Abstracts

Antibacterial

Antibacterial

Activated Charcoal Cloth with silver (Actisorb Plus) and solutions of silver nitrate, but not Actisorb (Activated Charcoal Cloth without silver), demonstrated antibacterial activity against Gram-negative and Gram-positive bacteria. This activity was unimpaired in the presence of plasma. Sodium thioglycollate was an effective neutralizer of Actisorb Plus and of silver nitrate, indicating that the release of silver from Actisorb Plus contributed to the antibacterial activity of the dressing.

Antibacterial activity of Actisorb Plus, Actisorb and silver nitrate. Furr-JR; Russell-AD; Turner-TD; Andrews-A. J-Hosp-Infect. 1994 Jul; 27(3): 201-8.

Carbamazepine

Carbamazepine

To describe the clinical effects of carbamazepine ingestion in a pediatric population.

Pediatric patients with suspected carbamazepine ingestion are at higher risk for dystonic reactions, coma, and apnea if the peak serum carbamazepine level exceeds 28 micrograms/mL (117 mumol/L). The development of seizures is not related to peak serum level. Multiple doses of activated charcoal can significantly shorten serum carbamazepine half-life.

Pediatric carbamazepine intoxication. Stremski-ES; Brady-WB; Prasad-K; Hennes-HA. Ann-Emerg-Med. 1995 May; 25(5): 624-30.

Cathartics

Cathartics

To compare the mean time to first stool, number of stools, and side effects of three commonly used cathartics in pediatric ingestions. DESIGN. This prospective clinical trial was a randomized, double-blinded comparison of sorbitol, magnesium citrate, magnesium sulfate, and water, administered with activated charcoal in the treatment of pediatric patients 1 to 5 years of age with acute ingestions. Outcome parameters were mean time to first stool, mean number of stools during 24 hours, and side effects. RESULTS. One hundred sixteen patients completed the study. Significant differences in mean time to the first stool were detected among cathartic agents (F = 9.29), with sorbitol-treated patients having a shortest mean time to the first stool (mean, 8.48 hours). Sorbitol produced a significantly higher number of stools (mean, 2.79) in the 24-hour follow-up period than other cathartics (F = 3.49).

The most common side effect of cathartic administration was emesis, which occurred more commonly in sorbitol-treated patients.

Sorbitol, when administered with activated charcoal in the treatment of children with acute ingestions, produced a shorter time to first stool and more stools than magnesium citrate, magnesium sulfate, or water.

A comparison of cathartics in pediatric ingestions. James-LP; Nichols-MH; King-WD. Pediatrics. 1995 Aug; 96(2 Pt 1): 235-8.

Complications & Activated Charcoal

Complications

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.

Goulbourne-KB; Cisek-JE :Small-bowel obstruction secondary to activated charcoal and adhesions. Ann-Emerg-Med. 1994 Jul; 24(1): 108-10

Decontamination

Decontamination

Gastrointestinal decontamination therapy in the patient with accidental or intentional ingestion of toxic substances has been standard therapy for several decades, although based on theory of presumed action and benefit. As scientific knowledge accumulates in this area of clinical toxicology, old assumptions are being challenged. An overview is presented of the scientific evidence relating to gastric emptying, efficacy of activated charcoal, and usefulness of whole-bowel irrigation with polyethylene glycol electrolyte lavage solutions.

Gaar-G.G.: Gastrointestinal decontamination for acute poisoning by ingestion. Prevention of absorption of toxic compounds. J-Fla-Med-Assoc. 1994 Nov; 81(11): 747-9

Many considerations factor into selecting the most appropriate method of gastrointestinal decontamination used in the poisoned patient. A thorough knowledge of the indications and efficacy as well as contraindications and complications of each modality is critical to the clinician's assessment. This article examines the current utility of syrup of ipecac-induced emesis, orogastric lavage, activated charcoal, cathartics, and whole bowel irrigation. In addition, the role of multiple dose activated charcoal and the controversial issue of the N-acetylcysteine and activated charcoal interaction are discussed.

Perrone-J; Hoffman-RS; Goldfrank-LR: Special considerations in gastrointestinal decontamination. Emerg-Med-Clin-North-Am. 1994 May; 12(2): 285-99

Dosages

Dosages

Although many studies in animals and volunteers have demonstrated that multiple-dose activated charcoal increases drug elimination significantly, this therapy has not been shown in a controlled study in poisoned patients to reduce morbidity and mortality. Further clinical studies are required to establish its role and the optimum dosage regimen of charcoal to be administered. Based on current evidence, multiple-dose activated charcoal should only be considered if a patient has ingested a life-threatening amount of phenobarbital (phenobarbitone), carbamazepine, theophylline, quinine, dapsone or salicylate. In all of these cases there are data to confirm enhanced elimination, though no controlled studies have demonstrated clinical benefit.

Multiple-dose activated charcoal: a review of relevant clinical studies. Bradberry-SM; Vale-JA. J-Toxicol-Clin-Toxicol. 1995; 33(5): 407-16.

Injection

Injection

The aim of our study was to evaluate the clinical efficacy of preoperative injection of activated carbon into the normal colonic wall surrounding cancer lesions in delineation of cancer location in laparoscopic colectomy.

The carbon-stained area was clearly recognizable as a blackened patch on the serosal surface of the colon. Using the carbon-stained area as a reference point, partial colectomies were successfully performed.

Rapid and accurate method for delineating cancer lesions in laparoscopic colectomy using activated carbon injection. Kitamura-K; Yamane-T; Oyama-T; Shimotsuma-M; Hagiwara-A; Yamaguchi-T; Sawai-K; Takahashi-T. J-Surg-Oncol. 1995 Jan; 58(1): 31-3; discussion 33-4.

Phenobarbital

Phenobarbital

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.

Superchar had a pulse-like effect. 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.

The presence of preservatives and palatibility enhancers in the commercial preparations may play a role but it appears that the in vivo effectiveness decreases as the surface area and the concentration of surface hydroxyl groups decrease.

Modi-NB; Veng-Pedersen-P; Wurster-DE; Berg-MJ; Schottelius-DD: Phenobarbital removal characteristics of three brands of activated charcoals: a system analysis approach. Pharm-Res. 1994 Feb; 11(2): 318-23

Safety & Activated Charcoal

Safety

To review published reports of adverse effects associated with single- and multiple-dose activated charcoal therapy, and to formulate recommendations for safe use of activated charcoal therapy.

Activated charcoal therapy should be used judiciously so that related morbidity and mortality can be prevented. Adequate consideration for the patient's airway protection capability is necessary. Judicious dosing of charcoal and concomitant cathartic therapy, along with adequate monitoring of fluid and electrolyte status, abdominal physical assessment, and clinical condition are all vital to the safe use of activated charcoal therapy.

Misadventures with activated charcoal and recommendations for safe use. Mauro-LS; Nawarskas-JJ; Mauro-VF. Ann-Pharmacother. 1994 Jul-Aug; 28(7-8): 915-24.

Therapeutic Prevention

Therapeutic Prevention

According to this study, activated charcoal (AC) does not place intubated overdose patients at a high risk of aspiration pneumonia. Objective evidence of infiltrate on chest radiograph during initial 48 hours of hospitalization was used to determine the incidence of aspiration pneumonia. Out of 50 patients (aged 1-64 years, 33% male), only 2 developed a new infiltrate after intubation and AC. These results show that AC is associated with very low incidence of aspiration pneumonia.

Moll J, Kerns W 2nd, Tomaszewski C, Rose R: Incidence of aspiration pneumonia in intubated patients receiving activated charcoal, J Emerg Med 1999 Mar-Apr; 17(2): 279-83

Acetaminophen Overdose

Acetaminophen Overdose

According to this study, a single dose of activated charcoal may be beneficial in treating acetaminophen overdose if administered within one hour of acetaminophen overdose. Acetylcysteine should be given if the acetaminophen concentration exceeds the treatment line in the Rumack-Matthew nomogram. Children diagnosed with acetaminophen overdose should be treated the same way as adults, and pregnant patients should be managed no differently than nonpregnant patients.

Zed PJ, Krenzelok EP: Treatment of acetaminophen overdose, Am J Health Syst Pharm 1999 Jun 1; 56(11):1081-91; quiz 1091-3

Controlled Release

Controlled Release

The main characteristic of overdose with controlled release formulations is the delay in presentation and onset of clinical effects. There is a prolonged absorption phase which leads to a delayed time to maximum plasma concentration and usually a prolonged time with levels close to the peak concentration. Absorption may continue for more than 24 hours. Overdose with controlled release formulations of toxic drugs therefore requires a longer period of observation as the onset of symptoms may be as late as 16 to 20 hours after ingestion.

The optimal gastrointestinal decontamination method is controversial, but in serious overdoses it should include gastric lavage and activated charcoal followed by whole bowel irrigation as a means of clearing whole tablets from the gastrointestinal tract.

Controlled release drugs in overdose. Clinical considerations. Buckley-NA; Dawson-AH; Reith-DA. Drug-Saf. 1995 Jan; 12(1): 73-84.

Digoxin Clearance

Digoxin Clearance

Digoxin continues to be an important cause of drug toxicity.

Calculated total body clearance of digoxin was 55 ml/min (S.D. 17 ml/min; 95% C.I. 45-64 ml/min) for the non-treated group versus 98 ml/min (S.D. 34 ml/min; 95% C.I. 83-113 ml/min) for the group receiving charcoal, representing an 78% increase in digoxin elimination.

Activated charcoal increases digoxin elimination in patients. Ibanez-C; Carcas-AJ; Frias-J; Abad-F. Int-J-Cardiol. 1995 Jan 27; 48(1): 27-30.

Drug Clearance

Drug Clearance

Multiple-dose activated charcoal therapy can enhance the systemic elimination of many drugs. Studies in animals and human volunteers provide a framework for understanding the indications and limitations of multiple-dose activated charcoal therapy. Enterocapillary exsorption creates a compartment for diffusion drugs out of the bloodstream and activated charcoal can augment this process to enhance drug clearance. Once charcoal reaches the intestine, there is a rapid onset of action. Clearance at exsorption sites is limited by blood flow; moreover, the rate of exsorption is related to the dose of charcoal up to a ceiling dose. Drug absorption, distribution, metabolism and elimination dynamically interact with multiple-dose activated charcoal therapy making it difficult to identify a single variable that may predict the success or failure with this therapy. Drug characteristics associated with enhanced systemic clearance with multiple-dose activated charcoal include a low intrinsic clearance, presence in the body for a sufficient time period for charcoal to act, a prolonged distributive phase, non-restrictive protein binding, and a small volume of distribution. Drugs that are unaffected at low doses may respond to multiple doses of activated charcoal when nonlinear kinetics are apparent due to overdose or disease. Although our current understanding is incomplete, multiple-dose activated charcoal therapy will play a role in the future therapy of poisoning patients.

Multiple-dose activated charcoal and enhancement of systemic drug clearance: summary of studies in animals and human volunteers. Chyka-PA. J-Toxicol-Clin-Toxicol. 1995; 33(5): 399-405.

Eucalyptus Oil Ingestion

Eucalyptus Oil Ingestion (Australia)

To determine the symptoms and signs of eucalyptus oil poisoning in infants and young children, to estimate the toxic dose and to recommend management strategies.

Ingestion of eucalyptus oil caused significant morbidity in infants and young children. Significant depression of conscious state should be anticipated after ingestion of 5 mL or more of 100% oil. Minor depression of consciousness may occur after 2-3 mL. Airway protection should precede gastric lavage.

Clinical effects and management of eucalyptus oil ingestion in infants and young children. Tibballs-J. Med-J-Aust. 1995 Aug 21; 163(4): 177-80.

Grilled Meat

Grilled Meat

With the aim of studying the effect of oral exposure to polycyclic "aromatic" "hydrocarbons" (PAH) on human "DNA"-adduct formation in mononuclear cells and excretion of 1-hydroxypyrene in urine, we examined the effect of consumption of charcoal-broiled hamburgers.

In conclusion, oral intake of PAH may dose-dependent induce elevated levels of aromatic DNA adducts in mononuclear cells and of 1-hydroxypyrene in urine, indicating substantial bioactivation of PAH, in particular via this route.

van-Maanen-JM; Moonen-EJ; Maas-LM; Kleinjans-JC; van-Schooten-FJ: Formation of aromatic DNA adducts in "white blood cells" in relation to urinary excretion of 1-hydroxypyrene during consumption of grilled meat. Carcinogenesis. 1994 Oct; 15(10): 2263-8

Medicinal Risk

Medicinal Risk

Activated charcoal administered orally is the usual treatment for many poisonings. However, the side effects of using activated charcoal during treatment may contribute to lung edema formation and pulmonary compromise. According to this study, intratracheal instillation of activated charcoal resulted in a significant increase in pulmonary microvascular permeability compared to lungs treated with sterile water or control lungs. Activated charcoal may be used to treat poisoning. However, health professionals might take precautions when prescribing activated charcoal to patients.

Arnold TC, Willis BH, Xiao F, Conrad SA, Carden DL: Aspiration of activated charcoal elicits an increase in lung microvascular permeability, J Toxicol Clin Toxicol 1999; 37(1): 9-16

Nursing Attitudes

Nursing Attitudes

In 1990, the American Association of Poison Control Centers identified that for the first time activated charcoal (AC) use had surpassed that of syrup of ipecac. As nurses are given the primary responsibility for AC administration, it was important to determine how AC was being administered, as well as nursing attitudes towards AC that have an impact on patient care.

82% of nurses stated they disliked administering AC for the following reasons: Patients did not like AC (64.4%); AC soiled clothing (54.7%); and AC took too long to give (35.5%). Prior to administration, 70.9% of the nurses responded that they shook the AC a minimum of 20 times; 9.3% commented that AC still failed to resuspend.

Specific administration techniques included attempts to mask the appearance the the AC (67.1%) and attempts to increase AC's palatability by adding a flavoring agent (37.6%) or by using AC with sorbitol instead of aqueous AC (25.7%). Of note was that the flavoring agents used were those known to decrease AC's ability to adsorb "toxins".

Scharman-EJ; Krenzelok-EP: Nursing attitudes towards charcoal administration--impact on patient care. Vet-Hum-Toxicol. 1994 Oct; 36(5): 472-4

Oral Health & Activated Charcoal

Oral Health

This study analysed the prevailing oral health-related knowledge, attitudes and behaviour of children entering school in Tanzania. Toothbrushing was a prevalent habit among these children, but its efficiency was low. Toothpaste was considered essential and commonly used in urban areas but "charcoal" or ash were used in rural areas.

Nyandindi-U; Palin-Palokas-T; Milen-A; Robison-V; Kombe-N: Oral health knowledge, attitudes, behaviour and skills of children entering school in urban and rural areas in Tanzania. Public-Health. 1994 Jan; 108(1): 35-41

Poisoned Child

Poisoned Child

More than 1 million children in the United States ingest poisons each year. The vast majority of these exposures result in no harm to the child. The task of the emergency physician is to discern which children are at risk and treat those children with appropriately aggressive therapy while minimizing intervention for the rest. In pediatric exposure cases, the "toxin" is usually identified.

In the ED, when it has been determined that "gastrointestinal" decontamination is indicated on the basis of the substance and quantity ingested, activated charcoal is the decontamination agent of choice if the substance ingested is absorbed by activated charcoal. Gastric emptying should be restricted to those circumstances when the substance ingested is not bound to activated charcoal or the rare event when a child presents to the ED within 1 hour of ingestion with significant CNS "depression". Whole bowel irrigation is a recently described technique to enhance the passage of drugs already beyond the pylorus.

The poisoned child. Evolving concepts in care. Bond-GR. Emerg-Med-Clin-North-Am. 1995 May; 13(2): 343-55.

Theophylline Overdose

Theophylline Overdose

To assess the effectiveness of oral activated charcoal and catharsis in preventing theophylline absorption, 12 healthy subjects, "aged" 20-35 years, received 3 x 200 mg sustained-release theophylline tablets and 16 radio-opaque placebo tablets on six occasions. On each occasion, they received either no treatment (control) or one of five treatments (oral activated charcoal [Carbomix] and sorbitol).

Oral activated charcoal may be the most effective treatment for sustained-release theophylline overdose, with maximum benefit when administered soon after an overdose, though later administration might still be of value. Sorbitol catharsis is of no benefit either alone or in combination with charcoal.

Minton-NA; Henry-JA: Prevention of drug absorption in simulated theophylline overdose. J-Toxicol-Clin-Toxicol. 1995; 33(1): 43-9

Home Administration & Act. Charcoal

Home Administration

While many people are tentative about administering activated charcoal (AC) in the home as part of treatment for poison ingestion, this study reports that AC can be successfully administered by the lay public in the home and that such treatment often provides a faster response than emergency room treatment. Data was collected over 18 months from patients who had been recommended to administer charcoal in the home and compared with that to patients who took AC at home but then went to the emergency department for treatment. Each of the poisoning cases were followed for at least three days after the poisoning incident, and it was found that in 115 out of 138 total cases, patients were successfully treated by home administration of AC. The top three reasons for failure to manage the poisoning at home were: 1) mother preferred to bring child to emergency department, 2) could not locate AC, and 3) pharmacy was closed for the night. Overall, the researchers conclude that administration of AC can be safe and successful when done in the home.

Spiller HA, Rodgers GC Jr: Evaluation of administration of activated charcoal in the home, Pediatrics 2001 Dec;108(6):100