The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations.

The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal?  Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal.

A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations.  One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study.

From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals.

This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death.  Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.

In 2016, according to the German Federal Statistical Office, 178 425 cases of intoxication (poisoning) were treated in German hospitals. The poison control centers in the German-speaking countries gave advice in a total of 268 787 instances of poisoning in that year, and use of activated charcoal was recommended in 4.37% of cases. The application of activated charcoal plays a major role in both primary and secondary detoxification. This article serves as an overview of the mechanism of action, indications, contraindications, modes of application, and dosing of activated charcoal.

This review is based on pertinent publications retrieved by a selective search in PubMed. The opinions of experts from the poison control centers in the German-speaking countries were considered in the interpretation of the data.

The administration of activated charcoal is indicated to treat moderately severe to life-threatening intoxication. It should be carried out as soon as possible, within the first hour of the ingestion; timed-release preparations can be given up to 6 hours after the ingestion. An important contraindication is impaired consciousness with the danger of aspiration in a patient whose air- way has not yet been secured. Activated charcoal is ineffective or inadequately effective in cases of poisoning with acids or bases, alcohols, organic solvents, inorganic salts, or metals. The proper dosage consists of an amount that is 10 to 40 times as much as that of the intoxicating substance, or else 0.5-1 g/kg body weight in children or 50 g in adults. Repeated application is indicated for intoxications with agents that persist for a longer time in the stomach and for intoxications with timed-release drugs or drugs with a marked enterohepatic or entero-enteric circulation. The routine combination of activated charcoal with a laxative is not recommended.

Even though intoxications are common, there is still no internationally valid guideline concerning the administration of activated charcoal. A precise analysis of the risks and benefits is needed for each administration, and a poison control center should be consulted for this purpose.

BACKGROUND We compared the factors that might impact the severity and the prognosis of carbamazepine (CBZ) intoxication in children, as well as the efficacy levels of the treatment options. MATERIAL AND METHODS Demographic information and clinical and laboratory findings for 40 patients were evaluated retrospectively. Predictive parameters for the development of serious complications were studied. RESULTS Median age of patients was 14 years; 65% of the patients were female. The most common pathological clinical finding and laboratory abnormality were inability to awaken the patient and hyperglycemia (45% and 60%, respectively). The incidences of convulsion, coma, and respiratory failure were 14 (35%), 10 (25%), and 3 (7.5%), respectively. The Glasgow Coma Scale (GCS) scores and pH levels at emergency service admission were significantly lower in the severe intoxication group and the ICU admission group, and body temperature and serum glucose and lactate levels were significantly higher in these groups. A significantly negative correlation was found between the serum CBZ level and the GCS score, but the serum CBZ level was found to be significantly positively correlated with the lactate level. CONCLUSIONS According to our study, the GCS score at admission to hospital, the serum CBZ, glucose, pH, and lactate levels, and body temperature might be useful in predicting serious CBZ intoxication and prognosis in pediatric cases. We conclude that invasive treatment methods, such as hemodialysis or albumin-enhanced continuous venovenous hemodialysis, should be used in patients who do not respond to supportive treatment.

Sometimes mistakenly characterized as a 'universal antidote,' activated charcoal (AC) is the most frequently employed method of gastrointestinal decontamination in the developed world. Typically administered as a single dose (SDAC), its tremendous surface area permits the binding of many drugs and toxins in the gastrointestinal lumen, reducing their systemic absorption. Like other decontamination procedures, the utility of SDAC attenuates with time, and, although generally safe, it is not free of risk. A large body of evidence demonstrates that SDAC can reduce the absorption of drugs and xenobiotics but most such studies involve volunteers and have little generalizability to clinical practice. Few rigorous clinical trials of SDAC have been conducted, and none validate or refute its utility in those patients who are intuitively most likely to benefit. Over the past decade, a growing body of observational data have demonstrated that SDAC can elicit substantial reductions in drug absorption in acutely poisoned patients. The challenge for clinicians rests in differentiating those patients most likely to benefit from SDAC from those in whom meaningful improvement is doubtful. This is often a difficult determination not well suited to an algorithmic approach. The present narrative review summarizes the data supporting the benefits and harms of SDAC, and offers pragmatic suggestions for clinical practice.

Nephrologists and critical care physicians are commonly involved in the treatment of severely poisoned patients. Various techniques exist presently to enhance the elimination of poisons. Corporeal treatments occur inside of the body and include multiple-dose activated charcoal, resin binding, forced diuresis, and urinary pH alteration. Extracorporeal treatments include hemodialysis, hemoperfusion, peritoneal dialysis, continuous renal replacement therapy, exchange transfusion, and plasmapheresis. This review illustrates the potential indications and limitations in the application of these modalities as well as the pharmacological characteristics of poisons amenable to enhanced elimination.

Carbamazepine (CBZ) poisoning has been associated with cases of severe toxicity and death. Multiple-dose activated charcoal was proposed to enhance the clearance of CBZ elimination, but there are no prospective controlled studies that demonstrated a change in clinical outcome after the use of multiple-dose activated charcoal. The aim of this study was to determine the CBZ elimination kinetics and the evolution of clinical features according to the dose of activated charcoal in acute poisoning patients. It is a prospective study for 6 months, from January to June 2004, including all pure acute CBZ-poisoned patients. Twelve patients were randomized to receive a multiple-dose activated charcoal (G1) or a simple dose of 1 g/kg (G2). Their mean age was 27.6+/-12.2 years; the Simplified Acute Physiology Score (SAPS II), 16.37+/-8.46; and the Acute Physiology and Chronic Health Evaluation (APACHE II), 8+/-3.96. They were 8 men and 4 women. The mean concentration of blood CBZ at hospital admission was of 29.42+/-6.68 mg/L. Each group includes 6 patients. The peak value of blood CBZ was comparable in the 2 groups: 33+/-3.46 mg/L (G1) vs 32.6+/-5.63 (G2) (P=.5); the requirement of mechanical ventilation was similar also (3 in each group). The duration of both coma and mechanical ventilation was significantly decreased in the first group compared with the second: 20.33+/-3.05 vs 29.33+/-4.11 hours for coma (P=.02) and 24.1+/-4.2 vs 36.4+/-3.6 hours for mechanical ventilation (P=.001). The length of stay was also significantly decreased in the first group: 30.3+/-3.4 vs 39.7+/-7.3 hours in the second group (P=.000006). Concurrently, we have noted a significant constant reduction of the half-life of CBZ from serum in the first group: 12.56+/-3.5 hours after multiple dose vs 27.88+/-7.36 hours after a simple dose (P=.0004). This decrease was correlated to the dose of charcoal. In summary, we can conclude that multiple-dose activated charcoal is more efficient than simple-dose; it permits a constant decrease of the half-life of blood CBZ without any rebound effect and could improve the prognosis by reducing the duration of coma and the length of stay.

We presented a case of a 55-year-old woman who intentionally ingested an unknown amount of carbosulfan, a carbamate insecticide. On admission, her clinical findings were coma, pinpoint pupils, hypersalivation, respiratory failure, bradycardia, and hypotension. Hertrachea was intubated after suction of secretions, and atropine was administered intravenously. After gastric lavage, multiple doses of activated charcoal were instilled through the nasogastric tube over five days (total doses of 840 g). On the fourteenth day, she developed right-lower quadrant abdominal pain, anorexia, nausea, and vomiting, and she underwent an appendectomy. On pathologic examination of the specimen, particles of activated charcoal were seen within the dilated part of the appendiculer lumen. The patient was discharged from the hospital after antidepressant therapy at the psychiatry clinic. This case documents that multiple doses of activated charcoal may be associated with acute appendicitis.

Peak serum levels following overdose with immediate-release formulations of carbamazepine have been reported to occur up to 2 days postingestion. We report a case of poisoning with carbamazepine controlled-release resulting in peak levels 96 h postingestion.

A 31-year-old female presented following a suspected polypharmacy overdose. She was haemodynamically stable with a Glasgow Coma Scale score of 3 and was endotracheally intubated in the emergency department. A single-dose of activated charcoal was administered on admission and her neurological status improved gradually Results of qualitative urine drug screen available 24 h postadmission to the intensive care department revealed benzodiazepines and carbamazepine. The serum carbamazepine concentration at this time was 66 micromol/L (therapeutic 17-42 micromol/L). A history of therapy with controlled-release carbamazepine was discovered. Repeat-dose activated charcoal and whole-bowel irrigation were commenced, but poorly tolerated. Serum carbamazepine levels continued to rise and gastrointestinal tract decontamination was ceased due to the presence of an ileus. By day 4, the serum carbamazepine concentration peaked at 196 micromol/L. This was associated with coma, generalized intermittent seizure activity and hypotension. Charcoal haemoperfusion was commenced due the presence of end-organ toxicity and failed gastrointestinal tract decontamination. Serum carbamazepine concentrations fell from 176 to 106 micromol/L after 1 h of haemoperfusion and the patient was rousable to voice and could obey commands at this time. She confirmed ingestion of 300 Tegretol-CR (200 mg) on extubation and was discharged without long-term sequelae.

Unrecognized poisoning with controlled-release carbamazepine has the potential to produce significant delayed carbamazepine toxicity and delayed peak serum carbamazepine concentrations. This may occur much later than previously reported with immediate-release carbamazepine preparations.

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. 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. Although many studies in animals and volunteers have demonstrated that multiple-dose activated charcoal increases drug elimination significantly, this therapy has not yet been shown in a controlled study in poisoned patients to reduce morbidity and mortality. Further studies are required to establish its role and the optimal dosage regimen of charcoal to be administered. Based on experimental and clinical studies, multiple-dose activated charcoal should be considered only if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. With all of these drugs there are data to confirm enhanced elimination, though no controlled studies have demonstrated clinical benefit. Although volunteer studies have demonstrated that multiple-dose activated charcoal increases the elimination of amitriptyline, dextropropoxyphene, digitoxin, digoxin, disopyramide, nadolol, phenylbutazone, phenytoin, piroxicam, and sotalol, there are insufficient clinical data to support or exclude the use of this therapy. The use of multiple-dose charcoal in salicylate poisoning is controversial. One animal study and 2 of 4 volunteer studies did not demonstrate increased salicylate clearance with multiple-dose charcoal therapy. Data in poisoned patients are insufficient presently to recommend the use of multiple-dose charcoal therapy for salicylate poisoning. Multiple-dose activated charcoal did not increase the elimination of astemizole, chlorpropamide, doxepin, imipramine, meprobamate, methotrexate, phenytoin, sodium valproate, tobramycin, and vancomycin in experimental and/or clinical studies. Unless a patient has an intact or protected airway, the administration of multiple-dose activated charcoal is contraindicated. It should not be used in the presence of an intestinal obstruction. The need for concurrent administration of cathartics remains unproven and is not recommended. In particular, cathartics should not be administered to young children because of the propensity of laxatives to cause fluid and electrolyte imbalance. In conclusion, based on experimental and clinical studies, multiple-dose activated charcoal should be considered only if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline.

We reviewed data from carbamazepine poisonings reported to the Kentucky Regional Poison Center from January 1986 through March 1992 to identify information available at the time of poison center contact which correlates to outcome. The Spearman rank correlation test was used to describe the relationship between two ordinal variables and interval-level variables. The Kruskal-Wallis test was used to determine the relationship between categorical and ordinal variables. Two way analysis of variance was used to test the effect of routine carbamazepine use on final severity and carbamazepine level of 345 reports involving carbamazepine poisoning; 263 (76%) involved only carbamazepine ingestion and formed the database. One hundred eighty four (70%) carbamazepine ingestions occurred in victims < or = 17 years old, 79 (30%) occurred in adults. Severity assigned at the time of initial poison center contact was significantly correlated with outcome severity for children and adults (r > or = 0.9, p < 0.00001). The amount reported ingested influenced the correlation between initial and final severity; whereas, time elapsed between ingestion and poison center contact did not alter the correlation between initial and final severity. The reason for ingestion was significantly correlated with outcome (p < 0.00001). A significant correlation between outcome and peak carbamazepine level for each age group was observed (pediatric r = 0.5, p < 0.00001, and adult r = 0.4, p = 0.008). Carbamazepine levels > 85 mumol/L (> 20 mcg/mL) were associated with more severe toxicity.

Although many studies in animals and volunteers have demonstrated that multiple-dose activated charcoal increases drug elimination significantly, this therapy has not been shown in a controlled study in poisoned patients to reduce morbidity and mortality. Further clinical studies are required to establish its role and the optimum dosage regimen of charcoal to be administered. Based on current evidence, multiple-dose activated charcoal should only be considered if a patient has ingested a life-threatening amount of phenobarbital (phenobarbitone), carbamazepine, theophylline, quinine, dapsone or salicylate. In all of these cases there are data to confirm enhanced elimination, though no controlled studies have demonstrated clinical benefit.