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Toxicology - Charcoal (single dose)

Indications

Significant toxic ingestion within the last hour

and

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

Uncooperative patient

Decreasing level of consciousness or risk of seizure (unless intubated)

Alternatives

Supportive care and antidote therapy

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Vomiting (30% patients within the hour)

Pulmonary aspiration

Impaired absorption of oral antidotes

Corneal abrasions (in the event of eye contact)

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, aprons, protective eyewear

Area

Acute bed or resuscitation bay (depending on conscious level, expected course and risk assessment)

Staff

Procedural clinician

Equipment

Cup (if alert)

Nasogastric tube with position confirmed by X-ray (if intubated)

Positioning

Sitting up or supine with head of bed elevated to at least 45 degrees

Medication

Activated charcoal 1g/kg to a maximum of 50g

250ml sterile water (for mixing with charcoal)

Sequence

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)

Post-procedure care

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)

Tips

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

Discussion

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.

Peer review

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.

References

Murray L, Little M, Pascu O, Hoggett KA. Toxicology handbook. 3rd ed. Sydney: Elsevier Australia; 2015.

eTG complete. Melbourne: Therapeutic Guidelines; 2012 Jul (updated 2018 Jul). Toxicology: general approach. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=toxicology-general-approach

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Royal Melbourne Children’s Hospital Clinical Guideline: Use of activated charcoal in poisonings

Hendrickson RG, Kusin S. Gastrointestinal decontamination of the poisoned patient. In: UpToDate. Waltham (MA): UpToDate. 2019 Mar 15. Retrieved Apr 2019. Available from: https://www.uptodate.com/contents/gastrointestinal-decontamination-of-the-poisoned-patient

Juurlink DN. Activated charcoal for acute overdose: a reappraisal. Br J Clin Pharmacol. 2016;81(3):482-487. doi:10.1111/bcp.12793

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. doi:10.1081/clt-200051867

Cooper GM, Le Couteur DG, Richardson D, Buckley NA. A randomized clinical trial of activated charcoal for the routine management of oral drug overdose. QJM. 2005;98(9):655-660. doi:10.1093/qjmed/hci102

Isbister GK, Kumar VV. Indications for single-dose activated charcoal administration in acute overdose. Curr Opin Crit Care. 2011;17(4):351-357. doi:10.1097/MCC.0b013e328348bf59

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