Activated Charcoal

1. Indications
   1. Patient presents within 1 to 2 hours of a potentially toxic ingestion
   2. Most effective against large and organic molecules and those with poor water solububility
   3. Overdose or Toxin Ingestion
      1. Antidepressants
      2. Aspirin
      3. Aminophylline
      4. Barbiturates
      5. Carbamazepine
      6. Digitalis
      7. Dilantin
      8. Dapsone
   4. Consider multidose Activated Charcoal with agents that undergo enterohepatic reabsorption
      1. Carbamazepine
      2. Theophylline
      3. Phenobarbital
      4. Dapsone
      5. Quinine
2. Precautions
   1. Patient must be low risk for aspiration
      1. Intact mental status or
      2. Advanced Airway with Gastric Tube (or similar protected airway)
   2. Many consumer products now contain Activated Charcoal (e.g. toothpaste, cleansers, supplements)
      1. No significant evidence of benefit in these marketed products
      2. Risk of binding and inactivating prescribed medications
      3. May also cause Constipation, skin irritation, Dental Erosions
      4. (2018) Presc Lett 25(12): 70
3. Advantages
   1. Few side effects
   2. Most effective method for Unknown Ingestion
4. Contraindications
   1. Decreased Level of Consciousness
   2. Increased risk of Gastrointestinal Bleeding or perforation
   3. Substances for which charcoal is ineffective or risk of aspiration
      1. Mnemonic: CHIME
         1. Caustics or corrosives
         2. Hydrocarbons
         3. Iron
         4. Metals (including Lithium) or Methanol
         5. Ethylene Glycol or Ethanol
         6. Tomaszewski (2016) Household Toxins Lecture, ACEP PEM Conference, Orlando, attended 3/8/2016
      2. Contraindicated agents
         1. Pesticides
         2. Hydrocarbons
         3. Alcohols
         4. Acids
         5. Alkalis
         6. Iron
         7. Lithium
         8. Solvents (e.g. household cleansers)
5. Complications
   1. Intestinal Obstruction
   2. Aspiration Pneumonitis
6. Safety
   1. See precautions above
   2. Multiple charcoal doses are safe with rare complication (in a patient controlling their airway)
      1. Dorrington (2003) Ann Emerg Med 41:370-7 [PubMed]
7. Dosing
   1. Dose
      1. Adult: 25 to 100 grams in 300 to 800 ml water
      2. Child (age 1 to 12 years): 0.3-1.0 g/kg (up to 25-50 grams) in 300 ml water
      3. Child (age <1 year): 0.5 to 1 g/kg (up to 10-25 grams)
   2. May repeat dose every 2-4 hours if bowel sounds present
   3. Additional measures
      1. May be used with Sorbitol 1-2 grams/kg
      2. Consider concurrent use of Antiemetic suppository
      3. Consider administering via Nasogastric Tube
8. References
   1. Chyka (2005) Clin Toxicol 43(2): 61-87 [PubMed]