Activated charcoal: Difference between revisions
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==Background==
==General==
if greater than 2 hrs or toxin already in intestine, gastric decontam not helpful
*Type: [[Antidote]]
*A fine, black, odorless powder recognized for more than 2 centuries as an effective adsorbent of many substances
*Common Trade Names: Actidose-Aqua [OTC]; Actidose/Sorbitol [OTC]; Char-Flo with Sorbitol [OTC]; EZ Char [OTC]; Kerr Insta-Char in Sorbitol [OTC]; Kerr Insta-Char [OTC] <ref>Activated Charcoal. online.lexi.com.elibrary.einstein.yu.edu/lco/action/doc/retrieve/docid/patch_f/6579?hl=5864#f_pregnancy-and-lactation. Updated 10/5/15. Accessed 12/30/15. </ref>


-   helpful however if delayed emptying or decreased intest motility
==Adult Dosing==
*25-100gm PO<ref name="AACT PP" />
*Common standard dose is 50gm
*10:1 ratio of charcoal to xenobiotic typically recommended
*If not pre-mixed best administered in a 1:8 ratio of AC to liquid (water, coke)
*AC alone comparably effective to AC to cathartic (sorbitol, Mg citrate)
**if cathartic is used, it should only be a single time (avoid in [[multidose activated charcoal]] therapy)
**repeated dosages associated with dehydration, hypotension, electrolyte derangements


-   always use charcoal asap unless agent/ quantity not toxic, agent not absorbed to charcoal, or delay so long absorption is complete
==Pediatric Dosing==
*0.5-1 gm/kg PO<ref name="AACT PP" />


-    gastric emptying before charcoal- higher risk of aspiration, intubation, icu- not routinely recommended
==Special Populations==
*[[Drug pregnancy categories‎‎|Pregnancy Rating]]: not absorbed
*[[Pregnancy and lactation drug labeling|Lactation risk]]: not absorbed
*Renal Dosing
**Adult
**Pediatric
*Hepatic Dosing
**Adult
**Pediatric


-   gastric emptying helpful if symptomatic within 1 hr, symptomatic with agents that slow gi motility, sustained release meds or massive/ life threatening amount
==Indications==
*should be considered for a poisoned or overdosed patient after risk-to-benefit assessment of the ingested substance and patient-specific factors
*Ingested drug is adsorbed by charcoal AND one of the following:
**Time since ingestion is less than 1-2hr
**Drug has significant enterohepatic circulation
**Drug delays gastric emptying AND time since ingestion is <4hr
**Drug is a controlled release preparation AND time since ingestion is <12-18hr


===AACT recommendations===
*Activated charcoal "should not be administered routinely in the management of poisoned patients."<ref name="AACT PP">Chyka PA, Seger D, Krenzelok EP, Vale JA; American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61-87.</ref>
*Consider if patient presents within one hour of an ingestion of a toxic amount of a substance known to be absorbed by charcoal
**Administration of charcoal after an hour may continue to be beneficial
*They emphasize that there is no definitive data that activated charcoal improves clinical outcome


==Does GI Decont Change Pt Outcome?==
==Contraindications==
*Altered mental status
*Intestinal obstruction
*Increased risk of aspiration
*Ingestion of substances not absorbed by charcoal
*Instances where urgent endoscopy will be needed (eg. Ingestion of caustic material)


-    effect only if used early- no effect if late
===Limitations===
*Does not work with:
**Heavy metals ([[Iron Toxicity|Iron]], [[Lead Toxicity|Lead]], [[Arsenic]], [[Mercury]], Zinc)
**Inorganic ions ([[Lithium]], Potassium, Sodium, Flouride and Iodine)
**[[Hydrocarbons]]/essential oils
**Toxic alcohols ([[Ethylene Glycol Toxicity|Ethylene Glycol]], [[Methanol Toxicity|Methanol]], [[Isopropyl Alcohol Toxicity|Isopropanol]])
**Acids/bases
**Organophosates


-    however, no prospective trial has proven charcoal or ipecac- only suggests it
==Adverse Reactions==
*[[Aspiration Pneumonia and Pneumonitis|Aspiration]]
*[[Small Bowel Obstruction (SBO)|Bowel obstruction]]


-   also, gi decont benefit never disproved either
==Pharmacology==
*Half-life: not absorbed
*Metabolism: not absorbed
*Excretion: excreted whole in feces
*Adsorption begins within about 1 minute but may not achieve equilibrium for 10-25 minutes
*Clinical efficacy inversely related to time elapsed after ingestion and depends on rate of adsorption of xenobiotic


==Risks==
===Mechanism of action===
#  aspiration- by cns depression, loss of gag reflex, spont or induced emesis, manipulation of airway or gi tract
*Large surface area of the charcoal binds toxins and prevents their absorption
#ipecac assoc with asp if used incorrectly-
*Interrupts enteroenteric/enterohepatic circulation of drugs<ref name="Multi">Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1999;37(6):731-51.</ref>
##charcoal usually not assoc with asp- but can be
##charcoal asp worse than gastric content asp because causes granulomatous reaction, tissue reaction to sorbitol or povidone, increased lung microvascular permeability
##risk of gastric lavage include unnecessary intubation
##intubation for airway protection/ aspiration not 100% protective
#lavage can also damage throat, esoph, stomach


==Which Pt Not Need GI Decon?==
==Comments==
*Created by heating wood and other natural materials in an airless environment
*"Activated" by turning into fine powder, which ↑ surface area


-    most preschool pts do not need decont
==See Also==
 
*[[Gastric Lavage]]
-    no need for decon if nontoxic dose or substance or drug taken so long ago already absorbed.
*[[Multidose Activated Charcoal (MDAC)]]
 
-    Gi decon reasonable if all pt and all symptomatic pt unless full absorption already occurred- risks of single dose low.
 
-    However- if low risk pt and uncooperative- may not be worth trauma/ risk to staff or pt
 
==Benefit of GI Emptying Before Charcoal?==
 
-    no- especially not if present late, are asymptomatic.
 
-    Gastric emptying will not add benefit to charcoal


-    Benefit of charcoal not even proven but is considered state of the art to give unless full absorption already occurred
==References==
 
<references/>
==Will Some Pts Benefit From Aggressive GI Decon?==
 
-    charcoal not useful for iron, lithium alcohol, caustics, hydrocarbons
 
-    even with sustained release meds, if most of drug has moved beyond stomach, lavage will only hold up charcoal
 
-    if pt given ipecac and vomits long time before ED presentation- probably don't need additional charcoal for pediatric pts
 
 
 
ED physician needs to evaluate each ingestions individually and design treatment plan.  If substance poorly aborbed to charcoal- try gastric lavage unless have prolonged delay.  Usually charcoal alone is best choice.  If late presenting pt and asymptomatic- no gi decon needed.  If ealy and symptomatic- personal choice to do gastric lavage followed by charcoal or just charcoal- examine relative risk.
 
==See Also==
[[Gastric Lavage]]


[[Category:Procedures]]
[[Category:Pharmacology]]
[[Category:Tox]]
[[Category:Procedures]]  
[[Category:Toxicology]]
[[Category:EMS]]

Revision as of 18:05, 26 March 2018

General

  • Type: Antidote
  • A fine, black, odorless powder recognized for more than 2 centuries as an effective adsorbent of many substances
  • Common Trade Names: Actidose-Aqua [OTC]; Actidose/Sorbitol [OTC]; Char-Flo with Sorbitol [OTC]; EZ Char [OTC]; Kerr Insta-Char in Sorbitol [OTC]; Kerr Insta-Char [OTC] [1]

Adult Dosing

  • 25-100gm PO[2]
  • Common standard dose is 50gm
  • 10:1 ratio of charcoal to xenobiotic typically recommended
  • If not pre-mixed best administered in a 1:8 ratio of AC to liquid (water, coke)
  • AC alone comparably effective to AC to cathartic (sorbitol, Mg citrate)
    • if cathartic is used, it should only be a single time (avoid in multidose activated charcoal therapy)
    • repeated dosages associated with dehydration, hypotension, electrolyte derangements

Pediatric Dosing

  • 0.5-1 gm/kg PO[2]

Special Populations

Indications

  • should be considered for a poisoned or overdosed patient after risk-to-benefit assessment of the ingested substance and patient-specific factors
  • Ingested drug is adsorbed by charcoal AND one of the following:
    • Time since ingestion is less than 1-2hr
    • Drug has significant enterohepatic circulation
    • Drug delays gastric emptying AND time since ingestion is <4hr
    • Drug is a controlled release preparation AND time since ingestion is <12-18hr

AACT recommendations

  • Activated charcoal "should not be administered routinely in the management of poisoned patients."[2]
  • Consider if patient presents within one hour of an ingestion of a toxic amount of a substance known to be absorbed by charcoal
    • Administration of charcoal after an hour may continue to be beneficial
  • They emphasize that there is no definitive data that activated charcoal improves clinical outcome

Contraindications

  • Altered mental status
  • Intestinal obstruction
  • Increased risk of aspiration
  • Ingestion of substances not absorbed by charcoal
  • Instances where urgent endoscopy will be needed (eg. Ingestion of caustic material)

Limitations

Adverse Reactions

Pharmacology

  • Half-life: not absorbed
  • Metabolism: not absorbed
  • Excretion: excreted whole in feces
  • Adsorption begins within about 1 minute but may not achieve equilibrium for 10-25 minutes
  • Clinical efficacy inversely related to time elapsed after ingestion and depends on rate of adsorption of xenobiotic

Mechanism of action

  • Large surface area of the charcoal binds toxins and prevents their absorption
  • Interrupts enteroenteric/enterohepatic circulation of drugs[3]

Comments

  • Created by heating wood and other natural materials in an airless environment
  • "Activated" by turning into fine powder, which ↑ surface area

See Also

References

  1. ↑ Activated Charcoal. online.lexi.com.elibrary.einstein.yu.edu/lco/action/doc/retrieve/docid/patch_f/6579?hl=5864#f_pregnancy-and-lactation. Updated 10/5/15. Accessed 12/30/15.
  2. ↑ 2.0 2.1 2.2 Chyka PA, Seger D, Krenzelok EP, Vale JA; American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61-87.
  3. ↑ Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1999;37(6):731-51.
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