Zolpidem (Ambien): a pediatric case series

BACKGROUND: In 1993, the nonbenzodiazepine sedative-hypnotic zolpidem tartrate (Ambien) was approved for use in the US. Zolpidem has an imidazopyridine structure and possesses a rapid onset of action and a short half-life. The toxic threshold and profile have not been well established in the pediatric population. METHODS: All pediatric zolpidem exposures reported to a regional poison information center over 24 months were reviewed retrospectively from the American Association of Poison Control Centers Toxic Exposure Surveillance System data collection forms. RESULTS: Twelve pediatric zolpidem exposures were reported. Seven were unintentional (ages 20 mon-5 y) and five were intentional misuse/suicide (ages 12-16 y). The regional poison information center was contacted within 1 h in ten cases with onset of symptoms within 10 to 60 min (mean 31.6 min). One child had no effect with 2.5 mg. As little as 5 mg caused symptoms with minor outcome in six unintentional ingestions (5-30 mg). Minor to moderate symptoms were reported 1-4 h after intentional ingestions (12.5-150 mg). The duration of symptoms in the unintentional cases ranged from less than 60 min up to 4 h (mean 2.4 h) and 6-10 h (mean 7.5 h) in the intentional exposures. Treatment consisted of observation (4), syrup of ipecac (1), lavage and activated charcoal (1), activated charcoal alone (5), and unknown (1). CONCLUSION: Due to the very rapid onset of central nervous system symptoms in children, emesis is not a treatment option. Supportive care, activated charcoal in large ingestions, and observation until symptoms resolve may be sufficient in most pediatric cases.     

Activated charcoal supercedes ipecac as gastric decontaminant

Syrup of ipecacuanha has previously been used to decontaminate patients following toxic or potentially toxic ingestions. The recent removal of this product from distribution in New Zealand has caused some concern to health professionals. This article outlines the relative merits of syrup of ipecacuanha and activated charcoal, and concludes that the latter is preferable in many respects. Details of its appropriate administration are discussed.     

Cholestyramine as an adsorbent in acute lindane poisoning: a murine model

STUDY OBJECTIVES: To compare the effectiveness of single-dose cholestyramine versus single-dose activated charcoal in preventing clinical toxicity after acute lindane ingestion. DESIGN: CD-1 mice received lindane by enteral (gavage) and parenteral (intraperitoneal) routes, followed by enteral administration of either cholestyramine (2.25 g/kg) or activated charcoal (2.25 g/kg), with subsequent observation for convulsions and death. MEASUREMENTS: The doses of lindane at which 50% of mice developed convulsions (CD50) and at which 50% of mice died (LD50) were established and compared among control, charcoal-, and cholestyramine-treated groups. RESULTS: For lindane administered by gavage, the differences in the CD50 and LD50 between the control and the activated charcoal groups were not statistically significant. However, a significant difference did exist in both the CD50 and the LD50 between the group receiving cholestyramine and the control group and between the cholestyramine and activated charcoal groups. After IP administration of lindane, the difference in CD50 or LD50 among control, activated charcoal, or cholestyramine groups was not significantly different. CONCLUSION: In the murine model, cholestyramine is more effective than activated charcoal in preventing absorption of lindane, thus preventing convulsions and death. These data support the need for clinical studies to determine whether cholestyramine may be a more effective treatment than activated charcoal for acute lindane ingestions in human beings.     

Approach to the poisoned patient

Routine poison management involves the following: (1) stabilization, (2) toxidrome recognition, (3) decontamination, (4) antidote administration, (5) enhanced elimination of toxin, and (6) supportive care. Stabilization involves airway, ventilation, and circulation support. In the patient with altered mental status, oxygen, naloxone, glucose, and thiamine should be administered. Symptom complexes that relate to specific classifications of toxins are referred to as toxidromes. Emesis by means of syrup of ipecac is rarely used for in-hospital gastric decontamination. Activated charcoal is a useful adsorbent for gastric decontamination. Whole bowel irrigation is useful for iron, lead, and lithium poisoning and for the body packer phenomenon. Enhancement of elimination may involve multiple doses of activated charcoal, hemodialysis, or charcoal hemoperfusion.     

Position statement: whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists

In preparing this Position Statement, all relevant scientific literature was identified and reviewed critically by acknowledged experts using agreed criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not usually considered. A draft Position Statement was then produced and subjected to detailed peer review by an international group of clinical toxicologists chosen by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. The Position Statement went through multiple drafts before being approved by the boards of the two societies and being endorsed by other societies. The Position Statement includes a summary statement for ease of use and is supported by detailed documentation which describes the scientific evidence on which the Statement is based. Whole bowel irrigation (WBI) should not be used routinely in the management of the poisoned patient. Although some volunteer studies have shown substantial decreases in the bioavailability of ingested drugs, no controlled clinical trials have been performed and there is no conclusive evidence that WBI improves the outcome of the poisoned patient. Based on volunteer studies, WBI may be considered for potentially toxic ingestions of sustained-release or enteric-coated drugs. There are insufficient data to support or exclude the use of WBI for potentially toxic ingestions of iron, lead, zinc, or packets of illicit drugs; WBI remains a theoretical option for these ingestions. WBI is contraindicated in patients with bowel obstruction, perforation, ileus, and in patients with hemodynamic instability or compromised unprotected airways. WBI should be used cautiously in debilitated patients, or in patients with medical conditions that may be further compromised by its use. A single dose of activated charcoal administered prior to WBI does not appear to decrease the binding capacity of charcoal or to alter the osmotic properties of WBI solution. Administration of charcoal during WBI appears to decrease the binding capacity of charcoal.     

Pediatric coin ingestion: a home-based survey

To improve understanding of the natural history of pediatric coin ingestions, an anonymous, home-based mail survey of parents followed by a five-physician private pediatric practice in suburban Maryland was conducted. Of 2,263 families surveyed, 798 (35.3%) responded, representing 1,510 children. Sixty-one (4.0%, 95% confidence interval: 3.1% to 5.1%) children had swallowed a coin, at a mean age of 2.8 years. Fifty-two (85%) coin ingestions were managed at home, usually without calling a physician or poison control center. Only 9 (15%) children were examined by a physician. No child (95% confidence interval: 0% to 4.9%) underwent a removal procedure or had an adverse outcome. Most coin ingestions were found to have been managed at home, often without calling a physician or poison control center. Hospital- or poison control center-based studies underestimate coin ingestion incidence and overestimate the frequency of complications.     

Drainage of the thoracic lymphatic duct and lymphosorption in the combined treatment of obstruction of the bile ducts and liver failure

Results of the application of the method of drainage of the lymphatic duct and lymphosorption in the complex treatment of 108 patients with obstruction of the bile eliminating ducts complicated by mechanical jaundice and hepatic insufficiency are described. Activated charcoal SKN, SUGS and SKT-6A were used for the sorption lymph detoxication. A pronounced detoxication effect of the sorption purification of the lymph with the activated charcoal and its reinfusion to the patient in the pre- and postoperative periods is shown.     

Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists

In preparing this Position Statement, all relevant scientific literature was identified and reviewed critically by acknowledged experts using agreed criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not usually considered. A draft Position Statement was then produced and subjected to detailed peer review by an international group of clinical toxicologists chosen by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. The Position Statement went through multiple drafts before being approved by the boards of the two societies and being endorsed by other societies. The Position Statement includes a summary statement for ease of use and is supported by detailed documentation which describes the scientific evidence on which the Statement is based. Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. Based on volunteer studies, the effectiveness of activated charcoal decreases with time; the greatest benefit is within 1 hour of ingestion. The administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to 1 hour previously; there are insufficient data to support or exclude its use after 1 hour of ingestion. There is no evidence that the administration of activated charcoal improves clinical outcome. Unless a patient has an intact or protected airway, the administration of charcoal is contraindicated.     

Colonic transit scintigraphy labeled activated charcoal compared with ion exchange pellets

Scintigraphic measurement of colonic transit is currently performed by delivering 111In ion exchange resin pellets to the colon in a methacrylate-coated capsule. However, use of this method is constrained by the need for an investigational drug permit. We have demonstrated previously optimal adsorption in vitro of commonly used radioisotopes (e.g., 99mTc or 111In) to activated charcoal in milieus that mimicked gastric and small intestinal content. The aim of this study was to compare the transit profiles of radioactive activated charcoal and resin pellets delivered to the colon in the same methacrylate-coated capsule. METHODS: In 10 healthy volunteers, we compared the colonic transit profiles over 32 hr of simultaneously administered resin pellets labeled with 111In and activated charcoal mixed with 99mTc-diethylenetriaminepentaacetic acid. Transit was summarized as the geometric center (weighted average of counts) in the colon at each scanning period. RESULTS: Colonic transit profiles were virtually identical with the two markers, with less than 0.1 geometric center unit differences in the transit profiles over the 32-hr periods. CONCLUSION: Activated charcoal is a suitable alternative to resin pellets when delivered in a methacrylate-coated, delayed-release capsule to the colon for measurement of transit by scintigraphy.     

Common pediatric esophageal disorders

Esophageal disorders in children can result in significant morbidity. The most common esophageal disorder seen in children is gastroesophageal reflux. Other common disorders affecting the esophagus include peptic esophageal strictures, esophageal atresia with or without tracheoesophageal fistula, caustic and foreign body ingestions, achalasia, and cricopharyngeal achalasia. We discuss what is currently known about these common pediatric esophageal disorders with regard to pathophysiology, clinical presentation, and diagnostic and treatment strategies.     

Paracetamol poisoning

Administration of paracetamol (acetaminophen) has analgetic and antipyretic effect. After trauma paracetamol has an anti-inflammatory activity. It was presumed that paracetamol in therapeutic doses had fewer and more acceptable side-effects than other analgetic drugs such as acetylsalicylic acid and NSAID-drugs. However, in toxic concentrations, paracetamol is more life-threatening. The toxic effects of paracetamol most often occur in the liver and kidneys. Phosphate and lactate turn-over can also be impaired. Paracetamol poisoning can induce temporary liver disfunction or even irreversible liver failure with liver transplantation as the only therapeutic possibility. Chronic alcoholics are especially at risk, as liver damage may occur following paracetamol even in recommended doses. When intoxication with paracetamol is presumed, administration of N-acetylcysteine is vital. N-acetylcysteine therapy should be initiated not later than 15 hours after paracetamol intake. Moreover, the antitoxic effect has been observed even when N-acetylcysteine therapy is initiated 24-36 hours after presumed paracetamol intake. Measures of preventing further absorption of paracetamol from the gastrointestinal tract should be taken. Activated charcoal should be given if less than two hours have passed since paracetamol intake. Between two and four hours following paracetamol intake gastric lavage should be performed. During the last 10 years the incidence of paracetamol self-poisoning has increased, but death following paracetamol poisoning is relatively constant at around nine per year in Denmark. It is suggested that the incidence of serious cases of paracetamol poisoning could be reduced by simple measures. Special attention should be paid to the risk-group of chronic alcoholics.     

Cleaning of waste gases in the production of alloys that contain rare-earth metals

A simple and effective system has been developed to clean the waste gases formed in small furnaces. It is proposed that a 5–10% solution of Ca(OH)₂ be used to neutralize SO₂ in the gases. The correct amount of solution to use has been determined. Activated charcoal of the 3–20 mm fraction has been tried as the adsorbent and can be used repeatedly after desorption. A high degree of efficiency is obtained in cleaning the waste gases: 88–99% for charges of composition I and 91–98% for charges of composition II. __________ Translated from Metallurg, No. 5, pp. 26–27, May, 2006.     

Assistive technology in Tennessee

OBJECTIVES: To compare two activated charcoal preparations (Carbomix and Actidose-Aqua) in terms of amount ingested and incidence of vomiting after ingestion. METHODS: Single blinded prospective randomised controlled trial. RESULTS: The mean amount of charcoal ingested was Carbomix 26.5 g, Actidose-Aqua 19.5 g. The mean difference was 7 g (95% confidence interval (CI) 1.5 to 12.4 g). The incidence of vomiting was for the Carbomix 6% and the Actidose-Aqua 8%. The mean difference in vomiting was 2% (95% CI -0.8 to 4.8) CONCLUSIONS: Carbomix administration results in an increased amount of activated charcoal ingested after oral administration. Rates of vomiting after activated charcoal administration were low when compared with previously reported rates.     

Charcoal deposits in the esophageal and gastric mucosa

We report the case of a 75-yr-old woman referred for gastrointestinal endoscopy to investigate severe iron deficiency anemia. Black linear lesions were observed in the distal esophagus and stomach. Biopsies revealed aggregates of coarse black foreign material, which was later identified as charcoal. The patient's previous medical history included an antidepressant overdose 5 yr before the current admission. The patient had a gastric lavage, using a large bore orogastric tube, followed by the administration of activated charcoal. The patient had no other history of charcoal ingestion. We propose that the charcoal became entrapped in mucosal tears caused by the traumatic intubation 5 yr previously, causing the incidental mucosal tattooing seen at endoscopy.     

Pain management in the pediatric intensive care unit

Control of pain in the pediatric intensive care unit has become increasingly important to intensivists. Improved understanding of the pharmacology of analgesics and the development of new techniques for analgesic administration have greatly enhanced the ability of intensivists to successfully manage patients in pain. The appropriate selection, use, and techniques for administration of analgesics in the treatment of pain in pediatric patients are discussed.     

Fibrinogen in neonatal infections

The in vivo effect on aspirin absorption of a potentially more palatable form of activated charcoal was compared to that of a simple aqueous slurry of activated charcoal. The experimental formulation consisted of 20.0 g of activated charcoal, 2.25 g of carboxymethylcellulose (CMC) and 42.8 ml of water; it was tested with and without chocolate syrup as a flavoring agent added just prior to administration. Six subjects were treated in crossover fashion following an aspirin dose of 972 mg. Total urinary excretion of salicylate was measured over 48 hours. Although all three treatments appeared to be effective in reducing the rate and extent of aspirin absorption, the slurry was significantly more effective in reducing the total amount absorbed than the charcoal-CMC gel with chocolate syrup. The slight difference in effectiveness between the gel formulation with and without the chocolate syrup was not significant.     

Activated charcoal interrupts enteroenteric circulation of phenobarbital

The possibility of activated charcoal interrupting the enteroenteric circulation of phenobarbital was conducted in rabbits prepared by colectomy biliary drainage to block enterohepatic circulation. Fifty minutes after the administration of phenobarbital IV over ten minutes, activated charcoal (N = 7) or non-adsorbent gel (N = 8) were placed into the intestine at a dose of 4 g/kg. Blood was taken hourly for 5 h from the femoral artery and portal vein for the determination of phenobarbital concentration by the homogeneous enzyme immunoassay. The arterio-portal differences of phenobarbital concentrations were significantly greater in the animals treated with the charcoal at 2, 3 and 4 h after the treatment. There were significantly shorter plasma half lives of phenobarbital in the animals given charcoal (3.8 +/- 0.3 h vs 6.9 +/- 0.9 h, p < .02). This study provided evidence of significant enteroenteric circulation of phenobarbital which can be interrupted by the activated charcoal and removed by the mechanism of intestinal dialysis.     

炭粉球团在硅铁生产中的应用

主要简述了硅铁生产原理及炭粉球团生产工艺,提出利用炭粉球团代替部分木炭做还原剂的理论依据,并在硅铁生产的试验过程中得到验证。结果表明：炭粉球团在冶炼硅铁技术上可行,且对硅铁质量无影响,同时降低了生产各项技术经济指标。