Single Dose Of Activated Charcoal Research Articles

The Role of Activated Charcoal in Prehospital Care.

Administration of a single-dose activated charcoal (SDAC) is an effective method used for gastric decontamination and for other types of poisoning and overdose. This is only true when given within the first hour of poison ingestion as the effectivity of SDAC reduces over time. In addition, generally, not all patients are able to avail treatment within the specified period. Hence, multi-dose activated charcoal is regarded as a solution to a delayed process, although, no proof outweighs the use of SDAC. This study aimed to review and assess the adequacy of the past and current use of AC. The author also aimed to offer recommendations believed to be the best method to consider for prehospital care. The author conducted 6,337 online literature searches for this review, wherein seven papers met eligibility criteria for inclusion and analysis. In this review, routine administration of AC in poisoning was found not related to the duration of hospital stay nor any other subsequent outcomes following poison ingestion. Further, this review did not establish that administration of AC could improve patient's clinical outcome. Further research and clinical trials is required to determine the efficacy of this therapy to appropriate patients in the prehospital setting. Activated charcoal can be used to treat highly acute to life-threatening poisoning if it is administered within the first hour of ingestion. Further studies would be necessary to investigate if this would affect clinical outcome..

Use and knowledge of single dose activated charcoal: A survey of Australian doctors.

The use of single dose activated charcoal (SDAC) as a means of gastric decontamination is declining. The present study examined the potential use of SDAC in common overdose scenarios by Australian emergency doctors, compared with clinical toxicologists and current guidelines. We conducted a cross-sectional survey of emergency doctors and toxicologists on the use of SDAC. The survey covered demographic data, education and previous use of SDAC and six clinical scenarios. The scenarios selected included agents not bound to SDAC, sustained-release preparations and ingestions at varying time points. Statistical calculations were performed using Fisher's exact test. There were 397 emergency doctors and 20 toxicologists who responded to the survey. Seventy-one per cent (n=280/397) of emergency doctors indicated they had received some education on decontamination. Eighty-three per cent (n=331/397) had administered SDAC during their medical career, 29% (n=117/397) within the past year. There was a significant difference in responses between emergency doctors and toxicologists in two scenarios; a toxic paracetamol ingestion presenting within 1 h (P=0.009) and verapamil ingestion in a 3 year old boy (P=0.001). Toxicologists were more likely to administer SDAC in these scenarios, 89% (n=16/18) and 88% (n=15/17), respectively, compared with 52% (n=197/381) and 43% (n=158/371) of emergency doctors. Our study showed that there is a significant variation in the use of SDAC between toxicologists and emergency doctors in some scenarios. Clinical toxicologists are more likely to administer SDAC in certain overdose settings. It is essential to provide education on the benefits versus actual risks of SDAC in acute poisoning so that doctors will understand when to administer SDAC or seek further advice.

Activated Charcoal Does Not Reduce Duration of Phenytoin Toxicity in Hospitalized Patients

Phenytoin toxicity frequently results in a prolonged inpatient admission. Several publications avow multidose activated charcoal (MDAC) will enhance the elimination of phenytoin. However, these claims are not consistent, and the mechanism of enhanced eliminaiton is unproven. The aim of this investigation is to compare the time to reach a clinical composite end point in phenytoin overdose patients treated with no activated charcoal (NoAC), single-dose activated charcoal (SDAC), and MDAC. This was a retrospective study using electronic poison center data. Patients treated in a health care facility with phenytoin concentrations >20 mg/L were included. Patients were grouped by use of SDAC, MDAC, and NoAC. The primary end points were either time to resolution of symptoms, hospital discharge, or the case was closed by a toxicologist. After applying inclusion and exclusion criteria, 132 cases were included for analysis. There were 88 NoAC, 13 SDAC, and 31 MDAC cases. The groups were similar in symptomatology, age, and chronicity of expsoure. Mean peak phenytoin concentrations (SD) were 42 mg/L (12), 41 mg/L (11), and 42 mg/L (11) for NoAC, SDAC, and MDAC, respectively. Mean time to reach the study end point was 39 hours [95% confidence interval (CI), 31-48], 52 hours (95% CI, 36-68), and 60 hours (95% CI, 45-75) for NoAC, SDAC, and MDAC, respectively. The groups appeared similar with respect to peak phenytoin concentrations and prevalence of signs and symptoms. In this observational series, the use of activated charcoal was associated with increased time to reach the composite end point of clinical improvement.

Single–dose activated charcoal—a feasibility study in an ambulance setting

Following a previous article published in the Journal of Paramedic Practice ( Walker, 2013 ) this article summarises the findings of a study conducted by South Western Ambulance Service NHS Foundation Trust (SWASFT). As a result of the literature review detailed in the previous article, approval was given to run a 6-month study examining the feasibility of paramedic crews carrying and administering single-dose activated charcoal (SDAC) to patients of self-poisoning attended within 1 hour of ingestion of a suitable toxin. Sixty nine patients were offered SDAC, with an acceptance rate of 94%. Fears of adverse incidents such as vomiting, aspiration and increased time on scene appeared almost entirely unfounded and crews found the medication easy to use and popular with patients. Paracetamol, usually at hepatotoxic levels accounted for 57% of all overdoses encountered, most of these receiving SDAC within 1 hour, with 81.5% of all patients receiving the medication in that time frame. SWASFT has now adopted SDAC as a treatment for patients of overdose.

SINGLE DOSE ACTIVATED CHARCOAL FOR PRE-HOSPITAL USE, A FEASIBILITY STUDY BY SOUTH WESTERN AMBULANCE SERVICE NHS FOUNDATION TRUST

In 2004 The National Institute for Health and Care Excellence (NICE) recommended in that ambulance services should carry Single Dose Activated Charcoal (SDAC) as an antidote to self-poisoning.A survey of...

An exploratory study; the therapeutic effects of premixed activated charcoal–sorbitol administration in patients poisoned with organophosphate pesticide

Objective. The effects of activated charcoal (AC) mixed with cathartics for gastric decontamination in the management of organophosphate (OP) poisoning remain unknown due to limited clinical evidence. This exploratory study assessed the effectiveness of premixed AC–sorbitol as a treatment for OP poisoning. Materials and methods. This retrospective observational case study included patients who either did not receive AC–sorbitol or received a single dose of AC–sorbitol within 24 h after OP ingestion. The patients were divided into three groups: no AC–sorbitol treatment, patients who received AC–sorbitol within 1 h of OP ingestion, and patients who received AC–sorbitol more than 1 h after OP ingestion. Mortality, the development of respiratory failure, and the duration of mechanical ventilation were used as outcome measurements for effectiveness, whereas aspiration pneumonia and electrolyte imbalance were employed as safety measurements. Result. Among 262 patients with OP poisoning, 198 were included. Of these, 133 patients did not receive AC–sorbitol, whereas 14 and 51 patients received AC–sorbitol within 1 h or more than 1 h after ingestion, respectively. The time from ingestion to hospital arrival and time from ingestion to administration of atropine and pralidoxime differed among the groups, whereas other characteristics, including age, amount ingested, and type of ingested OP, were similar among the groups. Univariate and multivariate analysis demonstrated that the administration of AC–sorbitol was not associated with outcome measures for effectiveness and did not significantly increase either aspiration pneumonia or electrolyte imbalances during hospitalization. Discussion and conclusion. The administration of AC–sorbitol exerted neither beneficial nor harmful effects on the outcomes of OP-poisoned patients regardless of the time from OP ingestion to administration, compared with those of patients who did not receive AC–sorbitol. However, this study enrolled a small number of patients who received AC–sorbitol; further qualified trials with a sufficient number of patients are therefore needed.

The pharmacokinetics of sertraline in overdose and the effect of activated charcoal.

To investigate the pharmacokinetics (PK) of sertraline in overdose and the effect of single dose activated charcoal (SDAC). Patients presenting to a toxicology unit with sertraline overdoses had demographic and clinical information recorded, and serial serum collected for measurement of sertraline concentrations. Monolix® version 4.2 was used to develop a population PK model of sertraline overdose and the effect of SDAC. Uncertainty in dose time was accounted for by shifting dose time using lag time with between subject variability (BSV). BSV on relative fraction absorbed was used to model uncertainty in dose. There were 77 timed sertraline concentrations measured in 28 patients with sertraline overdoses with a median dose of 1550 mg (250-5000 mg). SDAC was given to seven patients between 1.5 and 4 h post-overdose. A one compartment model with lag time of 1 h and first order input and elimination adequately described the data. Including BSV on both lag time and relative fraction absorbed improved the model. The population PK parameter estimates for absorption rate constant, volume of distribution and clearance were 0.895 h(-1) , 5340 l and 130 l h(-1) , respectively. The calculated half-life of sertraline following overdose was 28 h (IQR 19.4-30.6h). When given up to 4 h post-overdose, SDAC significantly increased the clearance of sertraline by a factor of 1.9, decreased the area under the curve and decreased the maximum plasma concentration (Cmax ). Sertraline had linear kinetics in overdose with parameter values similar to those in therapeutic use. SDAC is effective in increasing clearance when given 1.5 to 4 h post-overdose.

Predicting the requirement for N-acetylcysteine in paracetamol poisoning from reported dose

Context. There is contention over whether reported dose correlates with toxicity in paracetamol poisoning and risk assessment is currently based on serum paracetamol concentration compared to a nomogram, irrespective of reported dose. Objective. To determine if reported dose predicts the need for N-acetylcysteine (NAC). Methods. Data were taken from paracetamol overdoses presenting to a tertiary toxicology service. Age, sex, reported dose, ingestion time, timed paracetamol concentrations between 4 and 16 h, hepatotoxicity (peak alanine transaminase > 1000 U/L) and treatment (single dose-activated charcoal [SDAC] and NAC) were analysed. Data were analysed within a repeated measures logistic regression framework using NONMEM (ver 7.2). The primary outcome was administration of NAC, which was determined based on a serum paracetamol concentration greater than the nomogram line. Result.: There were 1571 admissions in 1303 patients, with a median age of 27 years (12–96 years) and 1140 (73%) were females. The median dose was 10 g (1–100 g). The paracetamol concentration was above the nomogram line in 337 of 1571 (22%) patients. Patients presenting later (first paracetamol concentration between 7 and 16 h post-overdose) compared to those presenting earlier (4–7 h post-overdose) were more likely to have hepatotoxicity (5.5% vs. 0.4%; p < 0.0001), have a toxic paracetamol concentration (34% vs. 18%; p < 0.0001) and receive NAC (48% vs. 23%; p < 0.0001). SDAC reduced the probability of the paracetamol concentration being above the nomogram. Based on SDAC not being administered there was a 5% probability of requiring NAC at a dose of 6–9 g, a 10% chance of requiring NAC at a dose of 13–16 g, a 50% chance of requiring NAC at a dose of 30–34 g and a 90% chance for needing NAC at 48–50 g. Conclusion. Reported dose was a good predictor of a toxic paracetamol concentration and SDAC reduced the probability of the concentration being above the nomogram. These predictions may assist in determining which patients could be started on NAC immediately.

Population pharmacokinetics and pharmacodynamics of escitalopram in overdose and the effect of activated charcoal

To describe the pharmacokinetics and pharmacodynamics (PKPD) of escitalopram in overdose and its effect on QT prolongation, including the effectiveness of single dose activated charcoal (SDAC). The data set included 78 escitalopram overdose events (median dose, 140mg [10-560mg]). SDAC was administered 1.0 to 2.6 h after 12 overdoses (15%). A fully Bayesian analysis was undertaken in WinBUGS 1.4.3, first for a population pharmacokinetic (PK) analysis followed by a PKPD analysis. The developed PKPD model was used to predict the probability of having an abnormal QT as a surrogate for torsade de pointes. A one compartment model with first order input and first-order elimination described the PK data, including uncertainty in dose and a baseline concentration for patients taking escitalopram therapeutically. SDAC reduced the fraction absorbed by 31% and reduced the individual predicted area under the curve adjusted for dose (AUC(i) /dose). The absolute QT interval was related to the observed heart rate with an estimated individual heart rate correction factor (α= 0.35). The heart rate corrected QT interval (QT(c) ) was linearly dependent on predicted escitalopram concentration [slope = 87ms/(mgl(-1) )], using a hypothetical effect-compartment (half-life of effect-delay, 1.0h). Administration of SDAC significantly reduced QT prolongation and was shown to reduce the risk of having an abnormal QT by approximately 35% for escitalopram doses above 200mg. There was a dose-related lengthening of the QT interval that lagged the increase in drug concentration. SDAC resulted in a moderate reduction in fraction of escitalopram absorbed and reduced the risk of the QT interval being abnormal.

Indications for single-dose activated charcoal administration in acute overdose

Gastrointestinal decontamination in overdose patients remains a controversial problem in emergency medicine. There has been a significant decrease in the use of single-dose activated charcoal (SDAC) in recent years based on little new evidence and possibly because the overall mortality in overdose patients is low. Human volunteer studies suggest SDAC is effective and this effect occurs for up to 4 h after ingestion, but the magnitude of the reduction in area under the curve (AUC) decreases over time. Two randomized controlled trials including one recent large study did not find SDAC to be beneficial. Pharmacokinetic and pharmacodynamic studies of specific drugs in overdose suggest that for most drugs SDAC decreases drug exposure, but this does not translate to clinical benefit in all cases. The administration of SDAC is a low-risk intervention. Although SDAC is unlikely to be beneficial in many overdose patients, for some subgroups with severe poisoning, the benefits will outweigh the low risk of administration. The use of SDAC should be based on the potential toxicity of the drug ingested and the potential benefit of SDAC balanced against the willingness of the patient to take SDAC and the low risk of administration.

The effect of decontamination procedures on the pharmacodynamics of venlafaxine in overdose.

To investigate the relationship between decontamination procedures and seizure events caused by venlafaxine overdose and to estimate the time at which 90% of patients would have had their first seizure in the presence and absence of decontamination. Data were collected from 319 patients who took an overdose of venlafaxine on 436 occasions. Seizures occurred on 24 of 436 occasions (5%). Patients received one of single dose activated charcoal (SDAC), whole bowel irrigation (WBI), a combination of either (SDAC/WBI) or no decontamination. Logistic regression and time to event analysis were used to investigate the influence of dose and decontamination on the probability of seizures and time to 90% (t(90) ) of seizure, respectively. A linear logistic regression model described the data. Simulation from the model showed that the probability of seizure was 0.05 (0.03-0.08), 0.19 (0.09-0.35) and 0.75 (0.30-0.96) at 1000, 5000 and 10 000 mg, respectively (median and 95% credible interval). At the mean dose of 2100 mg the odds ratios (OR) in the presence of SDAC, WBI and SDAC/WBI were 0.48 (0.25-0.89), 0.71 (0.35-1.22) and 0.25 (0.08-0.62), respectively. A modified Gompertz model described the time to seizure events. Simulations from the Gompertz model showed that the t(90) values for first seizure was 26 h and was not affected by dose or decontamination procedure. SDAC/WBI provided greater benefits than the sum of the independent effects of SDAC and WBI. Patients should be observed for at least 24 h for seizures based on the dose and risk of seizure occurring.

Therapeutic effects of multi-dose activated charcoal on the acute dichlorvos poisoning in rats

Objective To assess the therapeutic effects of activated charcoal on the acute dichlorvos poisoning in rats. Method Thirty male clean grade Wistar rats were randomly (random number) divided into three groups: control group (group A, n = 10), single dose activated charcoal group (group B, n = 10) and multi-dose activated charcoal (group C, n=10). The rats of group A were suffered from 35 mg/kg dichlorvos exposure by oral without activated charcoal and senna. The rats of group B received 35 mg/kg dichlorvos exposure by oral with 175 mg/kg activated charcoal given immediately after dichlorvos exposure and 35 mg/kg senna given half an hour later. In the group C, 35 mg/kg dichlorvos was given to rats by oral with 175 mg/kg activated charcoal given immediately after dichlorvos exposure and 35 mg/kg senna given half an hour later and then every four hours. Blood samples were collected from the carotid artery at different intervals after exposure. DDVP concentration and total blood acetyl-cholinesterase activity were detected. Differences in serum DDVP concentration, Cmax, AUC (0→∞ ), MRT and acetylcholinesterase among three groups were calculated by using ANOVA. Results Serum DDVP levels in single dose group and in multi-dose group were significantly different from those in control group (P 0.05). Another four hours later, no differences in acetylcholinesterase were found a-mong three groups (P > 0.05). Conclusions The peak concentrations of dichlorvos in blood are lower in group B and group C, and the blood acetylcholinesterase inhibition is quelled by activated charcoal. Therefore, the effects of multi - dose of activated charcoal is better than that of single dose of activated charcoal. Key words: Dichlorvos; Activated carbon; Organophosphate poisoning; Oral intaken; LC-MS; Rat; Toxicoki-netics; Statistical moment model

The Effect of Decontamination Procedures on the Pharmacokinetics of Venlafaxine in Overdose

The aim of this work was to investigate the pharmacokinetics (PK) of venlafaxine in overdose and the effects of single-dose activated charcoal (SDAC) and whole-bowel irrigation (WBI), alone or in combination, as methods of decontamination. The data included 339 concentration-time points from 76 venlafaxine overdose events (median dose 2,625 (150-13,500 mg)); 69 were slow-release doses. SDAC, WBI, a combination of both, or no decontamination were administered to patients as decided by the treating clinician. The data were modeled using WinBUGS (Windows Bayesian Inference Using Gibbs Sampling). A one-compartment model with first-order input and elimination provided an adequate description of the data. SDAC increased clearance (CL) of venlafaxine by 35%, and SDAC and WBI combined reduced the fraction absorbed by 29%. However, the latter produced a greater reduction in maximum plasma concentration (C(max)) for a similar drop in area under the plasma concentration-time curve (AUC). Both SDAC alone, and a combination of SDAC and WBI, decreased the AUC after venlafaxine overdose, but the combination may be more beneficial because it reduces peak concentrations to a greater extent.

Quetiapine overdose: predicting intubation, duration of ventilation, cardiac monitoring and the effect of activated charcoal

To investigate factors that predict the probability and duration of mechanical ventilation in quetiapine overdose, and if cardiac toxicity occurs, this cohort study involved 176 patients presenting to a toxicology unit on 286 occasions with quetiapine overdose. Patient demographics, dose, coingestants, single dose activated charcoal (SDAC) administration, requirement for and duration of mechanical ventilation and electrocardiogram parameters (heart rate, QT, QRS) were obtained. A fully Bayesian approach using logistic regression and time-to-event analysis was undertaken to investigate the relationship between predictor variables and the requirement for and duration of intubation. QT versus heart rate was plotted on a QT nomogram to investigate QT prolongation. The commonest clinical effects were central nervous system depression on 136 occasions (48%) and tachycardia (67%). There were no malignant arrhythmias and an abnormal QT occurred in only 24 admissions (8.4%), all with tachycardia. Hypotension (systolic blood pressure <90 mmHg) occurred on 35 occasions (12%). The logistic regression model supported dose and SDAC (<2 h) influencing the probability of intubation, but not age, sex, therapeutic use of quetiapine or coingestants. The probability of intubation was 10% after 2 g, 22% after 5 g, 37% after 10 g and 55% after 20 g and SDAC resulted in a reduced probability of intubation of 7% for 2 g ingestion. The median duration of ventilation was 22 h (interquartile: 19-28 h), which was not affected by SDAC. Ingested dose can inform early decision making about requirements for intensive care unit admission and intubation. SDAC seems to have only modest effects on outcomes but may be considered within 2 h for large ingestions. Electrocardiogram monitoring is unlikely to be necessary.

Use of Single-dose Activated Charcoal Among Canadian Pediatric Emergency Physicians

Gastric decontamination with single-dose activated charcoal (SDAC) is a mainstay in emergency department (ED) treatment of ingestions. Guidelines updated in 2005 encourage practitioners to use SDAC only in toxic ingestions presenting within 1 hour. Despite these guidelines, adult studies demonstrate a significant lack of consensus. This study examined the proposed use of SDAC for gastric decontamination in common pediatric ingestion scenarios by emergency physicians working in Canadian pediatric EDs. A standardized survey consisting of 5 clinical scenarios was mailed to all physicians with a primary clinical appointment to the ED at 9 Canadian children's hospitals. One hundred thirty-one physicians were surveyed, and 95 (72%) responded. The majority of respondents were pediatricians (68.1%) with a mean of 15.0 years of experience (SD, 6.8 years). Of those surveyed; 91 (97.8%) would use SDAC for a toxic ingestion presenting in less than 1 hour; 35 (36.8%) would use SDAC for a toxic ingestion presenting after 3 hours; 61 (64.9%) would use SDAC for a nontoxic exploratory ingestion presenting in less than 1 hour; and 29 (30.5%) would use SDAC for a mildly symptomatic intentional ingestion presenting at an unknown time. Eleven (11.7%) would use SDAC for an ingestion of a substance that does not adsorb to SDAC. There is variation in the use of SDAC among emergency physicians working in Canadian pediatric EDs. This variation suggests that optimal management is not clear and that continued education and research are required.

Application of pharmacokinetic-pharmacodynamic modelling in management of QT abnormalities after citalopram overdose

To develop guidelines for the management of QT prolongation after citalopram overdose, including decontamination with single-dose activated charcoal (SDAC) and cardiac monitoring. Simulation study using a previously developed pharmacokinetic-pharmacodynamic (PKPD) model which predicted the time-course of QT prolongation and the effect of citalopram dose and use of SDAC on QT prolongation. The previously developed PKPD model was used to address the following in patients following citalopram overdose: (1) Above what dose should patients be decontaminated? (2) Above what dose should patients have cardiac monitoring? (3) For what period of time should patients be monitored? The primary outcome was QT,RR combinations above an abnormal threshold as a surrogate predictor of torsades de pointes. Simulations were performed using MATLAB for an overdose patient with typical demographics: 30-year-old female with a heart rate of 79 bpm taking citalopram therapeutically. The simulations showed: (1) There was significant benefit associated with the administration of SDAC to patients following citalopram overdose ingesting >600 mg; (2) With citalopram overdoses >1,000mg it was advisable to give SDAC and cardiac monitor the patient; (3) The risk of developing future abnormal QT,RR combinations was less than 1% in patients with normal QT,RR combinations up to 13 h post-dose, so the minimum monitoring time for citalopram overdoses >1,000mg should be 13h. Recommended dose levels for intervention should be lowered in older patients and patients with tachycardia, while men are less sensitive to QT prolongation. Guidelines for the management of QT prolongation after citalopram overdose were developed. We believe the model will help clinicians to decide which patients to decontaminate and monitor.

Single-dose activated charcoal-backup and reassess.

Single-dose activated charcoal (SDAC) is frequently administered to poisoned patients. The assumption is that toxin absorption is prevented and that toxicity (as defined by morbidity and mortality) of the poisoning is decreased. Yet there is no evidence that SDAC improves outcome. Risks of this procedure have not been determined. The reported adverse events following SDAC administration are reviewed and risk:benefit ratio for this procedure is discussed.