A 16 year old female is admitted to the ICU following a multiple drug overdose.
a)Outline the role of activated charcoal in the management of drug overdose.
b) What are the complications of activated charcoal therapy?
c) When is dialysis utilised in toxic syndromes?
d) In the context of an overdose, list 3 drugs for which charcoal haemoperfusion may be useful.
a) Outline the role of activated charcoal in the management of drug overdose.
• Single dose activated charcoal is generally preferred method of decontamination but does not improve outcome when applied to unselected patients and should not be regarded as routine.
• Indicated when likely that toxic agent is still within the GI tract (1st hour for most agents) and potential benefits outweigh risks.
b) What are the complications of activated charcoal therapy?
• Vomiting
• Pulmonary aspiration
• Direct administration to lung via misplaced NG tube (potentially fatal)
• Impaired absorption of oral medications / antidotes
• Corneal abrasions
• Constipation / bowel obstruction (MDAC)
c) When is dialysis utilised in toxic syndromes?
• Best if drug is:
• Water soluble
• MW <500
• Not highly protein bound
• Eg Lithium, Ethylene glycol, Salicylates, Na Valproate
• Also good for correcting fluid and electrolyte abnormalities
d) In the context of an overdose, list 3 drugs for which charcoal haemoperfusion may be useful.
• Common drugs carbamazepine, theophylline, paraquat
The rationale for multiple-dose charcoal is slightly different. It's not a matter of "just give more of it for more effect".
The following is a list of well-accepted indications for multiple dose activated charcoal (from Pierre Gaudrealt, 2005)
Drugs which are absorbed too rapidly
Drugs which do not adsorb on to charcoal
c)
Use of dialysis in toxicology:
d)
The website of the American Academ of Clinical Toxicology has several position statements which might be useful to the fellowship candidate:
Single-Dose Activated Charcoal
Gaudreault, Pierre. "Activated charcoal revisited." Clinical Pediatric Emergency Medicine 6.2 (2005): 76-80.
Andersen, A. Harrestrup. "Experimental Studies on the Pharmacology of Activated Charcoal. III. Adsorption from Gastro‐Intestinal Contents." Acta Pharmacologica et Toxicologica 4.3‐4 (1948): 275-284.
Krenzelok, Edward P. "New developments in the therapy of intoxications." Toxicology letters 127.1 (2002): 299-305.
Eddleston, Michael, et al. "Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial." The Lancet 371.9612 (2008): 579-587.
Isbister, Geoffrey K., and Venkata V. Pavan Kumar. "Indications for single-dose activated charcoal administration in acute overdose." Current opinion in critical care 17.4 (2011): 351-357.
Chyka, P. A., and D. Seger. "Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists." Journal of toxicology. Clinical toxicology 35.7 (1996): 721-741.
Harris, Carson R., and Dean Filandrinos. "Accidental administration of activated charcoal into the lung: aspiration by proxy." Annals of emergency medicine22.9 (1993): 1470-1473.
Chyka, P. A., and D. Seger. "Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists." Journal of toxicology. Clinical toxicology 35.7 (1996): 721-741.
Isbister, Geoffrey K., and Venkata V. Pavan Kumar. "Indications for single-dose activated charcoal administration in acute overdose." Current opinion in critical care 17.4 (2011): 351-357.
Harris, Carson R., and Dean Filandrinos. "Accidental administration of activated charcoal into the lung: aspiration by proxy." Annals of emergency medicine22.9 (1993): 1470-1473.
UpToDate has a nice table of drugs which are removed by haemoperfusion.
Nenov, Vesselin D., et al. "Current applications of plasmapheresis in clinical toxicology." Nephrology dialysis transplantation 18.suppl 5 (2003): v56-v58.
Holubek, William J., et al. "Use of hemodialysis and hemoperfusion in poisoned patients." Kidney international 74.10 (2008): 1327-1334.
Ghannoum, Marc, et al. "Hemoperfusion for the treatment of poisoning: technology, determinants of poison clearance, and application in clinical practice." Seminars in dialysis. Vol. 27. No. 4. 2014.
Ghannoum, Marc, et al. "Blood purification in toxicology: nephrology’s ugly duckling." Advances in chronic kidney disease 18.3 (2011): 160-166.
Takki, S., et al. "Pharmacokinetic evaluation of hemodialysis in acute drug overdose." Journal of pharmacokinetics and biopharmaceutics 6.5 (1978): 427-442.