# Activated charcoal not so active anymore



## CoffeeInThatNebula (Feb 23, 2011)

We were going through general pharmacology in my EMT-B class today and my instructor informed us that the department is getting rid of activated charcoal.  Is this something going on nationwide?  I mean, I understand it's gross, but does anyone know why this is happening for any reason other than that?  I would've thought they'd at least find a replacement for it, but apparently they haven't.  

Once it's gone, what will be procedure for poisoned and OD patients?  Just get 'em to the hospital as fast as possible?


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## Shishkabob (Feb 23, 2011)

I don't know of any agency around here who has had charcoal for years.  I've only seen it used on a handful of patients in the ED, as well.


Reason it's going bye bye from EMS is, just like ipecac, most people don't know when or when not to use it, and when it'd be beneficial.  


The procedure is do an OG/NG tube, suction out what you can, and get them to the hospital for possible dialysis, charcoal administration there, or any other number of things.


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## lampnyter (Feb 23, 2011)

We have charcoal on our trucks. Only used it a few times though. Mix it with milk and they down it like a shake lol.


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## CoffeeInThatNebula (Feb 23, 2011)

Linuss said:


> I don't know of any agency around here who has had charcoal for years.  I've only seen it used on a handful of patients in the ED, as well.
> 
> 
> Reason it's going bye bye from EMS is, just like ipecac, most people don't know when or when not to use it, and when it'd be beneficial.
> ...



Ah, that makes sense.  Our region doesn't have PASGs for similar reasons.  No one used them much and when they did, no one had a clue how to use them since they didn't do much training on them.  They're working on getting those back though, apparently they work very well for those pesky pelvic injuries.


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## Cohn (Feb 23, 2011)

We got charcoal, I don't know where you are getting that it's gross, ever taste it? It's not that bad.


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## vquintessence (Feb 23, 2011)

We've carried charcoal going back quite a ways now, and like some have said, it's not used that often.  For us, statewide, it requires a medical consultation.

Removing something because "It's not used often and people forget" is a pretty asinine reason.  Hell, on that line of thought lets remove NG/OG insertions and intubation for any medics doing less than 15 a year.  I'm certain that people will spend the extra time keeping those skills fresh w/ con ed and practice, as opposed to remembering/relearning situations when (and when not) to administer a cup of mud.


Citing several studies done in late 70's & 80's, many of them suggest the timeframe to achieve the *BEST* results for parenteral toxicological emergencies using activated charcoal, is to give the drug (with or without lavage is debatable) within 30min to 2hrs of ingestion of the toxins.  One study even suggested a positive effect within 4 hrs of ingestion.

Sure, many of our PO toxicological emergencies don't present themselves within that timeframe.  However for those that do, or are on the cusp, does it not serve the pt to administer a treatment following a thorough assessment and a consultation w/ poison and/or med control?


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014891/

http://www.ncbi.nlm.nih.gov/pubmed/10417490

http://www.ncbi.nlm.nih.gov/pubmed/7109006
(this last link disputes the efficacy of charcoal following prolonged ingestion periods)


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## Aidey (Feb 23, 2011)

I've used it...4-5 times? In 3 of those I was told the charcoal had a direct affect on the patient. They were citalopram, Klonipin, and Tylenol. In the Tylenol case the pts APAP levels never reached the predicted level (under 100lbs, took ~19 grams). In the Klonipin case she didn't need to be intubated, and in the citalopram case the patient's seizures were less severe than expected. 

In all of those cases the charcoal was administered very shortly after patient contact, and all of the cases had been witnessed ODs that were called in immediately.


I also learned that giving the patient Zofran along with the charcoal will result in the ER MDs thanking you for being proactive and thinking of the patient. Who knew.


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## TransportJockey (Feb 23, 2011)

CHarcoal for APAP OD? I've always been taught not to give it so the ED can give Mucamyst IV...


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## CoffeeInThatNebula (Feb 23, 2011)

vquintessence said:


> We've carried charcoal going back quite a ways now, and like some have said, it's not used that often.  For us, statewide, it requires a medical consultation.
> 
> Removing something because "It's not used often and people forget" is a pretty asinine reason.  Hell, on that line of thought lets remove NG/OG insertions and intubation for any medics doing less than 15 a year.  I'm certain that people will spend the extra time keeping those skills fresh w/ con ed and practice, as opposed to remembering/relearning situations when (and when not) to administer a cup of mud.
> 
> ...



I agree with you on the reasons.  However, I think it's more of a speed and time issue in this case, since, at least with the PASG here, medics took so long trying to figure out how to get the pants on the patient that by the time they figured it out, they could've been in the ED.  Also, this is probably their way of cutting spending since that appears to be a theme right now.

As far as the taste, I've never tasted charcoal, I'm only basing that it's gross from what my teacher said.


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## Aidey (Feb 23, 2011)

jtpaintball70 said:


> CHarcoal for APAP OD? I've always been taught not to give it so the ED can give Mucamyst IV...



I have never heard that. How would the PO charcoal affect the IV Acetylcysteine ?


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## Cohn (Feb 23, 2011)

CoffeeInThatNebula said:


> I agree with you on the reasons.  However, I think it's more of a speed and time issue in this case, since, at least with the PASG here, medics took so long trying to figure out how to get the pants on the patient that by the time they figured it out, they could've been in the ED.  Also, this is probably their way of cutting spending since that appears to be a theme right now.
> 
> As far as the taste, I've never tasted charcoal, I'm only basing that it's gross from what my teacher said.



Take it out and taste it... It wont hurt ya if you just taste a little, it's really not that bad...


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## usafmedic45 (Feb 23, 2011)

> so the ED can give Mucamyst IV



Why would an oral drug impair an IV drug?   You mean that so they can give Mucomyst orally right?  (I've never seen it given IV in the US; it's most often given orally).


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## TransportJockey (Feb 23, 2011)

usafmedic45 said:


> Why would an oral drug impair an IV drug?   You mean that so they can give Mucomyst orally right?  (I've never seen it given IV in the US; it's most often given orally).



That might be where it came from, but while working as an ED tech and doing clinical shifts in an ED, I've seen it given IV many times. In fact my old hospital preferred to give it IV over PO. I'm reading up on why charcoal would affect it when given IV though. From what I AM finding out, PO and IV Mucamyst both work equally well for APAP OD.


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## 8jimi8 (Feb 23, 2011)

jtpaintball70 said:


> That might be where it came from, but while working as an ED tech and doing clinical shifts in an ED, I've seen it given IV many times. In fact my old hospital preferred to give it IV over PO. I'm reading up on why charcoal would affect it when given IV though. From what I AM finding out, PO and IV Mucamyst both work equally well for APAP OD.




I've given mucomyst IV quite a few times.  More times for liver protection, rather than for APAP overdose.  For contrast MRI i think, cant have taken metformin in 24 or 48 hours and must receive IV mucomyst prior to the examination.  (could have been for contrast ct tho, for some reason i always confuse CT and MRI in my head... especially since i'm not looking at the protocol...)


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## Aidey (Feb 23, 2011)

I've only ever heard of it being given IV. In fact, I specifically remember being told that IV access was a priority in APAP ODs because of the antidote. 

Looking at the info it looks like it works PO, but it doesn't taste very good and tends to make people nauseous. Maybe the preference is dependent on how big the OD is?


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## 8jimi8 (Feb 23, 2011)

Aidey said:


> I've only ever heard of it being given IV. In fact, I specifically remember being told that IV access was a priority in APAP ODs because of the antidote.
> 
> Looking at the info it looks like it works PO, but it doesn't taste very good and tends to make people nauseous. Maybe the preference is dependent on how big the OD is?



Mucomyst works as a prophylactic agent.  I would postulate that IV administration is more efficacious than PO, especially considering that PO must go through digestion and the first pass effect.  I've also heard that it has a very sulphur -like odor and taste. Give it with a straw if you give it orally.


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## Aidey (Feb 23, 2011)

Call me crazy, but it seems like giving IV would just be better in general. More consistent absorption, quicker onset, no chance of being affected by charcoal (for which there is plenty of evidence showing it is helpful in APAP ODs), and you aren't making your patient choke down another nasty thing after you made them drink the charcoal. 


Speaking of, I think the problem with the charcoal is not just the taste, but also the volume and texture.


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## 8jimi8 (Feb 23, 2011)

Aidey said:


> Call me crazy, but it seems like giving IV would just be better in general. More consistent absorption, quicker onset, no chance of being affected by charcoal (for which there is plenty of evidence showing it is helpful in APAP ODs), and you aren't making your patient choke down another nasty thing after you made them drink the charcoal.
> 
> 
> Speaking of, I think the problem with the charcoal is not just the taste, but also the volume and texture.




I won't call you crazy, as usual, I agree with you


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## tao (Feb 23, 2011)

EMT-B's in my area aren't allowed to administer charcoal.  I's and up can, but they also have more pharmacology training.

As for me, I don't think I've ever used it.  



Cohn said:


> Take it out and taste it... It wont hurt ya if you just taste a little, it's really not that bad...



No thanks.  Just looking at the stuff makes me gag.


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## Enforcer400 (Feb 23, 2011)

In Mass we have to contact medcon to administer activated charcoal. I think that the distance that the PT has to be transported to the hospital depends on whether or not the PT gets the shake or not. At least where I am by the time we contact medcon and administer the activated charcoal the PT could be at the ED.


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## CoffeeInThatNebula (Feb 23, 2011)

Cohn said:


> Take it out and taste it... It wont hurt ya if you just taste a little, it's really not that bad...



The charcoal we got to look at in class was expired so I wasn't allowed...:sad:

We're still supposed to learn about activated charcoal since the book and exam still have it in there, but before I think we had to contact the MD in order to actually administer it.  

I don't think it's possible, but I suggested that they just make charcoal taste like apples...or something...


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## Veneficus (Feb 23, 2011)

jtpaintball70 said:


> CHarcoal for APAP OD? I've always been taught not to give it so the ED can give Mucamyst IV...



Really? I was always told mucamyst was basically long the lines of what to use when the timeline for charcol was past


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## usafmedic45 (Feb 23, 2011)

Ah....all the vials I've ever seen of the stuff state on it "Not for intravenous injection" and used to be it wasn't FDA approved in the US for that route.  Never bothered to look into it further since it's not part of my job.


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## zmedic (Feb 23, 2011)

Okay, couple of things:

There is pretty much no real evidence that activated charcoal prevents mortality. It makes sense theoretically but it hasn't really been born out in practice. 

The reason is is going away is because if the person has taken something that reduces their level of conciousness and they aspirate the charcoal, it is very very bad. People have died of it, and often in cases where the ingestion itself probably wouldn't have killed them. 

So you have a treatment of limited use, that can be very dangerous. Especially since the people who are at the greatest risk of dying (ie large ingestion, unconcious) are at the biggest risk. 

Also a large number of ingestions won't kill people. Opioids? Give Narcan. Benzos? Intubate and wait. Tylenol? NAC. Caustics like acid? Don't give charcoal anyway. 

So the question is what are these ingestions that you think this will make a difference? 

Activated charcoal is only appropriate in my book for a recent ingestion of a potentially life threatening substance, in an awake and cooperative patient who you have low suspicion that they will have a deterioration in mental status. Which describes almost no one.  

To N-Acytlcystien. You can give it IV or PO. PO tastes bad. Also even though PO is "cheaper" it's a much longer course. (I think PO is like a 72 hour course), where IV they can often be done in 21 hours. So the IV ends ip being cheaper overall because they spend less time in the hospital. 

IV is better in my opinion because of that.


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## Veneficus (Feb 23, 2011)

zmedic said:


> Activated charcoal is only appropriate in my book for a recent ingestion of a potentially life threatening substance, in an awake and cooperative patient who you have low suspicion that they will have a deterioration in mental status. Which describes almost no one.


 
The only people I have seen charcoal given to usually meet that description and are most commonly teenage female suicide attempts with a variety of various substances. 

If not given as an NG lavage, they usually vomit immediately after drinking it from a cup and seem to feel better. (I would think most likely becase of the vomiting rather than the charcoal) But if you suction it out the NG, I stipulate at least the benefits of a lavage can be gained.


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## zmedic (Feb 23, 2011)

I know people who advocate against putting it down the NG tube. It's a big mess, the patient is gagging. And they feel like you are at higher risk of aspirating once you start going with an NG tube. 

They are also not big fans of the lavage.


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## Veneficus (Feb 23, 2011)

zmedic said:


> I know people who advocate against putting it down the NG tube. It's a big mess,



Absolutely it is.



zmedic said:


> the patient is gagging. And they feel like you are at higher risk of aspirating once you start going with an NG tube.



That is what xylocaine is for. I swear, people in the US outside of anesthesia simply are too conservative to effectively chemically manage patients.


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## jgmedic (Feb 23, 2011)

Enforcer400 said:


> In Mass we have to contact medcon to administer activated charcoal. I think that the distance that the PT has to be transported to the hospital depends on whether or not the PT gets the shake or not. At least where I am by the time we contact medcon and administer the activated charcoal the PT could be at the ED.



It's BHO only here too. I've given it twice in my 2 years as a medic, both with prescription med OD's less than an hour PTA.


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## xshellyx (Feb 23, 2011)

My partner and I gave charcoal to a teenage male OD on a call, kid downed it like a champ, and was even given a second one. He said it didn't taste bad at all....


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## TreySpooner65 (Feb 25, 2011)

CoffeeInThatNebula said:


> We were going through general pharmacology in my EMT-B class today and my instructor informed us that the department is getting rid of activated charcoal.  Is this something going on nationwide?  I mean, I understand it's gross, but does anyone know why this is happening for any reason other than that?  I would've thought they'd at least find a replacement for it, but apparently they haven't.
> 
> Once it's gone, what will be procedure for poisoned and OD patients?  Just get 'em to the hospital as fast as possible?



We have charcoal. Ive heard its getting phased out but no word on whats coming in yet


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## zmedic (Feb 25, 2011)

The procedure is going to be basic support of ABCs, monitor vital signs, and gather info at the scene (pill bottles, etc). 

Not much specific antidotes that have to be done quickly, maybe bicarb for aspirin ODs but truth is we don't see many of those, they are hard to diagnosis in the field, and those people really need a bicarb drip, an amp of bicarb isn't going to do it.


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