UMEM Educational Pearls

 

Throughout medical history one of the basic tenets of poisoning therapy is to remove the poison from the patient. For hundreds of years, gastric decontamination has been the cornerstone treatment for acute poisonings by ingestion. This commonsense approach endeavors to remove as much of the the ingested toxin as possible before systemic absorption and organ toxicity occurs. Multiple GI decontamination methods have been utilized including gastric emptying by lavage and ipecac, toxin binding by activated charcoal, and increasing GI transit time with cathartics and bowel irrigation. Numerous studies have been conducted to assess the effectiveness of GI decontamination including measurement of amount of toxin removed by gastric retrieval, reduction of bioavailability by measuring blood levels, and finally comparison of clinical outcomes of patients treated with and without GI decontamination. Controlled studies have failed to show conclusive evidence of benefit and have even demonstrated resultant harm especially with use of gastric lavage. Activated charcoal has a tremendous surface area capable of binding many substances. Although viewed as relatively safe it does have risks in certain subsets of patients, pulmonary aspiration the most common, and is no longer routinely recommended.

Considerations for use of Activated charcoal (AC) use in acutely poisoned patients:

• AC does not bind alcohols, hydrocarbons, heavy metals
• Contraindications include diminished level of consciousness, seizure, emesis, unprotected airway, and intestinal obstruction
• Consider AC use in cases where there is potential for toxin to remain in the gut longer such as with delayed-release formulations or slowed gastric emptying
• Consider AC use in cases of expected severe toxicity with lack of effective antidote

The decision to use activated charcoal is no longer standard of care but should be individualized to each clinical situation weighing the risk versus clinical benefits.

References

Olson KR. Activated Charcoal for Acute Poisoning: One Toxicologist’s Journey. J Med Toxicol 2010;6:190-198. Activated charcoal for acute overdose: a reappraisal.

Juurlink D. Br J Clin Pharmacol 2015 Sep 26  

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.

Lapus RM, Activated charcoal for pediatric poisonings: the universal antidote? Curr Opin Pediatr. 2007;19:219-222.