is the way that EMS is going to be in the future. We'll get told things, demand evidence and then make changes (or not) based on the EBM. I want to give you a better answer than just the articles above. But I'm a bit limited on my knowledge of the literature in tox because it's not one of my big interests. So here's what I suggest: If you really want to change the protocols in your system call the poison control center that you are under and ask to talk to one of the toxicologists or fellows. See what the attitude is at your PCC about AC prehospital. Make sure they understand that you're talking about prehospital. If they love AC you're probably screwed until more data emerges. If they think AC is on the way out ask for them to send you what they feel are the relevant studies. See if they'd be willing to present the evidence to the board that sets your protocols. It's slow and boring and the bureaucracy is mind numbing but that's the way to do it. Hopefully as EBM influences EMS more and more EMS boards will become more adaptable.

Thats and interesting suggestion, but I really don't think its necessary at my agency. Our protocols are ALL decided on my our protocol committee, on which I sit with about four or five other paramedics. All of our changes are obviously approved or rejected by our physician advisor, but in general, the changes made are the ones that WE bring. Interestingly enough, one of the toxicologists at our local PCC is actually also one of our paramedics and I've already e-mailed him to ask him what he thinks about the whole thing. So thank you for those studies, if I actually have a free minute here I'm gonna go order them and probably look for a couple others so I can bring them to our next committee meeting and get the ball rolling!

Nate.

 

[docB]

Thats and interesting suggestion, but I really don't think its necessary at my agency. Our protocols are ALL decided on my our protocol committee, on which I sit with about four or five other paramedics. All of our changes are obviously approved or rejected by our physician advisor, but in general, the changes made are the ones that WE bring. Interestingly enough, one of the toxicologists at our local PCC is actually also one of our paramedics and I've already e-mailed him to ask him what he thinks about the whole thing. So thank you for those studies, if I actually have a free minute here I'm gonna go order them and probably look for a couple others so I can bring them to our next committee meeting and get the ball rolling!

Nate.

It sounds like you are fortunate to have a system with less bureaucratic overhead than I'm used to. I envy you.

 

[TerraMedicX]

It sounds like you are fortunate to have a system with less bureaucratic overhead than I'm used to. I envy you.

No kidding!! This is the fourth system I've worked in during my career, and I DEFINITELY appreciate how good I have it! Not to say that there aren't problems, but there's no such thing as a 'perfect' system.

Nate.

 

[ParamedicMan]

Nate,

I was completely and totally joking about the ipecac. It would indeed be possibly the worst thing possible to give a caustic ingestion. I guess my sarcasm doesn't come across so well on the computer. Sorry about that,

Josh

 

[greytmedic]

Nate,

I was completely and totally joking about the ipecac. It would indeed be possibly the worst thing possible to give a caustic ingestion. I guess my sarcasm doesn't come across so well on the computer. Sorry about that,

Josh

Don't worry Man, I think almost everybody got that you were not serious. But next time you should follow all sarcasm with the following symbols.

"Insert sarcastic statement here."

 

[docB]

Nate,

I was completely and totally joking about the ipecac. It would indeed be possibly the worst thing possible to give a caustic ingestion. I guess my sarcasm doesn't come across so well on the computer. Sorry about that,

Josh

Holy crap! You were kidding? I've been giving ipecac to all my caustic ingestions since you said it. It did seem like a bad idea after the now legendary "fountains of Drano" incident but I figured the facial burns and pneumonitis were somehow therapeutic.

 

[TerraMedicX]

Nate,

I was completely and totally joking about the ipecac. It would indeed be possibly the worst thing possible to give a caustic ingestion. I guess my sarcasm doesn't come across so well on the computer. Sorry about that,

Josh

Yea, sorry man...sometimes when I get reading quickly I miss obviously sarcastic comments...

Nate.

 

[ParamedicMan]

Holy crap! You were kidding? I've been giving ipecac to all my caustic ingestions since you said it. It did seem like a bad idea after the now legendary "fountains of Drano" incident but I figured the facial burns and pneumonitis were somehow therapeutic.


I like to call that a "teachable moment." See as their skin is sloughing off, you can remind them how smart drinking Drano was in the first place. Then ask, beg, bribe, them to keep their seed out of the gene pool for the good of mankind...