What is the place of decontamination with activated charcoal in drug overdose? In several emergency departments where I have previously worked, it was common practice to administer this in most cases of overdose. However, since working at my current location, poison control never recommends this. What is the current evidence-based recommendation?
Harvey Solomon, MD
Response from Desiree Lie, MD, MSEd
Multiple-dose activated charcoal involves the administration of more than 2 doses of oral activated charcoal to enhance elimination of drugs ingested in acute poisoning. The rationale is that charcoal interrupts the enteroenteric, enterogastric, and enterohepatic circulation of absorbed drugs, whereas unabsorbed drugs will be adsorbed to activated charcoal. The charcoal is prepared from vegetable matter such as peat, wood, coal, or coconut shell. It is then activated by high heat in oxidizing gas, such as steam or carbon dioxide, that increases its surface area to at least 900 m2/g to meet industry standards.
The optimal dose of charcoal is unknown. However, the adult dose ranges from 50 to 100 g per dose, administered at a rate no less than 12.5 g/h or its equivalent. Lower doses of 10-25 g are used in children. When drug-induced vomiting is anticipated (for example, with a theophylline overdose), an intravenous antiemetic is recommended.
Although treatment with charcoal is perceived as simple, inexpensive, and safe and avoids the need for invasive procedures, such as hemodialysis and hemoperfusion, the rationale for use is based primarily on animal studies. Most of the clinical data are based on anecdotal case reports, case series, or observational and crossover volunteer human studies, with 6-10 participants per study. Larger, randomized controlled trials are needed, but conducting such studies are challenged by ethical and methodologic limitations and considerations.
Recommendations for activated charcoal in acute ingestions are provided in the position statement of the American Academy of Clinical Toxicology and European Association of Poison Centres and Clinical Toxicologists. A 1997 statement on single-dose activated charcoal was supplemented by the most recent 1999 statement on multidose activated charcoal.
Core recommendations are summarized as follows:
Absolute contraindications include unprotected airway, intestinal obstruction, a gastrointestinal tract that is not intact, and decreased peristalsis. Potential complications include transient constipation (especially in nonambulatory patients), bowel obstruction, regurgitation, and aspiration, with consequent pulmonary complications (including death) if the nasogastric tube is incorrectly placed. Emesis is more frequent with sorbitol administration and less frequent with aqueous activated charcoal.
In summary, physicians should base the clinical decision to use activated charcoal for acute ingestions on best judgment according to available evidence the presence of contraindications, and the effectiveness and availability of alternative treatment.
Medscape Family Medicine. 2004;6(1) © 2004 Medscape
Cite this: Desiree Lie. Use of Activated Charcoal in Drug Overdose - Medscape - Mar 25, 2004.