Activated charcoal

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Background

if greater than 2 hrs or toxin already in intestine, gastric decontam not helpful

- helpful however if delayed emptying or decreased intest motility

- always use charcoal asap unless agent/ quantity not toxic, agent not absorbed to charcoal, or delay so long absorption is complete

- gastric emptying before charcoal- higher risk of aspiration, intubation, icu- not routinely recommended

- gastric emptying helpful if symptomatic within 1 hr, symptomatic with agents that slow gi motility, sustained release meds or massive/ life threatening amount


Does GI Decont Change Pt Outcome?

- effect only if used early- no effect if late

- however, no prospective trial has proven charcoal or ipecac- only suggests it

- also, gi decont benefit never disproved either


Risks

  1. aspiration- by cns depression, loss of gag reflex, spont or induced emesis, manipulation of airway or gi tract
  2. ipecac assoc with asp if used incorrectly-
    1. charcoal usually not assoc with asp- but can be
    2. charcoal asp worse than gastric content asp because causes granulomatous reaction, tissue reaction to sorbitol or povidone, increased lung microvascular permeability
    3. risk of gastric lavage include unnecessary intubation
    4. intubation for airway protection/ aspiration not 100% protective
  3. lavage can also damage throat, esoph, stomach


Which Pt Not Need GI Decon?

- most preschool pts do not need decont

- no need for decon if nontoxic dose or substance or drug taken so long ago already absorbed.

- 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


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.