Do not give charcoal for iron, alcohol, or lithium ingestions - it is ineffective
Do not give charcoal for iron, alcohol, or lithium ingestions - it is ineffective: Excerpt from Avoiding Common Pediatric Errors
Author:
Craig DeWolfe, MD
What to Do - Interpret the Data,
Make a Decision, Take Action
Activated charcoal is the best proven technique for eliminating most toxic
ingestions. Charcoal's large surface area adsorbs poisons and reduces the
amount of free agent available for absorption by means of van der Waals
forces and covalent binding. Up to 75% of the toxin may be eliminated
when a dose of 1 g of charcoal per kg is given in the first hour of ingestion
and repeated every 4 hours as needed. It is especially effective in enhancing
the elimination of theophylline, phenobarbital, and carbamazepine, as it can
decrease thereabsorptionof thesedrugsasthey movethroughthegutduring
enterohepatic recirculation, but charcoal is not indicated in all ingestions.
It should be used based only on its efficacy for a specific toxin, the toxicity
of the ingestion, the elapsed time from ingestion, and individual patient
characteristicssuchastheircooperation,levelofconsciousness,andpresence
of vomiting.
There are several significant risks associated with charcoal administration. If it is vomited, which occurs in 15% of treated patients, and then
aspirated, it can result in pneumothorax, empyema, pulmonary parenchymal injury, or bronchiolitis obliterans. If charcoal is inadvertently instilled
in the lungs through a misplaced orogastric or nasogastric tube, it can result
in death.
Importantly, charcoal is ineffective in adsorbing or eliminating alcohols, hydrocarbons, metals, and minerals. Specifically, it should not be used
to treat iron, alcohol, lithium, or magnesium ingestions, as the risk far exceeds any benefit. In fact, during the period of 1995 to 1998, more children died from the administration of activated charcoal than the ingestion
of alcohol, lithium, or magnesium. Only iron was associated with more
deaths.
Although the evidence is limited due to the lack of clinical trials and the
limitsofcasereportsandanimalandhumanvolunteermodels,therearetechniques available to reducethe toxicity of iron, alcohol, andlithium overdoses.
Treatment may include any combination of supportive care, whole-bowel
irrigation, chelation agents, and hemodialysis. In any ingestion, consult the
poison control center for specific recommendations.
Lithium toxicity may occur with acute, acute on chronic, or chronic
ingestions. The patient may present with gastrointestinal symptoms before
tissue distribution causes other central nervous system symptoms. Manifestations include tremor, clonus, agitation, lethargy, delirium, seizures, coma,
myocardial dysfunction, and arrhythmia. If ingestion is suspected, a blood
lithium level should be assessed on presentation and 2 hours later to evaluate for increasing levels. Whole-bowel irrigation is the treatment of choice,
as charcoal is ineffective. Large volumes of polyethylene glycol electrolyte
solution should be administered until the rectal effluent is clear. Often a
nasogastric tube needs to be placed, the head of bed positioned at 45 degrees
to decrease the likelihood of vomiting and aspiration, and the airway protected in patients with a depressed level of consciousness. In patients who
have renal dysfunction, severe neurologic dysfunction, and lithium concentrations >=4 mEq/L in an acute ingestion or >=2.5 mEq/L in a chronic
ingestion, hemodialysis should be considered. Redistribution between intraandextracellular compartmentsnecessitatesrepeatedandprolongeddialysis
sessions.
Acute iron poisonings are one of the most common pediatric ingestions
and are associated with the greatest risk of death. Throughout the 1980s
and 1990s, iron ingestions accounted for 2% of the total number of poisonings in the United States. Toxic ingestions of 20 mg/kg of elemental
iron are associated with direct corrosive injury to the gastrointestinal mucosa and are commonly associated with fluid and blood losses leading to
shock. Ingestions >60 mg/kg of elemental iron often lead to hepatotoxicity, metabolic acidosis, coagulopathy, and cardiovascular collapse. If syrup of
ipecac is available at home, the patient may benefit from its use on the way
to the emergency department (ED). In the ED, the patient should be treated
with fluids and cardiovascular care. To determine the extent of poisoning,
the clinician should obtain iron levels in addition to blood gases, electrolytes,
liver function tests, and coagulation studies. Plain abdominal films should be
obtained to evaluate for radiopaque iron particles, which may be treated with
cathartics and whole-bowel irrigation. Finally, for iron levels >500 µg/dL
or for evidence of systemic toxicity with lower iron levels, deferoxamine is
the iron-chelating agent of choice. The intravenous route of deferoxamine
is preferred and is generally dosed at 15 mg/kg/hour over 8 to 24 hours,
depending on the extent of toxicity.
Children can ingest excessive alcohol form beverages, elixirs, and
personal care products, such as mouthwash and aftershave. Manifestations include hypoglycemia, central nervous system depression, respiratory depression, hypotension, and death. The health care provider should
evaluate the patient with a measurement of serum electrolytes, glucose, and
a blood ethanol level, in addition to a more broad-spectrum drug screen in
appropriate circumstances. Management is primarily supportive. The clinician should provide parenteral fluids while correcting any hypoglycemia and
electrolyte disruptions. Airway management is important in the obtunded
patient with emesis or in a patient with respiratory depression.
In summary, activated charcoal is an important and useful agent in the
treatmentofmosttoxicingestions.Alcohol,hydrocarbon,metal,andmineral
ingestions are an important exception to this rule and will not benefit from
charcoal administration. Rather, toxin-specific treatments are indicated with
the guidance of a toxicologist or poison control center.
Suggested Readings
McGuigan MA. Acute iron poisoning. Pediatr. Ann. 1996;25:33–38.
McGuigan ME. Poisoning potpourri. Pediatr Rev. 2001;22:295–302.
Shannon M. Primary care: ingestion of toxic substances by children. N Engl J Med.
2000;342:186–191.
Zimmerman JL. Poisonings and overdoses in the intensive care unit: general and specific management issues. Crit Care Med. 2003;31:2794–2801.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Fetal alcohol syndrome
More Medical Textbooks Online about Fetal alcohol syndrome
Review other book chapters online related to Fetal alcohol syndrome:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
|
|
» Next page: Measure growth patterns at eachwell-child visit and each health care encounter (Avoiding Common Pediatric Errors)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
