Activated Charcoal: The Next EMS Myth?

[JPINFV]

Summary

Background

The case-fatality for intentional self-poisoning in the rural developing world is 10–50-fold higher than that in industrialised countries, mostly because of the use of highly toxic pesticides and plants. We therefore aimed to assess whether routine treatment with multiple-dose activated charcoal, to interrupt enterovascular or enterohepatic circulations, offers benefit compared with no charcoal in such an environment.

Methods

We did an open-label, parallel group, randomised, controlled trial of six 50 g doses of activated charcoal at 4-h intervals versus no charcoal versus one 50 g dose of activated charcoal in three Sri Lankan hospitals. 4632 patients were randomised to receive no charcoal (n=1554), one dose of charcoal (n=1545), or six doses of charcoal (n=1533); outcomes were available for 4629 patients. 2338 (51%) individuals had ingested pesticides, whereas 1647 (36%) had ingested yellow oleander (Thevetia peruviana) seeds. Mortality was the primary outcome measure. Analysis was by intention to treat. The trial is registered with controlled-trials.com as ISRCTN02920054.

Findings

Mortality did not differ between the groups. 97 (6·3%) of 1531 participants in the multiple-dose group died, compared with 105 (6·8%) of 1554 in the no charcoal group (adjusted odds ratio 0·96, 95% CI 0·70–1·33). No differences were noted for patients who took particular poisons, were severely ill on admission, or who presented early.

Interpretation

We cannot recommend the routine use of multiple-dose activated charcoal in rural Asia Pacific; although further studies of early charcoal administration might be useful, effective affordable treatments are urgently needed.

Eddleston, M., Juszczak, et al. "Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial." The Lancet. 2008: 371: 579-587

http://www.thelancet.com/journals/lancet/article/PIIS0140673608602706/abstract

 

[MikeRi24]

We do not even carry it on our rigs anymore and are taught not to use it under any circumstances.

 

[Ridryder911]

I wonder about the study? Why would one want to adsorb (delay) poison especially insecticides/ petroleum based? Personally, I would not use A.C. on those types of poison anyway.

Activated charcoal has a place but it must be the type with Sorbital included into it. (Which most EMS does not carry) Otherwise, it will sit in the gut and still be distributed systemically. Yes, it is found not to be needed in many cases but there are a few that poison control still advises it as treatment especially for those that had just ingested such as medications, again the sorbital (causes it be expelled through feces, rapidly).

R/r 911

 

[BossyCow]

In my experience it doesn't 'sit in the gut' so much as erupt out forcefully all over whatever piece of equipment is hardest to clean.

 

[firecoins]

I have seen the use of activated charcoal with sorbitol by an MD in a major NYC ER a couple of months ago for a patient who ODed on medications. It worked. Clearly it must a have a place.

 

[MikeRi24]

In my experience it doesn't 'sit in the gut' so much as erupt out forcefully all over whatever piece of equipment is hardest to clean.

lol. supposedly, its supposed to take whatever is in there and 'encase it' so that it can't be absorbed in the stomach. We were taught that it doesn't do a good job of 'encasing' the big chunks which have to be vomited out. my understanding of it is, that its kinda contradicted since the person has to vomit anyway and you would think that would get most of it out. so basically, you or something near you is getting vomited on either way. or you could be like the person we had the other day and politely wait to vomit until we got to the ED and then proceeded to do so all over the floor.

 

[rgnoon]

I wonder about the study? Why would one want to adsorb (delay) poison especially insecticides/ petroleum based? Personally, I would not use A.C. on those types of poison anyway.

Activated charcoal has a place but it must be the type with Sorbital included into it. (Which most EMS does not carry) Otherwise, it will sit in the gut and still be distributed systemically. Yes, it is found not to be needed in many cases but there are a few that poison control still advises it as treatment especially for those that had just ingested such as medications, again the sorbital (causes it be expelled through feces, rapidly).

R/r 911

Upon doing a little reading I've realized that this is the same sorbitol used as a sweetener in many sugar-free gums, although it is being used less frequently as xylitol becomes more popular. I knew that I knew of sorbitol from SOMEWHERE, now I realize that it was just from the Trident label.

...The more you know!!!


P.S....don't swallow your gum!

 

[LucidResq]

I've heard a lot of skepticism about activated charcoal, and it is not in my SAR team's protocols at all due to the limited uses for it and weight issues.

I do believe that AC is not critical per se, but from what I have heard it is definitely effective in several situations.

Also, this study shouldn't cause one to disregard the use of AC at all. Although the sample size is decent and the design is fairly solid, it still has major limitations. Namely, 87% of the poisons involved were either pesticides or yellow oleander seeds. What about the countless other poisonous substances that people ingest every day? Also, although the difference may be slight or nonexistant, this study seems to relate to hospital use of AC, not prehospital use.

 

[jaron]

Just to throw my two cents in. I'm currently working in an ER and we have used AC twice this week. Both times were used on pt's of med overdoses. In both cases we also mechanically evacuated the stomach before the AC went in. Good results all around.