Toxicology Pearls – Active Charcoal – Infographic

Emergency Indications

• Oral intake < 60 minutes
• the life-threatening dose of the toxic substance

Multi-Dose Activated Charcoal (MDAC) Indications

• Life-Threatening Oral Intake of
  • Carbamazepine
  • Dapsone
  • Phenobarbital
  • Quinine
  • Theophylline

Contraindications

• For patients with compromised airway reflexes, unless they are intubated. If the critical situation of the patient indicates intubation, then, gastric lavage may be performed. Intubation, only for decontamination, is not recommended.
• Oral intake of caustic substances
• Late presentation
• Increased risk and severity of aspiration associated with AC use (e.g., hydrocarbon ingestion)
• Need for endoscopy (e.g., significant caustic ingestion)
• Toxins poorly adsorbed by AC (e.g., metals including iron and lithium, alkali, mineral acids, alcohols)
• Presence of intestinal obstruction (absolute contraindication) or concern for decreased peristalsis (relative contraindication)

Equipment and Patient Preparation

There is no specific equipment for activated charcoal administration. However, drinking the charcoal can be very unpleasant for many patients, especially children. Therefore, mixing with fruit juice can be an option. In addition, if necessary nasogastric or orogastric tube placement can facilitate the active charcoal treatment.

Procedure steps

• Recommended empirical single-dose of activated charcoal is as follows:
  • <1 year – 0.5-1 g/kg or 10-25 g
  • 1-12 years – 0.5-1 g/kg or 25-50 g
  • >12 years – 1-2 g/kg or 25-100 g

• Multidose activated charcoal
  • Give the recurrent dose of charcoal by 0.5 g/kg (≤50 g) every 4 hours
• How to administer:
  • If the patient is awake and cooperative, AC may be given orally. Alternatively, it may be given by gastric or nasogastric tube, if these procedures are indicated.
  • Mixing the activated charcoal with fruit juices increases tolerability.
  • If the patient is unconscious or airway is compromised, gastric lavage should be done, and activated charcoal should be given after intubation. Tracheal intubation is not recommended solely in order to give activated charcoal. Only activated charcoal is to be given, the nasogastric tube is adequate and is preferred.
  • If MDAC is indicated, the gastric tube should be withdrawn after gastric lavage and the first dose of activated charcoal. Further doses should be given via nasogastric tube.

Hints and Pitfalls

• The substances that cannot bind to activated charcoal are as follows:
  • Lithium
  • Strong acids and bases
  • Metals and inorganic minerals
  • Alcohols
  • Hydrocarbons
• Multi-dose activated charcoal enhances elimination of (But not necessarily indicated in all)
  • Amitriptyline
  • Aspirin
  • Caffeine
  • Carbamazepine
  • Cyclosporine
  • Dapsone
  • Digoxin
  • Disopyramide
  • Nadolol
  • Phenobarbital
  • Phenytoin
  • Piroxicam
  • Quinine
  • Sotalol
  • Sustained-release thallium
  • Theophylline
  • Valproate
  • Vancomycin
• MDAC increase the risk of constipation and bowel obstruction in some cases. Therefore, consider adding a cathartic agent to the second or third dose of AC.

Post Procedure Care and Recommendations

• Control possible nausea and vomiting.
• Look for traces of aspiration or gastrointestinal complications.

Complications

Complications of AC and MDAC include:

• Constipation, diarrhea, vomiting
• Pulmonary aspiration

Pediatric, Geriatric, and Pregnant Patient Considerations

• In pediatric and geriatric patients, extra caution should be exercised to avoid and monitor complications.
• Activated charcoal is considered safe for pregnant women.