Why do we UNDERTREAT our patients ?

[Ace844]

Also, since you were championing it's use, I am surprised you didn't post this. For those who are interested heres a MNEMONIC for AC use:

Charcoal, Substances Poorly Absorbed by Activated

CHARCOAL

C austics and corrosives

H eavy metals (arsenic, iron, lead, lithium, mercury)

A lcohols (ethanol, methanol, isopropyl) and glycols (ethylene glycol)

R apid onset or absorption of cyanide and strychnine

C hlorine and iodine

O thers insoluble in water (substances in tablet form)

A liphatic and poorly absorbed hydrocarbons (petroleum distillates)

L axatives, sodium, magnesium, potassium

[Ace844]

"GAmedic,"

Here's what the Tox Text says about your wonder drug.... :roll:

ACTIVATED CHARCOAL ALONE

Administering charcoal to the typical overdose patient without gastric emptying has become a common treatment modality. There is significant literature support for this approach.

Charcoal has been used for medicinal purposes since antiquity; the first recorded use was by the ancient Egyptians circa 1550 B.C. [24] The first recorded scientific studies of charcoal being used to treat human poisoning were from France, England, and America in the 1800s. Medical use of charcoal has greatly increased since those earliest studies alluded to its effectiveness.[20] [21] [22] [23] [24] [33] [42] [50] [55] [90] [102] [113]

Modern activated charcoal is a far more efficient product than that used in initial studies. It is manufactured by the pyrolysis of wood or other carbonaceous material, which is then oxidized at high temperatures using steam, air, carbon dioxide, or oxygen. Metallic chlorides may be used to enhance pore development and removed later with a dilute acid. The final product has a surface area of 950 to 2000 m2 /g. A superactivated charcoal with a surface area of 3150 m2 /g was previously marketed[29] but is not currently available.

There are several advantages to the use of activated charcoal not seen with other methods of GI decontamination:

It can be administered very quickly. If the patient is awake and cooperative, the patient may drink a dose immediately after presentation. If the patient is comatose or uncooperative, the dose can be quickly administered down a nasogastric tube. Drugs or chemicals can continue to be absorbed during more time-consuming procedures such as ipecac-induced emesis or gastric lavage.

Charcoal is effective even if the history is inaccurate. Even if the substances in question and the time of ingestion are unknown, charcoal can still be effective, as it adsorbs most commonly ingested drugs and chemicals (see Table 5–2 ).

Unlike induced vomiting and lavage, which under the best of circumstances might remove some of the ingested material still in the stomach, a charcoal slurry can easily pass through the pylorus to the primary site of drug absorption—the small intestine.

There are no contraindications to the use of activated charcoal in overdose patients if the GI tract is intact (i.e., without perforation) and there is no bowel obstruction or ileus to impede passage through the gut. Because acids and alkalis are not well adsorbed to charcoal, and because charcoal may obscure the view of an endoscopist, it should not be given in cases of isolated acid or alkali ingestion. However, if charcoal is administered for other ingested agents that are systemic toxins, the corrosive is not a contraindication. There are no published cases of anaphylaxis from charcoal.

There are several disadvantages to and complications from activated charcoal:

Charcoal may induce vomiting in some patients.[77] Whether this is due to the gritty texture of the charcoal, the volume administered, additives such as sorbitol, or a combination of factors is unclear. Volunteers who drink charcoal have a low incidence of vomiting.[79] Some options for antiemetics in patients vomiting from either the charcoal or the ingested drugs are shown in Table 5–3 .

Although charcoal itself is inert, aspiration into the lungs can result in a mechanical obstruction of the airways, particularly if the slurry is inadequately diluted. This may result in respiratory failure and other pulmonary complications.[35] [44] [53] [74] [92] [94] In most cases, aspiration of the acidic stomach contents is the likely cause of the pneumonitis seen, and the presence of charcoal in the aspirate is incidental.

Charcoal may cause constipation and mechanical bowel obstruction when used in a multiple-dose manner.[10] [41] [69] [114] This is not seen after a single dose.

Charcoal may not be readily accepted by children, which might necessitate a nasogastric tube for administration.

Charcoal might theoretically adsorb oral antidotes such as N-acetylcysteine, D-penicillamine, and DMSA (dimercaptosuccinic acid; Chemet). Usual adult doses of charcoal have not been shown to significantly alter absorption of N-acetylcysteine.

Charcoal is generally unpleasant for health care personnel to use, as it stains clothing, walls, floors, ceilings, and so forth.

TABLE 5-3 -- Parenteral Antiemetics of Possible Utility in Poisoned Patients with Severe Vomiting Generic Name Trade Name Adult IV Dose Pediatric IV Dose *

Prochlorperazine Compazine 2.5–10 mg q 4 hr 0.06 mg/lb IM †

Promethazine Phenergan 12.5–25 mg q 4 hr 0.50 mg/lb IM †

Metoclopramide Reglan 10 mg 0.25 mg/kg

Droperidol Inapsine 1.25–5 mg q 4 hr prn 0.05 mg/kg/dose ‡

Ondansetron Zofran 4–32 mg qd 0.1 mg/kg qd

Granisetron Kytril 10 μg/kg qd 10 μg/kg qd

Dolasetron Anzemet 12.5 mg qd 0.35 mg/kg qd up to 12.5 mg qd

* For children 2 years of age and older. Doses may be based on those used during chemotherapy; the package insert may not have a recommended pediatric dose.

† Children are very susceptible to the dystonic effects of these agents, and they should be used only if essential for treatment. Based on the package insert, intramuscular (IM) and not intravenous (IV ) use is recommended.

‡ May cause significant sedation or dysphoria.

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37

The evidence for the efficacy of activated charcoal in the treatment of poisoning comes primarily from in vitro binding studies, in vivo mortality studies, volunteer studies, and comparison studies in overdose patients. The combined knowledge gathered from these studies demonstrates that charcoal effectively binds the vast majority of drugs and chemicals likely to be acutely ingested (see Table 5–2 ). There have been some differences of opinion regarding what constitutes “significant adsorption,” resulting in numerous review articles claiming that, for example, cyanide, DDT, N-methyl carbamate, and others are not adsorbed. If the goal of charcoal therapy is to bind an amount of toxin that could result in major toxicologic effects (for example, as defined by the Amercian Association of Poison Control Centers), then by extrapolating these data to humans or by examining the in vivo data, these chemicals are adsorbed by charcoal. Using the same criteria, substances more clearly shown not to be adsorbed are also listed in Table 5–2 .

Cyanide is an example of the importance of the principles just outlined. The original research[6] demonstrated that 1 g of charcoal could bind 35 mg of potassium cyanide in vitro. This was claimed in multiple review articles to demonstrate lack of adsorption, which seems to overlook that as little as 200 mg of potassium cyanide is a potentially lethal dose in humans, while 50 g of charcoal is a typical charcoal dose. If this stoichiometry holds at higher doses, 50 g of charcoal might bind up to 1750 mg of cyanide, which would be multiple potential lethal doses. Adsorption was clearly demonstrated by in vivo research,[61] whereby the mortality rate in rats given 35 mg/kg of cyanide was reduced from 93 per cent to 33 per cent when charcoal was administered immediately afterward, and from 100 per cent to 27 per cent when a dose of 40 mg/kg of cyanide was used. It is disturbing that clinicians relying on inaccurate information over the years might have withheld charcoal therapy in patients known to be poisoned by cyanide.

Another approach to the issue of adsorbability is demonstrated for boric acid. In this case, the original research[31] showed that 5 g of charcoal could bind 30–45 mg of borate. Another in vitro study[86] demonstrated that 30 g of charcoal bound 38.6 per cent of 1 g of boric acid. Extrapolating the latter data, 100 g of charcoal would likely be unable to bind a significant amount of a toxic adult dose of borate (approximately 15 g).

The advantage of in vitro work is that many different substances can be tested at the same time, and the research is relatively less expensive and less time intensive than other types of charcoal research. Historically, in vitro studies[4] [5] [6] [22] [31] [32] [65] have provided important background that has driven the enthusiasm for the use of charcoal in patients and for additional charcoal research.

In vivo studies of charcoal are commonly performed in small animals in which the median lethal dose (LD50 ) or LD100 of the substance in question is administered, with and without activated charcoal, and the decrease in mortality is evaluated. Assuming that the doses of drug and charcoal are, by extrapolation, analogous to what might be seen in overdose patients, this type of study provides some evidence for the efficacy of charcoal in humans. However, because of the higher metabolic rates of small animals, charcoal is usually administered very soon after the toxin. This technique has been employed, for example, for cyanide[61] and carbamates.[13]

A different in vivo approach in dogs was used to evaluate lavage versus charcoal versus a charcoal-lavage-charcoal approach in which the 6-hour level of salicylate was measured and used to compare efficacy.[18] In this study, charcoal was superior to lavage, and the combined approach tended toward even more efficacy but did not achieve statistical significance. This type of charcoal study can be very valuable, as toxic doses of drugs can be administered, but it has the disadvantage of requiring anesthesia and a large budget.

Volunteer studies in general have attempted to compare activated charcoal with ipecac or lavage when volunteers are given a therapeutic or slightly supratherapeutic dose of medications. By examining the area under the serum concentration time curve, or the total amount of drug excreted (by implication, the amount absorbed), a comparison of the efficacy of charcoal versus lavage versus ipecac can be attempted. This technique has been used to evaluate many drugs, including acetaminophen, ampicillin, aspirin, chlorpropamide, theophylline, and numerous others.[63] [72] [79] [80] [81] [82] [83] [84] [85] [98] [110] In most cases, charcoal alone proved superior to ipecac and lavage either alone or with charcoal. The obvious disadvantage to volunteer studies is the inability to administer an overdose of medications and chemicals, the kinetics and the binding ability of charcoal not necessarily being similar to what is seen after overdose.

Charcoal studies in actual overdose patients are few in number and may be the hardest to interpret because of the heterogeneous nature of overdose patients and the difficulty in determining whether it was the charcoal that altered the outcome. The first of these compared charcoal alone versus ipecac plus charcoal and found no difference in clinical outcomes.[60] The same study also compared charcoal by nasogastric tube alone versus lavage plus charcoal and detected a difference only if lavage was performed within 1 hour of ingestion in patients who were already obtunded from the overdose. It was clear from these data that charcoal alone was a viable treatment option to gastric emptying.

A similar study[3] examined ipecac plus charcoal versus charcoal alone in overdose patients. Outcomes were similar, but the group that received ipecac had a higher incidence of iatrogenic complications (5.4 per cent vs. 0.9 per cent; p < .05), which included four cases of aspiration pneumonitis after ipecac-induced vomiting.

One must be cautious in ascribing certain complications to “charcoal,” as if they occurred from a single dose and not from multiple doses. The two main published complications have been pulmonary aspiration with sequelae[35] [44] [45] [53] [74] [92] [94] and GI obstruction.[10] [69] [95] [114] The pulmonary complications are more commonly seen after multiple-dose rather than single-dose charcoal, and it is not clear whether they are from the charcoal or the accompanying acidic gastric contents in the aspirate.

Likewise, inspissated charcoal causing obstruction is not seen from single-dose charcoal and should not be considered a complication of “charcoal” but of repeated use in patients with decreased GI motility.

There have been reports of corneal abrasions from charcoal getting into the eyes of overdose patients during vomiting.[71]

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38

This complication should be avoidable or easily treatable if it occurs.

Not infrequently, it is desirable to administer charcoal to a patient who is vomiting and therefore unlikely to retain charcoal or an oral antidote in the GI tract. Antiemetics can be effectively used in this setting (see Table 5–3 ). Serotonin 5-HT3 antagonists appear particularly effective in this regard but are very expensive. The less expensive agents may be used first, with the more expensive agents used only if the former are ineffective.

Here's a Pre-hospital Study as well:

Out-of-hospital administration of activated charcoal by emergency medical services

Ari O. Alaspää, MD ∗

Markku J. Kuisma, MD, PhD

Kalle Hoppu, MD, PhD

Pertti J. Neuvonen, MD, PhD

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From the Helsinki Emergency Medical Services, Poison Information Centre, and Department of Clinical Pharmacology, Helsinki University Central Hospital, Helsinki, Finland

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* Address for correspondence: Ari O. Alaspää, Ensihoitoyksikkö, Helsinki University Central Hospital, PO Box 112, FIN-00099 Helsinki, Finland; 358-40-5084071, fax 358-9-3936-2179

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E-mail address: ari.alaspaa@luukku.com

Manuscript received June 23, 2003 , revised manuscript received November 12, 2003 , revised manuscript received June 15, 2004 , revised manuscript received June 28, 2004 , revised manuscript received July 16, 2004 , accepted July 26, 2004

Author contributions: AOA, MJK, and KH were involved in the design and planning of the study. AOA conducted data collection. AOA and KH performed statistical analysis. The study was supervised by PJN. AOA drafted the manuscript, and all authors contributed substantially to its revision. AOA takes responsibility for the paper as a whole. Funding and support: Supported by the Helsinki University Central Hospital Research Fund. Reprints not available from the authors.

PII S0196-0644(04)01207-7

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Study objective

We assess the feasibility of activated charcoal provided by emergency medical services (EMS).

Methods

This was a 12-month follow-up study on the feasibility of a newly introduced protocol to administer activated charcoal by EMS to acutely poisoned patients before arrival at the hospital. Administration of activated charcoal (50 g or 1 g/kg orally or by nasogastric tube) was considered in 2,047 patients with acute poisoning. Main outcome measures were success rate and elapsed times in and adverse effects of administering charcoal.

Results

Activated charcoal was considered to be an indication for 722 patients (35% of the study population) and was administered to 555 patients. Median elapsed time from poison ingestion to activated charcoal administration was 88 minutes, and median time from activated charcoal administration to hospital arrival was 20 minutes. Activated charcoal was not given to 101 (15.4%) patients, although considered indicated, because of patient refusal (n=72), inability to ingest a charcoal mixture (n=23), technical problems (n=4), or recommendation by the hospital after telephone consultation (n=2). Charcoal caused no reported adverse effects.

Conclusion

Out-of-hospital activated charcoal administration by EMS is feasible, even in severe poisonings. Adverse events were rare.

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Editor's Capsule Summary

What is already known on this topic

Activated charcoal is widely used in the treatment of poisoned patients, but its use and safety have not been well described in out-of-hospital care.

What question this study addresses

This study prospectively describes the out-of-hospital use of activated charcoal in patients with a wide range of poisoning and severity.

What this study adds to our knowledge

In 2,047 eligible patients, activated charcoal was indicated for 722, of whom 555 actually received it. The charcoal caused no observable adverse effects. Its effect on patient outcome was not examined.

How this might change clinical practice

This study is too small to categorically establish safety. Furthermore, although the theoretical advantages of early charcoal administration are well known, it is unclear whether out-of-hospital administration will actually improve clinical outcomes.

INTRODUCTION

BACKGROUND

In acute poisonings, prevention of absorption is essential. The efficacy of all gastric decontamination procedures is strongly time dependent and decreases rapidly with time after ingestion of a toxic substance.1 Activated charcoal significantly reduces the absorption of many toxic drugs when given sufficiently early after ingestion of toxin.2 The American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists position statement recommends that activated charcoal be considered within 1 hour of toxin ingestion.3

IMPORTANCE

If activated charcoal could be given out-of-hospital, considerable reduction in delay would be possible,4, 5 especially because delays within hospitals have been considerable.6 Only limited data, however, exist on the feasibility of protocol-based out-of-hospital administration of activated charcoal.5

GOALS OF THIS INVESTIGATION

The aim is to assess the feasibility of a protocol-based out-of-hospital administration of activated charcoal by emergency medical services (EMS) to patients who have a suspected acute intoxication and who fulfill the criteria of activated charcoal administration.

MATERIALS AND METHODS

SETTING, STUDY DESIGN, AND SELECTION OF PARTICIPANTS

The prospective follow-up study was performed in Helsinki, the capital city of Finland, with a population of about 550,000 and a geographic area of 590 km2. The Helsinki EMS system receives about 35,000 urgent ambulance calls annually. Virtually all overdose patients needing medical treatment are triaged by the Helsinki EMS, which has been described in detail previously.7 A protocol for EMS personnel to administer activated charcoal to selected overdosed patients was launched on April 1, 1999; this study covers the first 12 months after its initiation. The institutional review board approved the study plan.

The protocol defines indications and contraindications for out-of-hospital administration of activated charcoal. Activated charcoal is indicated if clinical signs and symptoms suggest a serious overdose or if the patient admits having ingested medicines considered to pose a high risk for serious poisoning (ie, cardiovascular drugs, opioids, moclobemide with selective serotonin reuptake inhibitors, chloroquine). Furthermore, activated charcoal is to be considered in any poisoning if time since ingestion is less than 120 minutes, the causative agent is adsorbable to activated charcoal, and there is no contraindication for activated charcoal (ingestion of corrosives).

The activated charcoal preparation used was Carbomix (powder 50 g; Leiras Inc., Turku, Finland) in tap water or, if unavailable, infusion solution (Ringersteril; Baxter Inc., Deerfield, IL). A dose of 50 g of activated charcoal for adults and 1 g/kg for children was administered orally or by a nasogastric tube (18 Ch), the positioning of which had been checked by aspiration of gastric contents or by epigastric auscultation during inflation with air by syringe. The first-response unit emergency medical technicians or paramedics administered activated charcoal. To deeply comatose patients, activated charcoal was given by an advanced life support unit or by a physician-staffed mobile ICU.

DATA COLLECTION AND PROCESSING

Data of this prospective study were retrieved from the patient database of the EMS and the Helsinki City Dispatching Center and scrutinized by one of the investigators (AOA). When the treatment protocol was introduced, EMS providers were instructed to report all potential adverse effects (eg, vomiting, respiratory complications) into the patient report form. Immediately after the call, patient report forms were sent by fax to the emergency physician on call, who checked the forms during the same working shift. A standardized study form including a section for a listing of adverse events was completed either by one of the investigators (AOA) or by the emergency physician on call if the mobile ICU had participated in the treatment of the patient. Times of initiation of calls to the dispatching center, dispatch of EMS units, arrival of EMS units on the scene, and the beginning and end of each patient's transportation were registered automatically. The times of each EMS unit's reaching the patient's side and administration of activated charcoal were registered manually. The observation period for this study ended with the arrival at the hospital. In addition, some hospital data (eg, chest radiograph, duration of intubation time) were included. Descriptive statistics and Mann-Whitney test were used as appropriate.

RESULTS

During the study period (April 1, 1999, to March 31, 2000), 2,213 intoxication patients were treated by EMS (Figure 1). Of these patients, 166 had incomplete data and were excluded, leaving 2,047 patients eligible for analysis. According to the protocol, activated charcoal was indicated for 722 and contraindicated for 7 patients (ingestion of corrosives). Activated charcoal was not indicated for 1,318 patients. Of those patients, 25% had only a minor intoxication, 25% had pure alcohol intoxication, 15% had inhaled or administered parenterally toxic substances, or the intoxication was uncertain (11%) or nonexistent (6%). The most frequently fulfilled indication was “time less than 120 minutes from ingestion” (382 patients, 53%). Because of an obvious minor toxicity of the ingested compound, many patients did not receive activated charcoal even though it was indicated according to this time limit.

Figure 1 Study population. AC, Activated charcoal.

An effort to administer activated charcoal, whether indicated or not, was made for 646 patients (intention to treat). Activated charcoal was given to 555 patients, and the effort was unsuccessful in 101 patients (15.4% of all intention-to-treat patients) because of patient refusal, patient inability to ingest activated charcoal, technical problems in administration of activated charcoal, or recommendation against activated charcoal by a hospital after telephone consultation (Figure 2).

Figure 2 Reasons for failure in out-of-hospital administration of activated charcoal. ∗Activated charcoal via nasogastric tube failed (3), insertion of nasogastric tube failed (1); ‡After hospital telephone consultation.

Approximately half (47%) of the calls to the dispatching center were made between 4 pm and midnight. Demographic data, dose of activated charcoal, route of administration, first recorded vital signs, and selected out-of-hospital EMS treatments of those receiving activated charcoal are shown in Table 1.

Table 1 . First recorded vital signs and the characteristics of patients (n=555) receiving activated charcoal. Characteristic Descriptive Statistics

Age

Mean 38 y

Range 10 mo to 93 y

<7 y, No. (%) 5 (1)

Sex, No. ∗

Male 234

Female 320

Administration route of AC

Orally 490

Nasogastric tube 65

AC dose administered in adults, No.

50 g 526

<50 g 24

Systolic blood pressure, mm Hg, No. (%)

<90 42 (8)

90–150 449 (86)

>150 30 (6)

Pulse rate, beats/min, No. (%)

<50 4 (1)

50–120 483 (90)

>120 52 (9)

Pulse oximeter value, SpO2, No. (%)

<90 26 (5)

90–100 469 (95)

Consciousness level, GCS score, No. (%)

3–7 53 (10)

8–12 21 (4)

13–15 480 (86)

Out-of-hospital treatments, No. (%)

Tracheal intubation 65 (12)

Left-sided position 64 (12)

Fluid resuscitation >500 mL 52 (9)

Inotrope infusion 19 (3)

Antidote 16 (3)

GCS, Glasgow Coma Scale.

∗ One patient missing data.

Data about the toxic substances (Table 2) are based on patient interview or other evidence elicited at the scene. Alcohol was detected by alcometer in approximately 60% of the patients; approximately 60% had taken more than 1 medicinal product. One child was given activated charcoal after ingestion of a corrosive (oven cleaner), although the treatment was contraindicated.

Table 2 . The most common toxic substances ingested by 555 patients treated with activated charcoal. Medicinal Products Medicinal Product Category Proportion of AC Patients, %

Hypnosedatives 408 74

Antidepressants 144 26

Neuroleptics 143 26

NSAIDs 95 17

Cardiovascular drugs 61 11

Opioids 49 9

Acetaminophen (20 with codeine) 29 5

Others 147 26

Total 1,076 194

NSAIDs, Nonsteroidal anti-inflammatory drugs.

The elapsed times from ingestion of toxic substance to arrival at the hospital for the 555 patients receiving activated charcoal are presented in Figure 3. More than half of the total out-of-hospital delays (from ingestion of toxic substance to arrival at hospital) were patient dependent.

Figure 3 Median out-of-hospital times and elapsed times. Data on 555 patients receiving activated charcoal before hospital admission (number of patients with data available on each elapsed time). Elements in total out-of-hospital time lapse (108 min): A, time from ingestion to call received by dispatching center (n=367); B, time to dispatch first response unit (n=552); C, time for EMS to arrive at scene (n=534); D, time for EMS to give activated charcoal (n=223); E, time from leaving scene to ED arrival (n=499).

The time of the toxic-substance ingestion was available and recorded for two thirds of the patients. The median delay from ingestion of toxin to administration of activated charcoal was 88 minutes, but the exact time of activated charcoal administration was recorded for only 40% of patients. However, there was no difference between the groups for which activated charcoal administration time was recorded or not recorded (median delay from arrival at the scene to transportation to hospital 20 minutes versus 21.5 minutes; Mann-Whitney test P>.05).

Table 3 shows the elapsed times in 2 subgroups: the patients who could drink activated charcoal and the patients to whom activated charcoal was given by a nasogastric tube. The intervals from the arrival of the first responding unit to the activated charcoal administration were 13 minutes and 38 minutes, respectively (P<.0001). Also, the patient transportation times from activated charcoal administration to arrival at hospital were considerably longer (21 minutes and 34.5 minutes, respectively; P<.0001) for patients given activated charcoal by a nasogastric tube.

Table 3 . The subgroups of the study by administration route of activated charcoal. Subgroup Orally (n=490) Nasogastric Tube (n=65)

Only BLS, No. (%)∗ 307 (63) 0

ALS unit at the scene, No. (%)∗ 159 (32) 20 (31)

MICU at the scene, No. (%)∗ 27 (6) 57 (88)

Median interval (minutes) to BLS unit arrival 10 12

Median interval (minutes) to MICU arrival 16 28

Median interval (minutes) to AC administration from BLS arrival 13 38

Median interval (minutes) to AC administration from MICU arrival 16 22

Median interval (minutes) from AC administration to hospital 21 34,5

Adverse events reported, No.

Cardiopulmonary resuscitation (n=2) 0 2

Before AC (died) 0 1

After AC (survived) 0 1

Vomiting (n=47) 36 11

Before AC 19 9

After AC 17 2

Convulsions (n=9) 2 7

Before AC 1 4

After AC 1 3

Deterioration of consciousness‡ 7 0

Deterioration of pulse oximeter values‡ 1 0

ALS, Advanced life support unit staffed by paramedics; BLS, basic life support unit staffed by emergency medical technicians; MICU, mobile ICU staffed by EMS physician.

∗ More than 1 unit could be at the poisoning scene at the same time.

‡ Data before activated charcoal not available.

Of the 555 patients given activated charcoal, 525 (95%) were transported to a hospital, and 30 were not transported because the poisoning was not considered to require hospital admission, because the patient refused it, or death (n=1).

Vomiting was the most common adverse event, but it occurred more frequently before activated charcoal administration (28 patients) than afterward (19 patients; Table 3). Before hospital arrival, 2 patients required cardiopulmonary resuscitation; the one who died had asystole as an initial heart rhythm, and activated charcoal was administered after cardiopulmonary resuscitation and the return of spontaneous circulation. The other patient developed ventricular fibrillation after activated charcoal administration, was successfully defibrillated, and survived. We consider it unlikely that activated charcoal administration caused the cardiac arrest in the surviving patient. In theory, a nasogastric tube can provoke arrhythmia. However, this patient had a massive tricyclic antidepressant overdose and hypotension and was in a deep coma, suggesting that the intoxication itself caused her arrhythmia. There was no evidence of endotracheal insertion of a nasogastric tube. The adverse events are shown in detail in Table E1 (available at http://www.mosby.com/AnnEmergMed). For the 7 patients who had deterioration of consciousness or of pulse oximeter values (patient 53 to 60; Table E1), these events probably were caused by the poisoning (ethanol and other central nervous depressants) and not by the activated charcoal.

LIMITATIONS

Our study has some limitations. First, some essential events may have escaped notice or have not been reported during the short periods of treatment by EMS personnel. Repeated accurate measurement of vital signs and observation of a patient's condition are difficult during transportation to hospital. Secondly, the present study may not include all hospital data on potential complications arising from treatment but detected later. The environment in which activated charcoal is administered may itself influence the risk of later complications. However, the time-interval from overdose ingestion to gastric decontamination, the condition of the patient, and the experience of the personnel may play a greater role in the risk of complications than the environment of activated charcoal administration itself.

DISCUSSION

Out-of-hospital administration of activated charcoal by EMS personnel to patients who had ingested toxic substances was feasible and reduced time to gastric decontamination markedly. Once the decision had been made, activated charcoal could be administered to 85% of patients. In our study population, in which the majority of the patients are suicidal, our finding can be considered promising. Technical problems were rare and mostly related to the use of a nasogastric tube. We believe that the incidence of technical problems can be further reduced when EMS personnel gain more experience. In addition, an increase in the proportion of intoxicated patients who received activated charcoal toward the end of the study period (data not shown) indicates the high acceptance rate of this new treatment protocol by the EMS personnel.

Because the efficacy and safety of protocol-based administration of activated charcoal were unknown at the initiation of the study, the indication for administration was evaluated in 2 phases, first by emergency medical technicians and second by an EMS physician. This double-checking was the main reason for the apparent discrepancy between the protocol and activated charcoal administration in many of the patients.

A surprising proportion of patients themselves called the dispatching center within a short time after ingestion (median lag time 60 minutes for patients who received activated charcoal). Our median time from EMS arrival to activated charcoal administration, 16 minutes, is longer than the 5 minutes reported elsewhere.5 Although we have no data on inhospital delays in Helsinki, a mean time of 48 minutes has been reported between arrival in an emergency department (ED) and activated charcoal administration.8 If we assume that in the ED this median time would be the same 16 minutes, the total time savings could be at least 36 minutes (with our own transportation time of 20 minutes). Probably time savings can be even greater, although shorter intervals to the gastric decontamination procedures have been reported for patients who arrived at the ED by ambulance compared with patients who arrived by other means.9 Experimental studies indicate that reducing delays in activated charcoal administration by 30 minutes can have a significant effect on the amount of toxic substances adsorbed.1, 2, 3, 5

It is worth questioning whether it is prudent to start gastric decontamination procedures outside the hospital. Our EMS protocol denies transportation of the medical patients who have depressed vital signs before emergency treatment (endotracheal intubation, intravenous infusion, inotropes, etc) is started. Second, the transportation intervals between the subgroups of the study by administration route of activated charcoal (orally versus nasogastric tube) differed considerably. The median transportation time of the critically ill patients (activated charcoal by nasogastric tube) was 34.5 minutes compared with 21 minutes when activated charcoal was administered orally (Table 3).

IN RETROSPECT

The results could have been even better if the feasibility study had not been started immediately after the new activated charcoal administration protocol was launched. It took some time until the EMS personnel were fully familiar with administration of activated charcoal; the proportion of intoxicated patients who received activated charcoal increased toward the end of the study period.

In summary, our study demonstrated that in an urban 3-tiered EMS system, activated charcoal is easy to administer before arrival at the hospital, even in severe intoxications. Time savings could be even greater in a rural EMS system, but the safety of such treatment in that environment remains to be shown. That earlier administration of activated charcoal influences patient prognosis positively remains to be confirmed.

We thank Carol Norris for her review of the manuscript.

Appendix SUPPLEMENTARY DATA

Table E1

Adverse events reported.

Appendix SUPPLEMENTARY DATA

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.annemergmed.2004.07.448

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REFERENCES:

1 Bond G.R., The role of activated charcoal and gastric emptying in gastointestinal decontamination: a state-of-art review. Ann Emerg Med (2002) 39 : pp 273-286. Full Text

2 Neuvonen P.J., Olkkola K.T., Oral activated charcoal in the treatment of intoxications: role of single and repeated doses. Med Toxicol (1988) 3 : pp 33-58.

3 , Position statement: single-dose activated charcoal. J Toxicol Clin Toxicol (1997) 35 : pp 721-741. Abstract

4 Thakore S., Murphy N., The potential role of prehospital administration of activated charcoal. Emerg Med J (2002) 19 : pp 63-65. Abstract

5 Crockett R., Krishel S.J., Manoguerra A., Prehospital use of activated charcoal: a pilot study. J Emerg Med (1996) 14 : pp 335-338. Abstract

6 Pond S.M., Lewis-Driver D.J., Williams G.M., Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aust (1995) 163 : pp 345-349. Abstract

7 Kuisma M.J., Määttä T., Out-of-hospital cardiac arrests in Helsinki: Utstein style reporting. Heart (1996) 76 : pp 18-23. Abstract

8 Allison T.B., Gough J.E., Brown L.H., Potential time savings by prehospital administration of activated charcoal. Prehosp Emerg Care (1997) 1 : pp 73-75. Abstract

9 Wolsey B.A., McKinney P.E., Does transportation by ambulance decrease time to gastrointestinal decontamination after overdose?. Ann Emerg Med (2000) 35 : pp 579-584. Abstract

Hmmm...can we see your evidence now??????

ACE844