Gastrointestinal decontamination after poisoning. Where is the science?

The approach to the use of gastrointestinal decontamination procedures in the treatment of ingested toxins has changed in recent years. Many toxicologists and physicians have taken strong positions either for or against the use of emesis, gastric lavage, activated charcoal, or other procedures. What is the scientific basis for these positions? This article reviews and comments on the published studies comparing the effectiveness of these widely used procedures.     

Innovative approaches to the administration of activated charcoal in pediatric toxic ingestions

Toxic ingestions (accidental or intentional) continue to occur within the pediatric population. Activated charcoal has replaced syrup of ipecac as the gastrointestinal decontamination method of choice. Activated charcoal has poor palatability and poses acceptability and administration problems with children. This article proposes innovative approaches to the administration of activated charcoal as an antidote for pediatric toxic ingestions.     

Germ cell-specific enhancer activity of a repeated element in a variable region of the mouse genome

The initial evaluation and management of poisoned patients should be comprehensive and include an accurate history whenever possible, stabilization of the patient's condition, a physical assessment to evaluate the extent of poisoning and the presence of concurrent conditions, decontamination of the gastrointestinal tract using activated charcoal, gastric lavage, administration of ipecac or irrigation, poison-specific treatment with administration of antidotes when indicated and proper disposition. Consultation with a poison control center is often helpful in assessing and treating these patients.     

Oral activated charcoal and dapsone elimination

The effect of orally given activated charcoal on the elimination of therapeutic and toxic doses of dapsone was studied in 5 healthy subjects and in 2 intoxicated patients. In a randomized crossover study the subjects took a total dose of 500 mg dapsone over 4 days; 10 hr after the last 100-mg dose of dapsone 50 gm activated charcoal as a water suspension (or water) was taken, followed by 4 consecutive doses of 17 gm at 12-hr intervals. The half-life (t 1/2) of serum dapsone was 20.5 +/- 2.0 hr during the control period and 10.8 +/- 0.4 hr during the charcoal period (p less than 0.01). The t 1/2 on serum monoacetyldapsone (MADDS) was shortened from 19.3 +/- 1.2 hr to 9.5 +/- 0.7 hr (p less than 0.01) by charcoal. The t 1/2s of dapsone and MADDS, calculated on the basis of urinary excretion rate, were shortened by charcoal; Two patients had taken large doses of dapsone in suicide attempts. The use of activated charcoal, 80 gm/day for 1 or 2 days, increased (3 to 5 times) the rate of elimination of both dapsone and MADDS, as reflected in serum concentration and urinary excretion data. The use of multiple doses of charcoal seems to be indicated as supplementary treatment of certain intoxications during the postabsorption phase if the drugs have a long t 1/2 and if they are secreted into the gut with subsequent reabsorption.     

Clinical and toxicological data in fenthion and omethoate acute poisoning

This study paper reports on two cases of poisoning with the organophosphorus insecticides, fenthion and omethoate. The two victims were admitted in the Intensive Care Unit (ICU) a few hours after ingestion of the two insecticides. They received appropriate treatment for organophosphorous poisoning (gastric lavage, activated charcoal, atropine and pralidoxime) and supportive care. Both patients survived. Organophosphate blood levels were determined on admission (fenthion 2.9 micrograms/ml, omethoate 1.6 micrograms/ml) and during the hospitalisation and proved to be considerably high. Slow elimination rate of the poison already distributed in the body was indicated for both pesticides. The patient with omethoate poisoning remained clinically well (Glasgow Coma Scale: 15) and was discharged three days later. The patient with fenthion poisoning, who had also ingested 30 mg of bromazepam and 720 mg of oxetoron, developed cholinergic crisis six hours after admission and was intubated for 24 days, with concomitant complications.     

Excretion of endogenous and exogenous purine derivatives in sheep: effect of increased concentrate intake

The scintigraphic measurement of colonic transit is currently performed using 111In ion exchange resin pellets delivered to the colon in a capsule coated with a pH sensitive polymer, methacrylate, which dissolves in the distal ileum. However, in the USA, this requires an investigational drug permit. Our aim was to evaluate the in vitro binding characteristics of activated charcoal in milieus that mimicked gastric and small intestinal content. The in vitro incubation of activated charcoal was performed with Na99Tc(m)O4, 99Tc(m)-DTPA, 111InCl3, 111In-DTPA, 201TlCl and 67Ga-citrate in the pH range 2-4 and pH 7.2 at 37 degrees C. We estimated the association of radiopharmaceuticals with the activated charcoal over a 3 h in vitro incubation. With the exception of 67Ga-citrate, the association of activated charcoal with the other radiopharmaceuticals was approximately 100% throughout the 3 h incubation. In conclusion, activated charcoal appears to adsorb avidly with common radioisotopes, and appears promising as an alternative to resin ion exchange pellets used for the measurement of gastrointestinal transit by scintigraphy.     

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.     

The pathogenesis of the low pleural fluid pH in esophageal rupture

To determine the possible mechanisms responsible for the low pH pleural effusion associated with esophageal rupture we evaluated the following possibilities: (1) gastric acid reflux, (2) bacterial metabolism, and (3) leukocyte metabolism. Neither elimination of gastric hydrogen ion contribution by distal esophageal ligation nor elimination of bacteria with antibiotics prevented the progressive fall in pleural fluid pH after esophageal rupture. Only elimination of polymorphonuclear leukocytes from the pleural space by rendering animals leukopenic with nitrogen mustard, prevented a low pH effusion after esophageal rupture. It appears that pleural fluid leukocyte metabolism is primarily responsible for the low pH effusion associated with esophageal rupture.     

Effects of three different types of management on the elimination kinetics of volatile anaesthetics. Implications for malignant hyperthermia treatment

The effectiveness of three types of management on the elimination kinetics of volatile anaesthetics was studied prospectively in 45 patients randomised to one of three groups. Patients were anaesthetised using isoflurane. Inspiratory and expiratory isoflurane concentrations were measured. After reaching a steady-state isoflurane concentration, the vaporizer was turned off. In group 1, only the fresh gas flow was increased from 40 to 120 ml.kg-1 x min-1. Patients in group 2, in addition to the increase in the fresh gas flow, had a charcoal filter connected in the inspiratory limb of the circuit. Patients in group 3 had the fresh gas flow increased and the anaesthetic machine and breathing system changed. There was a statistically significant difference in the isoflurane washout from the anaesthetic machines between group 1 (90% elimination time 39 [10] s) and group 2 (90% elimination time 25 [5] s) (p < 0.01). However, there was no significant difference in the isoflurane washout from the patients in any of the groups. Thus the use of a charcoal filter or a change of the anaesthetic machine and breathing system proved to be of no clinical advantage.     

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.     

Study on the adsorption of lanthanum(III) from aqueous solution by bamboo charcoal

The adsorption behaviors of La(III) ion on bamboo charcoal were investigated with various chemical methods and IR spectrometry. Parameters studied include the effects of pH, average particle size, initial ion concentration, contact time and temperature by batch method. The results showed that bamboo charcoal could remove La(III) ions effectively from aqueous solution. The loading of La(III) ions was strongly dependent on pH of the medium and the optimal adsorption condition was in HNO₃-TEA medium with pH value of 7.20. In the batch system, the modified bamboo charcoal exhibited the highest La(III) ion uptake as 120 mg/g at 298 K, at an initial pH value of 7.20. The adsorption kinetics were tested with Lagergren-first-order model and pseudo-second-order model. The adsorption data were conformed to the Langmuir and Freundlich isotherms, and the correlation coefficients had been evaluated. Thermodynamic parameters such as free energy (ΔG), which were all negative, indicated that the adsorption of La(III) ion onto bamboo charcoal was spontaneous and the positive value of enthalpy (ΔH) showed that the adsorption was endothermic in nature. Thomas model was applied to experimental column data to determine the characteristic parameters of column useful for process design. The characterization of both before and after adsorption of La(III) ion on bamboo charcoal was undertaken using IR spectroscopic technique. The results revealed that bamboo charcoal was a good choice as a biosorbent for the recovery of lanthanum from aqueous solution.     

Study on the adsorption of lanthanum(Ⅲ) from aqueous solution by bamboo charcoal

The adsorption behaviors of La(Ⅲ) ion on bamboo charcoal were investigated with various chemical methods and IR spectrometry. Parameters studied include the effects of pH,average particle size,initial ion concentration,contact time and temperature by batch method. The results showed that bamboo charcoal could remove La(Ⅲ) ions effectively from aqueous solution. The loading of La(Ⅲ) ions was strongly dependent on pH of the medium and the optimal adsorption condition was in HNO3-TEA medium with pH value of 7.20. In the batch system,the modified bamboo charcoal exhibited the highest La(Ⅲ) ion uptake as 120 mg/g at 298 K,at an initial pH value of 7.20. The adsorption kinetics were tested with Lagergren-first-order model and pseudo-second-order model. The adsorption data were conformed to the Langmuir and Freundlich isotherms,and the correlation coefficients had been evaluated. Thermodynamic parameters such as free energy(ΔG) ,which were all negative,indicated that the adsorption of La(Ⅲ) ion onto bamboo charcoal was spontaneous and the positive value of enthalpy(ΔH) showed that the adsorption was endothermic in nature. Thomas model was applied to experimental column data to determine the characteristic parameters of column useful for process design. The characterization of both before and after adsorption of La(Ⅲ) ion on bamboo charcoal was undertaken using IR spectroscopic technique. The results revealed that bamboo charcoal was a good choice as a biosorbent for the recovery of lanthanum from aqueous solution.     

Acute solitary gastric erosion (Dieulafoy) (author's transl)

Acute solitary gastric erosion (Dieulafoy) is one rare cause of fulminant, fatal acute gastric haemorrhage. Conservative treatment is usually lethal and elimination of the source of haemorrhage by active surgical intervention is the only possible form of therapy. The key to successful surgical treatment is early preoperative diagnosis by means of emergency gastroscopy.     

Gastric and biliary excretion of meperidine in man

The role and importance of enterogastric secretion in the disposition and elimination of the weak base, meperidine (pKa 8.63), was studied after intravenous administration (50 mg) of the drug to 6 normal volunteers. Continuous collection of the gastric fluid over a 4-hr period demonstrated the establishment of high gastric fluid/plasma concentration ratios for meperidine (mean about 50, range, 10 to 200). However, the total amount of drug recovered, even after correction for incomplete collection, was only a small percentage of the administered dose. Under basal conditions a mean +/- SE of 1.9 +/- 0.3 mg, equivalent to 3.7% of the administered dose, was found in the total gastric aspirate. Stimulation of gastric secretion by subcutaneous injection of betazole (1.5 mg/kg) increased this recovery to 3.6 +/- 0.3 mg (7.2%) primarily due to the increase in gastric volumen output. Aspiration of the gastric fluid in either the basal or stimulated situation had no observable effect upon the plasma concentration/time profile of meperidine whether assessed by the terminal half-life, t 1/2 beta, or the plasma clearance; control values were 3.8 +/- hr and 1,190 +/- 130 ml/min, respectively. In 2 subjects "bile fluid" was also collected for 2.5 hr and found to contain less than 0.2% of the administered dose. Enterosystemic recycling is therefore of minor importance in the disposition and elimination of meperidine in man.     

Detection of carriers of group B streptococci in pregnant women with absorbed charcoal culture. Streptococcal Diseases Study Group

For prevention of group B streptococcal (GBS) infection in neonates, GBS carriers of pregnant women should be detected. Procedures for detection of carriers were needed to get higher positive rate and to be handled with easy. Urine samples were shown to detect higher rates than vaginal smear samples in pregnant women. GBS in the urine were adsorbed to charcoal granula for easier transporting. These adsorbed charcoal were tested as to whether they could be preserved with different temperatures and days. Urine with 10(1) CFU/ml of GBS added could be detected after 7 days at temperatures of 4, 25, 37, 42 degrees C. The cultures of this procedure with the cultures of urine sediment of pregnant women were compared. Detecting rates of this procedure and urine sediment were 177 (26.2%) and 136 (20.1%) of 676 pregnant women, respectively. These data suggested that adsorbed charcoal culture was useful with higher positive rates for detection of the GBS carriers in pregnant women.     

Thorn apple poisoning

A 20-year-old man presented with signs of thornapple intoxication: restlessness, disorientation, hallucinations, euphoria, and furthermore dry and red skin and symmetrical dilation of the pupils. Thornapple intoxication mimics atropine intoxication. Thorn apples (Datura stramonium) are seemingly becoming popular as a hallucinogenic drug. When the symptoms are mild gastric lavage leaving active charcoal in the stomach afterwards will suffice. In case of severe symptoms treatment with physostigmine is indicated.     

Analysis of the electroencephalogram in growing calves by use of power spectrum and cross correlation

Electromechanical dissociation (EMD) occurred in a 20-year-old woman 48 hours after an overdose of atenolol, despite intensive treatment of the beta-blocker poisoning (gastric lavage, charcoal, glucagon, epinephrine, atropine, correction of electrolyte abnormalities, administration of fluids, cardiac pacing, and mechanical ventilation). Administration of calcium chloride during EMD repeatedly restored blood pressure. Therefore it may have a role to play in management of atenolol overdose.     

Successful treatment by direct hemoperfusion of coma possibly resulting from mitochondrial dysfunction in acute valproate intoxication

PURPOSE: We evaluated the efficacy of direct hemoperfusion (DHP) for treatment of acute valproate (VPA) intoxication and speculate on the biochemical perturbations that suggest a mechanism of coma induced by VPA overdose. PATIENT AND METHODS: The comatose patient was hospitalized approximately 6 h after ingesting 18 g VPA. DHP, with 200 g activated charcoal, was performed for 6 h. The plasma concentrations of VPA and Glasgow coma scale scores after admission were estimated. Before and after DHP, urine samples were tested in serial fashion for VPA metabolites, organic acids, and acyl carnitine esters of fatty acids. RESULTS: Plasma VPA was efficiently adsorbed on activated charcoal. The patient's plasma concentration of VPA decreased from 471 microg/ml (2,830 microM) to 45 microg/ml (270 microM), at which point the patient became alert. The half-life (t1/2) of VPA was calculated as 4.4 h before DHP and as 1.8 h during DHP. Before DHP, lactate and VPA-glucuronide markedly increased in urine samples, but beta-keto-VPA, a major mitochondrial metabolite, was not detected. Urinary excretion of carnitine esters of medium chain (C8-C10) dicarboxylic acids was increased. After DHP, lactate and VPA-glucuronide decreased, but a significant amount of beta-keto-VPA was demonstrated. Carnitine esters of medium chain dicarboxylic acids were decreased. CONCLUSIONS: DHP with activated charcoal was effective treatment for the patient with acute VPA intoxication and coma. The onset of coma may have been related to inhibition of beta-oxidation in the mitochondria, which was reversible by elimination of plasma VPA by DHP.     

Reactivity and Conversion Behaviour of Brazilian and Imported Coals,Charcoal and Blends in view of their Injection into Blast Furnaces

For about 10 years the steel industry in Brazil has been using pulverized coal injection (PCI) technology in blast furnaces based on imported coals. In order to decrease the dependence on imported coals, Brazilian coal which has limited use due to high ash content is suggested to be mixed with imported coal and charcoal. The aim of this study is to examine the reactivity and combustion behaviour of the mentioned materials. The use of charcoal in the Brazilian steel industry reduces the CO₂ emissions, since it represents a renewable source of carbon. The reactivity of the coal, charcoal and mixtures is evaluated through TGA. To provide a useful insight into the practice of PCI in blast furnaces, experiments are carried out with a laboratory rig at RWTH Aachen University that simulates the behaviour of fines injected into the raceway. The results of this study are presented and discussed.     

Hemoperfusion with coated activated charcoal for treating acute poisoning by remedies, plant protectants, and fungi. I. Remedies (author's transl)

Hemoperfusion with coated activated charcoal is a novel procedure for treating acute poisoning. It enables the elimination of both, water-soluble and liposoluble toxins. Hemoperfusion with coated activated charcoal has proved to be superior to hemodialysis in the treatment of barbiturate or bromocarbamide poisoning both under experimental conditions as well as in the ward. Analogous statements may be made for the therapy of glutethimide poisoning. Methaqualone, on the other hand, could not be eliminated sufficiently well in animal trials. Intoxications by "mild" analgetics, such as paracetamol and acetylsalicylic acid, may be treated successfully with hemoperfusion. Treatment of acetylsalicylic acid poisoning is equally effective with hemoperfusion as with hemodialysis. Prospects for the success of hemoperfusion in treating intoxication from tricyclic antidepressants and neuroliptics are slight. It is simply the danger of antidepressant poisoning that justifies using this method of treatment in the first few hours after ingestion in order to reduced the flow of the psychopharmaceutical substance into the tissue.