Why do we UNDERTREAT our patients ?

[akflightmedic]

This all comes back to evidence based medicine. There are more studies out there debunking the efficacy of AC in the field and in the ER as well. Most times it does more harm than good.

We no longer carry it here in FL, this happened several years ago actually, because we researched and realized it was useless. We pulled all our runs for a set period of time and the committee did some calculations and found it to not be indicated in the majority of OD calls. The calls where it was indicated, it was pointless due to the time that had passed.

As for "seeing the light" now that you are working in a hospital, I find that very interesting, as I had the opposite experience. When I started working in an ER, I swore by AC because I did not know better. It was there in the ER that I learned how little as medics we knew about the pharmocology and pharmokinetics of the drugs we carry and administer. This is a Level 1 ER by the way. They very rarely ever gave charcoal and the few times I witnessed it, they fought the patient to insert a NG tube, then the pt either spit it up or puked it up. But regardless of this hassle, the doctor would say it really it isnt worth it anyways due to all the studies that say and I quote"When AC is given in a timely fashion, it still only has a 33% efficacy".

With all the problems our EMS system is facing, our lacking in education, and our cookbook approach medicine, I am surprised that you are hung up on this singular issue. Do some homework before you come on here chastising medics for under treating. Please remember, just because this hospital you work at does things one way, does not make them right for all. Research, research and research. Doctors do not know it all and they are not all up to date on the latest studies.

Just wanted to add that since 1996, I have given charcoal only once and that was due to my 2.5 hour flight to a higher level of care.

[flight-lp]

OK, this doesnt apply to flightmedics or services that do not carry AC. Let's play "courtroom":

Plaintiff Attorney: Mr. medic, did you respond to a 14 year old female who had overdosed on "abc" pills approximately 20 minutes prior to you arrival on the date of 07/14/05 ?

Mr. Medic: Yes

Plaintiff Attorney: You arrived on the scene at 14:31, and recorded phone records indicate that you called poison control at 14:35.You were told that Activated Charcoal was the treatment of choice, is that true.

Mr. Medic: Yes

Plaintiff Attorney: You then transported this patient to the nearest emergency room, is that correct ?

Mr. Medic : Yes

Plaintiff Attorney: Records show that you left the scene at 14:54, why was there a delay.

Mr. Medic: We had to assess her, load her on the stretcher and move her down some steps.

Plaintiff Attorney: So when you left the scene, the pills had been in her system for approximately 30-40 minutes.

Mr. Medic: I do not know for sure, thats what the patient told us, I wasnt there when she took the pills

Plaintiff Attorney: Did you start an IV

Mr. Medic : yes, while enroute to the hospital

Plaintiff Attorney: Why

Mr. Medic: In case we needed to administer some emergency medications.

Plaintiff Attorney; So you thought there was a chance that her condition would deteriorate

Mr. Medic: Well, she had overdosed on "abc".

Plaintiff Attorney: So, as her body absorbed these meds, there was a chance for her life to be endangered.

Mr. Medic : Uuuuhhhhhhhhh, yes

Plaintiff Attorney: Mr. Medic do you carry Activated Charcoal on your ambulance

Mr. Medic: yes

Plaintiff Attorney: Is Activated Charcoal difficult to administer, I mean does it require special equipment, or special training, does it take hours to mix

Mr. Medic: Well the prefered method is to administer it via an NG tube, but it can be drank from a cup.

Plaintiff Attorney: So then I guess someone who was totally untrained could adminster it, if you only have to pour it in a cup. As a matter of fact, I believe this is sold over the counter at drug stores to the public. Is that right

Mr. Medic: Yes

Plaintiff Attorney: So if it is sold to the public, over the counter, it must be a pretty safe drug, am i missing something? Could this medicine have killed her if you gave it to her

Mr. Medic: Well if she lost consciousness, it could cause airway problems.

Plaintiff Attorney: Why would she lose consciousness

Mr. Medic: Well as the body absorbed the medicines ........................ ddoooppppeeee

Plaintiff Attorney: We now know that our plaintiff has kidney and liver damage because these medicines were allowed to be absorbed in her body. You could have stopped this absorbtion within 5-10 minutes after you arrived on scene, and you knew it was needed, because poison control told you it was the treatment of choice, why didnt you administer it ?

Mr. medic: Uuuuuuuhhhhhhhhhhhhhhhh

Plaintiff Attorney: You knew the patient needed treatment, You knew that her condition was likely to worsen, You had Activated Charcoal in the drug-box, but YOU chose not to give the medicine that would save her life. Her life-expectancy has been tremendously reduced, she is now on dialysis for the rest of her life. I ask you again Mr Medic, why did you choose not to save this patient's life:

Mr. Medic: Uuuhhhhhhhhhh, the hospital was just 20 minutes away.

Uuuhhhhhhhhhh, we dont have a protocol for that

Uuuhhhhhhhhhh, no one in my state gives it

Uuuhhhhhhhhhh, if she vomited, I would have trouble intubating her

Better yet, you'all write the excuse that gets you out of writing a big check.

You ought to be a writer, thats the best fictional drama that I have read all week!!! To bad it wouldn't occur that way. Any decent defense lawyer and any sound medical professional can offer rebuting testimony as to why it is rarely ever used pre-hospital anymore. But then again, we are wrong of course................

[tinman694]

I always love the Perry Mason dramatics......

AC and Foley Catheters ALL AROUND!!!

NO EXCEPTIONS.

[GAmedic1506]

Thank you all. The purpose of this post was to spark conversation and make you think about the care you deliver, I appreciate all that responded, even those who personally attacked me. If you will go to the Admin side, (Personnel growth and development) you will find a new post regarding Rated R and X TV programs viewed in the EMS or Fire Station. As always, I welcome your comments, as I think we all learn something through a healthy debate. But lets try to have the next debate without any personal attacks, stick to the issues and facts.

[paramedicmike]

So, just so I understand this, you became argumentative, obstinate and obtuse and now you're going to say that it was all simply for the sake of sparking debate?

Come on. We deserve better than that! Is that the best you can do? :shock:

-be safe. :wink:

[GAmedic1506]

Oh no, not at all. I still believe my premice to be correct, as no service that carries AC has stood up and said that they can guarantee that their service is administering this drug as they should. Most admitted that they had never used it, or only used it a handful of times in their career. But I am big enough to realize that one opinion does not fit all EMS services or all regions of the country. My purpose was to put out an idea, spark conversation and debate, and see where we all fall on the issue. Like it or not, agree or not, we have three good pages of debate on one subject in about a week's time, that no one had paid much attention to in the past. Debate and disagreement are good, regardless of the subject, as long as they are constructive.

To me, forums such as this, should not be about who won or lost a debate; I think we should be happy that we have the forum for the debate (and for the record, many times throughout our history the most unpopular decision that was being put forth at any particular time, was often the right decison when viewed through historical reflection). I can remember medics who were threatening to quit in the 80s when our employer forced them to wear gloves (i cant start an IV with gloves on). We all know how dumb that sounds now. Again, thank you for a healthy debate of the issue. I will continue to ask the unpopular questions, even though that gets your reputation score killed in this forum. There are alot of pretty smart folks in this forum, I believe they can take the heat. And yes, I will often take the most assinine position on something just to make you think (but that wasnt the case this time).

[Ace844]

[stream:94e0e31ac8]http://koti.mbnet.fi/badbee/wavs/potential.wav[/stream:94e0e31ac8]

[AZCEP]

Okay, GA, after looking at the QA file for the last year, I can say with all assuredness that every patient that met the recommendations from the AZ Poison Center for the administration of Activated Charcoal received this drug.

We had a total of 8 ingestions. Not many granted, but that's what we had. 5 were attended within 45 minutes of the ingestion. 2 of those were confirmed ingestions of substances responsive to AC, and 1 did not have an associated airway compromise. Each of them had the poison center contacted while enroute to the scene--long response times--and the recommendation was given as noted above.

There you go. I hope that you are satisfied.

[redwolfef6]

Okay.. I know different in Denver!.. Load and go, is not highly recommended. As well driving fast went out with Mother, Jugs, and Speed. Diesel medicine KILLS!

Hint: http://www.emsnetwork.org/ambulance_crashes_2000.htm

R/r 911

I said "almost better". I am sorry for making that overt generalized comment. :oops:

What do you mean "I know better in Denver"?

[Ace844]

Here ya go "GAmedic," here's a current study about your favorite med, ACTIVATED CHARCOAL...

(The American Journal of Emergency Medicine

Volume 24 @ Issue 4 , July 2006, Pages 440-443 doi:10.1016/j.ajem.2005.12.025

Copyright © 2006 Elsevier Inc. All rights reserved.

Original Contribution

Influence of activated charcoal on the pharmacokinetics and the clinical features of carbamazepine poisoning

Nozha Brahmi MD, a, , Nadia Kouraichi MDa, Hafedh Thabet MDa and Mouldi Amamou MDa

aIntensive Care Unit, Centre d'Assistance Médicale Urgente, 1008 Montfleury, Tunis-Tunisia

Received 1 December 2005; revised 29 December 2005; accepted 30 December 2005. Available online 17 June 2006.)

Abstract

Carbamazepine (CBZ) poisoning has been associated with cases of severe toxicity and death. Multiple-dose activated charcoal was proposed to enhance the clearance of CBZ elimination, but there are no prospective controlled studies that demonstrated a change in clinical outcome after the use of multiple-dose activated charcoal. The aim of this study was to determine the CBZ elimination kinetics and the evolution of clinical features according to the dose of activated charcoal in acute poisoning patients. It is a prospective study for 6 months, from January to June 2004, including all pure acute CBZ-poisoned patients. Twelve patients were randomized to receive a multiple-dose activated charcoal (G1) or a simple dose of 1g/kg (G2). Their mean age was 27.6 ± 12.2 years; the Simplified Acute Physiology Score (SAPS II), 16.37 ± 8.46; and the Acute Physiology and Chronic Health Evaluation (APACHE II), 8 ± 3.96. They were 8 men and 4 women. The mean concentration of blood CBZ at hospital admission was of 29.42 ± 6.68 mg/L. Each group includes 6 patients. The peak value of blood CBZ was comparable in the 2 groups: 33 ± 3.46 mg/L (G1) vs 32.6 ± 5.63 (G2) (P = .5); the requirement of mechanical ventilation was similar also (3 in each group). The duration of both coma and mechanical ventilation was significantly decreased in the first group compared with the second: 20.33 ± 3.05 vs 29.33 ± 4.11 hours for coma (P = .02) and 24.1 ± 4.2 vs 36.4 ± 3.6 hours for mechanical ventilation (P = .001). The length of stay was also significantly decreased in the first group: 30.3 ± 3.4 vs 39.7 ± 7.3 hours in the second group (P = .000006). Concurrently, we have noted a significant constant reduction of the half-life of CBZ from serum in the first group: 12.56 ± 3.5 hours after multiple dose vs 27.88 ± 7.36 hours after a simple dose (P = .0004). This decrease was correlated to the dose of charcoal. In summary, we can conclude that multiple-dose activated charcoal is more efficient than simple-dose; it permits a constant decrease of the half-life of blood CBZ without any rebound effect and could improve the prognosis by reducing the duration of coma and the length of stay.

Article Outline

1. Introduction

2. Materials and methods

2.1. Patients

2.2. Methods

2.3.Statistics

3. Results

4. Discussion

References

1. Introduction

Carbamazepine (CBZ) poisoning is associated with cases of severe toxicity and death [1]. The frequency of CBZ poisoning is increasing during these last years. It represents about 8.4% of all drug intoxications in our unit. The degree of toxicity depends on the dose and the quality of the substance. Pharmacokinetic studies have demonstrated a discrepancy between absorption of solid and suspension formulations. A substantial interindividual variability of the half-life of CBZ has also been reported. This variability may be explained by some factors such as age, sex, coingestion of others substances, and administration of charcoal [2], [3], [4] and [5]. The aim of this study was to determine the CBZ elimination kinetics according to the modality of activated charcoal administration in acute CBZ-poisoning patients.

2. Materials and methods

2.1. Patients

We prospectively included all patients admitted for CBZ poisoning on a period of 6 months from January to June 2004 in a 16-bed intensive care and toxicological unit.

The diagnosis of CBZ poisoning was based on a history of CBZ ingestion, clinical features of poisoning, and laboratory findings. The determination of CBZ blood level was performed using gas chromatography (therapeutic value ranges between 5 to 12 mg/L).

Children and mixed poisoning were excluded.

2.2. Methods

Once CBZ poisoning was retained, no gastric lavage was done, and patients were randomized in 2 groups.

The first group (G1) received multiple doses of activated charcoal (50 g every 6 hours), administrated via a nasogastric tube until a return to a CBZ blood concentration less than 12 mg/L.

The second group (G2) received a simple-dose charcoal of 1g/kg.

Symptomatic treatment as the need of mechanical ventilation or supportive treatment was the same in the 2 groups.

Carbamazepine blood level was measured successively at admission (CBZH0) every 3 hours until the peak then every 6 hours until annulation of CBZ blood level.

The half-life of CBZ in blood was calculated using the following equation: CBZ t1/2 = (t2 − t1) × ln (2)/ln (CBZ t1/CBZ t2), where CBZ t1/2 is the half-life CBZ in blood, t2 − t1 denotes the times between the 2 CBZ measurements, and ln, the natural logarithm.

The criteria for judgment were the duration of coma, mechanical ventilation, and the length of stay. This protocol was approved by the hospital ethics committee.

2.3. Statistics

Statistical analysis was performed with SPSS 11.0 (SPSS Inc, Chicago, Ill).

Continuous variables were expressed as means (±SD) and subgroups evaluated by the χ2 test; a 2-tailed test was used in the statistical analysis. A P value less than .05 was considered statistically significant.

Correlations were determined using both Pearson and Spearman rank methods.

3. Results

Twelve patients were included in the study for acute CBZ poisoning in a suicidal attempt. Their mean age was 27.6 ± 12.2 years; the SAPS II, 16.37 ± 8.46; and the APACHE II, 8 ± 3.96. They were 8 men and 4 women. The mean concentration of blood CBZ at hospital admission (CBZH0) was of 29.42 ± 6.68 mg/L.

Six of them were comatous, requiring mechanical ventilation with a mean Glasgow Coma Scale of 8.28 ± 1.60. The analysis of the CBZ blood elimination showed that the concentration (y) in the blood at given time is expressed by the following equation: y = −10.56 ln (x) + 32.436, where y is in mg/L and x is in hours. Each group includes 6 patients. The peak value of blood CBZ was comparable in the 2 groups: 33 ± 3.46 mg/L (G1) vs 32.6 ± 5.63 (G2) (P = .5). The requirement of mechanical ventilation was similar also (3 in each group). The duration of both coma and mechanical ventilation was significantly decreased in the first group compared with the second: 20.33 ± 3.05 vs 29.33 ± 4.11 hours for coma (P = .02) and 24.1 ± 4.2 vs 36.4 ± 3.6 hours for mechanical ventilation (P = .001). The length of stay was significantly decreased also in the first group: 30.3 ± 3.4 vs 39.7 ± 7.3 hours in the second group (P = .000006). Concurrently, we have noted a significant reduction of the half-life of CBZ from serum in the first group: 12.56 ± 3.5 hours after a multiple dose vs 27.88 ± 7.36 hours after a single dose (P = .0004) (Table 1). We have noted also a constant decrease of the CBZ blood concentration without any rebound effect in the first group (Fig. 1). A linear correlation was also found between the half-time of blood CBZ (y) and the dose of charcoal (x) (r = −0.93; P = .01), expressed by the following equation: y = 35.279 − 0.1458x, where y is in hours and x is in grams (Fig. 2).

Table1.

Influence of charcoal administration modality on the elimination of CBZ serum Multiple dose (n = 6) Simple dose (n = 6) P

SAPS II 24 ± 11 13 ± 7.8 NS

APACHE II 10.33 ± 3.5 6.5 ± 3 NS

Glasgow Coma Scale 10 ± 7.8 12.3 ± 8.5 NS

CBZ concentration at admission (mg/L) 29.33 ± 5.03 31 ± 6.08 NS

Peak value of blood CBZ (mg/L) 33 ± 3.46 32.6 ± 5.63 NS

Total dose of charcoal (g) 166.6 ± 28.8 61.7 ± 6.8 .000002

Half-life of blood CBZ (h) 12.56 ± 3.5 27.88 ± 7.36 .0005

NS, non significant.

(15K)

Fig. 1. Kinetics of CBZ according to the dose of activated charcoal.

(15K)

Fig. 2. Relationship between the half-life of CBZ and the dose of charcoal.

4. Discussion

Carbamazepine distribution and metabolism is complex. Carbamazepine is reasonably bioavailable and rapidly absorbed from the gastrointestinal tract. It is highly bound to plasma proteins (75%-80%) with a moderately large volume of distribution (Vd = 1.0-2.0 L/kg) [2], [3] and [4]. Because of these characteristics (prolonged elimination and a small volume of distribution), several modalities have been proposed to enhance drug clearance of CBZ using multiple doses of activated charcoal and hemoperfusion [4] and [6]. Multiple-dose activated charcoal has been recommended by the American Association of Poison Centres and Clinical Toxicologists and the European Association of Poison Centres and Clinical Toxicologists in a consensus position statement as useful in enhancing systemic clearance of CBZ in severe or life-threatening cases of poisoning. However, it should be noted that currently, there are no prospective controlled studies that demonstrated a change in clinical outcome after the use of multiple-dose activated charcoal in CBZ poisoning [4] and [7]. In our study, we try to demonstrate the influence of multiple-dose activated charcoal on elimination of CBZ and the clinical features.

In fact, the biologic half-life of CBZ in humans shows substantial interindividual variability. It averages 35 hours after the administration of a simple dose and 20 hours after a multiple dose [3]. Multiple-dose activated charcoal is thought to produce its beneficial effect by interrupting the enteroenteric and, in some cases, the enterohepatic and the enterogastric circulation of drugs. In addition, any unabsorbed drug still present in the gut will be adsorbed to activated charcoal, thereby reducing drug absorption. It should be used if no contraindication exists [2], [4] and [7]. A few series have studied the impact of charcoal on the elimination of CBZ and demonstrated a significant decrease of the half-life in those who have received charcoal compared with supportive measures [4]. In 1987, Boldy et al [7] have demonstrated that the half-life of CBZ after a total dose of 203 ± 58 g of activated charcoal decreased to 8.6 ± 2.4 hours in 15 acute poisoned patients. Montoya-Cabrera et al [8] also found approximately the same results as those of Boldy et al with a decrease of the half-life to 9.5 ± 1.9 hours after multiple doses of charcoal (386 ± 72 g). The decrease of the half-life was remarkable if compared with the half-life with only supportive treatment, as it is the case in the studies of Hundt et al [9] and Vree et al [10], who evaluated the half-life of the blood CBZ at approximately 19 hours and in the study of Wason et al [11], at 23.3 hours. In our study, the dose-activated charcoal has been found to influence the duration of both coma and mechanical ventilation, and, consequently, the length of stay. The beneficial effect of charcoal may be explained by the decrease of the blood CBZ half-life, which was in correlation with the dose of activated charcoal. We have demonstrated also that the metabolic clearance of CBZ depends on the activated charcoal dose in favor of multiple dose, and that with a simple dose, we can observe a distribution of CBZ from tissue stores. This rebound phenomenon was reported with simple dose and hemoperfusion [1]. In fact, metabolic clearance has been reported to increase from 20 mL/kg per hour after a single dose to 55 mL/kg per hour after multiple-dose [1]. As a result, multiple-dose activated charcoal seems to be as efficient as hemoperfusion, which has been reported to reduce serum concentrations by 25% to 50% and the half-life to 6 to 8 hours, and could be proposed instead of hemoperfusion in severe patients with hemodynamic disturbance because charcoal hemoperfusion is an invasive method of CBZ purifying [1], [4], [12] and [13]. They are also interesting because they showed that a simple dose of charcoal (1g/kg) was less efficient than multiple dose and could be compared with supportive measures. The same result was reported by Winnicka et al [3] who do not demonstrate any in fluency of 30 to 70 g of charcoal on the half-life of CBZ. In summary, in spite of the little number of patients, we can conclude that multiple-dose activated charcoal is more efficient than simple dose; it permits a constant decrease of the half-life of blood CBZ without any rebound effect and could improve the prognosis by reducing the duration of coma and the length of stay.

References

[1] C. Low, S. Haqqie and R. Desai et al., Treatment of acute carbamazepine poisoning by hemoperfusion, Am J Emerg Med 14 (1996), pp. 540–541. SummaryPlus | Full Text + Links | PDF (214 K)

[2] A. Perez and J.F. Wiley, Pediatric carbamazepine suspension overdose—clinical manifestations and toxicokinetics, Pediatr Emerg Care 21 (2005), pp. 252–254. Abstract-EMBASE | Abstract-MEDLINE | Full Text via CrossRef

[3] R. Winnicka, B. Lopacinski and W. Szymczak et al., Carbamazepine poisoning: elimination kinetics and quantitative relationship with carbamazepine 10,11-epoxide, J Toxicol Clin Toxicol 40 (2002), pp. 759–765. Abstract-EMBASE | Abstract-Elsevier BIOBASE | Abstract-MEDLINE | Full Text via CrossRef

[4] AAMT and EAPCCT, Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning, J Toxicol Clin Toxicol 37 (1999), pp. 731–751.

[5] L. Bertilsson and T. Tomson, Clinical pharmacokinetics and pharmacological effects of carbamazepine and carbamazepine-10,11-epoxide. An update, Clin Pharmacokinet 11 (1986), pp. 177–198. Abstract-MEDLINE | Abstract-EMBASE

[6] D. Askenazi, S. Goldstein and I.F. Chang et al., Management of a severe carbamazepine overdose using albumin-enhanced continuous venovenous hemodialysis, Pediatrics 113 (2004), pp. 406–409. Abstract-MEDLINE | Abstract-Elsevier BIOBASE | Abstract-EMBASE | Full Text via CrossRef

[7] D. Boldy, A. Heath and S. Ruddock et al., Activated charcoal for carbamazepine poisoning, Lancet 1 (1987), p. 1027. Abstract

[8] M.A. Montoya-Cabrera, J.M. Sauceda-Garcia and P. Escalante-Galindo et al., Carbamazepine poisoning in adolescent suicide attempters. Effectiveness of multiple-dose activated charcoal in enhancing carbamazepine elimination, Arch Med Res 27 (1996), pp. 485–489. Abstract-MEDLINE | Abstract-EMBASE

[9] H.K.L. Hundt, A.K. Aucamp and F.O. Müller, Pharmacokinetic aspects of carbamazepine and its two major metabolites in plasma during overdosage, Hum Toxicol 2 (1983), pp. 607–614. Abstract-EMBASE | Abstract-MEDLINE

[10] T.B. Vree, T.J. Janssen and Y.A. Hekster et al., Clinical Pharmacokinetics of carbamazepine and its epoxy and hydroxy metabolites in humans after an overdose, Ther Drug Monit 8 (1986), pp. 297–304. Abstract-EMBASE | Abstract-MEDLINE

[11] S. Wason, R.C. Baker and P. Carolan et al., Carbamazepine overdose—the effects of multiple dose activated charcoal, J Toxicol Clin Toxicol 30 (1992), pp. 39–48. Abstract-MEDLINE | Abstract-EMBASE

[12] H. Spiller, Management of carbamazepine overdose, Pediatr Emerg Care 17 (2001), pp. 452–456. Abstract-EMBASE | Abstract-MEDLINE | Full Text via CrossRef

[13] A. Graudins, G. Peden and R.P. Dowsett, Massive overdose with controlled-release carbamazepine resulting in delayed peak serum concentrations and life-threatening toxicity, Emerg Med 14 (2002), pp. 89–94. Abstract-MEDLINE | Abstract-EMBASE | Full Text via CrossRef