Toxicology - Charcoal (single dose)
Significant toxic ingestion within the last hour
Patient intubated or able to protect their own airway
Contraindications (absolute in bold)
Immediate resuscitation required
Unsuitable toxin (hydrocarbons, alcohols, metals, acids, alkalis)
Good outcome expected with supportive care and antidote therapy alone
Decreasing level of consciousness or risk of seizure (unless intubated)
Supportive care and antidote therapy
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
Less complex non-emergency procedure with low risk of complications
Vomiting (30% patients within the hour)
Impaired absorption of oral antidotes
Corneal abrasions (in the event of eye contact)
PPE: non-sterile gloves, aprons, protective eyewear
Acute bed or resuscitation bay (depending on conscious level, expected course and risk assessment)
Cup (if alert)
Nasogastric tube with position confirmed by X-ray (if intubated)
Sitting up or supine with head of bed elevated to at least 45 degrees
Activated charcoal 1g/kg to a maximum of 50g
250ml sterile water (for mixing with charcoal)
Place nasogastric tube (if intubated or unable to swallow solution)
Confirming nasogastric position with chest X-ray
Mix with charcoal with 250ml sterile water
Shake mixture vigorously
Administer orally (if conscious and co-operative) or via nasogastric tube (if intubated)
Toxicology discussion (call poisons information on 13 11 26)
Supportive care and monitoring
Maintain head up positioning and observe for vomiting (do not repeat dosing if vomiting occurs)
Always confirm nasogastric position with an X-ray prior to administration of activated charcoal
Larger doses or multi-dose activated charcoal is recommended for certain toxins
Activated charcoal is rarely indicated in children (discussion with a toxicologist is recommended)
Mixing with ice cream improves palatability for children
Charcoal has an important role in patients presenting shortly after ingestion of highly lethal drugs. However, its routine administration following oral overdose does not show evidence of benefit and is not recommended.
The current consensus is to use activated charcoal in significant poisonings when it is expected there is drug still in the upper gastrointestinal tract, so long as the risk versus benefit is considered. For most overdoses, this is within one hour of the estimated time of ingestion. Patients must be able to protect their airway or be intubated. Use should be cautioned when rapid deterioration in conscious state is expected or there is a significant chance of seizures.
Risk-benefit analysis rarely justify administration of activated charcoal to the uncooperative conscious patient.
Passing a nasogastric tube in such patients increases the chances of tube misplacement, trauma and emesis and is not recommended. Charcoal aspiration has the potential to be fatal. Only in very rare circumstances does the risk assessment justify intubation specifically for the purposes of facilitating administration of charcoal. Discussion of such cases with a toxicologist is recommended.
After intubation, it is reasonable to routinely administer oral activate charcoal to patients who have ingested pharmaceutical agents. The risk-benefit analysis in this case is almost always in favour of administration.
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
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Royal Melbourne Children’s Hospital Clinical Guideline: Use of activated charcoal in poisonings
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