Objective Measurement of Extrapyramidal Symptoms Through Forearm Tremors in Humans by Automatic Recordings

Abstract

Cocaine body-packers and body-stuffers have become a common medical problem. Significant morbidity and mortality result when cocaine is absorbed from the gastrointestinal tract due to cocaine package compromise. The clinical prevention of gastrointestinal absorption of cocaine includes oral activated charcoal and/or whole bowel irrigation with polyethylene glycol — electrolyte lavage solution. This in vitro study investigates the maximal adsorptive capacity of activated charcoal for cocaine at varying activated charcoal:cocaine ratios, at pH 1.2 and pH 7.0, and the effect of polyethylene glycol — electrolyte lavage solution upon this binding. The percent adsorption of cocaine to activated charcoal was significantly better at pH 7.0 for all ratios of activated charcoal:cocaine tested and the maximal adsorptive capacity was 29% greater at pH 7.0 (273 μg/mg) than at pH 1.2 (212 μg/mg) (p ≤ 0.05). Addition of polyethylene glycol — electrolyte lavage solution to the cocaine-activated charcoal slurry caused significant desorption of cocaine from activated charcoal at all pHs and ratios tested (except the 1:1 ratio at pH 7.0) and was most pronounced at pH 1.2. The addition of polyethylene glycol — electrolyte lavage solution to activated charcoal prior to adding cocaine solution further decreased the adsorption of cocaine to activated charcoal. This difference was significant at both pHs and all ratios tested except the 1:1 ratio at pH 1.2. The maximal adsorptive capacity of activated charcoal for cocaine at pH 1.2 was reduced 75% by pretreatment with polyethylene glycol — electrolyte lavage solution from 212 to 54.2 /μg/mg, while at pH 7.0 the maximal adsorptive capacity was reduced by 11%, from 273 to 243 /μg/mg. Polyethylene glycol — electrolyte lavage solution significantly reduces the adsorption of cocaine to activated charcoal particularly if the two are combined at a low pH prior to the addition of cocaine. The in vitro effects suggest that activated charcoal mixed in water should be administered first, followed by the polyethylene glycol — electrolyte lavage solution.     

THA—A Review of the Literature and Its Use in Treatment of Five Overdose Patients

Abstract

Background: This in vitro investigation was performed to study the adsorption characteristics of fluoxetine to activated charcoal and its commercial formulation Carbomix® powder in simulated gastric (pH=1.2) and intestinal (pH=7.2) fluid environments. Methods: Solutions containing fluoxetine and charcoal were incubated at 37°C for one hour. Reversed phase high performance liquid chromatography was used for the determination of free fluoxetine concentrations (range 0.2–8 ug/mL) in the diluted filtrate. Results: The maximum adsorption capacities at pH 1.2 for activated charcoal and Carbomix were 223 and 333?mg/g, respectively; at pH 7.2 they were 301 and 453?mg/g, respectively. The affinity constant values at pH 1.2 of activated charcoal and Carbomix were 441 and 122 L/g, respectively, while at pH 7.2 they were 482 and 589 L/g, respectively, indicating a strong binding of fluoxetine onto charcoals. Conclusions: Relative to the toxic and lethal doses in cases of fluoxetine intoxications, both types of charcoals tested were found effective for adsorption at gastric and intestinal pH. Adsorbed fluoxetine was significantly increased at intestinal pH, consistent with predominant adsorption of the undissociated form of the drug. We conclude that activated charcoal and Carbomix have adsorptive properties appropriate to medical treatment in cases of fluoxetine overdose     

Gastrointestinal decontamination. Which method is best?

Why has ipecac syrup become less popular in emergency management of poisoning and overdose? When should gastric lavage, activated charcoal, cathartics, or a combination of methods be used? Which patients are candidates for whole-bowel irrigation with polyethylene glycol-electrolyte solution? Drs Harris and Kingston answer these questions and present their recommendations for each of the available management options.     

Prospective single blinded randomised controlled trial of two orally administered activated charcoal preparations.

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.     

Decontamination

Decontamination is the removal or reduction of chemical, biologic, or radiologic agents from the patient's skin, mucosa, lungs, and gastrointestinal tract. Decontamination is an important step in decreasing the clinical effects of the agent on the patient, as well as protecting coworkers from exposure. For most agents and the vast majority of scenarios, the removal of clothing and a simple 5- to 6-minute shower with soap and water is sufficient to eliminate the risks to the patient and hospital staff. In rare circumstances, additional steps in decontamination including gastric lavage, broncho-alveolar lavage, surgical removal of wound foreign bodies, and administration of activated charcoal, polyethylene glycol electrolyte solution, and radioisotope binding agents, may be necessary.     

聚乙二醇电解质溶液在结肠镜检查前肠道准备中的应用与护理

目的研究口服聚乙二醇电解质溶液2 000 ml在肠镜检查前肠道准备中的效果和安全性。方法将100例行结肠镜检查的病人随机分为实验组和对照组,实验组口服聚乙二醇电解质溶液清肠,对照组口服电解质溶液加蓖麻油清肠。观察服药后的排便次数和性状,肠道清洁程度,病人服药后的反应,肠腔内气泡情况。服药前、结肠镜检查结束时分别测心率、血压,进行血、尿常规检查和电解质测定。结果实验组肠道准备时间较对照组明显缩短,两组差异有显著意义;两组清洁肠道有效率均达100%,无明显差异;不良反应实验组明显少于对照组;在耐受性方面,实验组优于对照组。结论口服聚乙二醇电解质溶液清洁肠道效果佳,安全性好,可替代我科传统的电解质溶液加蓖麻油清肠方法。     

Activated Charcoal Reduces the Need for N-Acetylcysteine Treatment After Acetaminophen (Paracetamol) Overdose

Background: The evidence for efficacy of gastric lavage and activated charcoal for gastrointestinal decontamination in poisoning has relied entirely on volunteer studies and/or pharmacokinetic studies and evidence for any clinical benefits or resource savings is lacking. au1,Aim of Study: To investigate the value of gastrointestinal decontamination using gastric lavage and/or activated charcoal in acetaminophen (paracetamol) poisoning. Patients and Methods: We analyzed a series of 981 consecutive acetaminophen poisonings. These patients were treated with gastric lavage and activated charcoal, activated charcoal alone, or no gastrointestinal decontamination. The decision as to which treatment was received was determined by patient cooperation, the treating physician, coinigested drugs, and time to presentation after the overdose. Results: Of 981 patients admitted over 10 years, 10% (100) had serum concentrations of acetaminophen that indicated a probable or high risk of hepatotoxicity. The risk of toxic concentrations for patients ingesting less than 10 g of acetaminophen was very low. In patients presenting within 24 hours, who had ingested 10 g or more, those who had been given activated charcoal were significantly less likely to have probable or high risk concentrations (Odds ratio 0.36, 95% CI 0.23–0.58, p < 0.0001). Gastric lavage, in addition to activated charcoal, did not further decrease the risk (Odds ratio 1.12, 95% CI 0.57–2.20, p = 0.86). Conclusions: Toxic concentrations of serum acetaminophen (paracetamol) are uncommon in patients ingesting less than 10 g. In those ingesting more, activated charcoal appears to reduce the number of patients who achieve toxic acetaminophen concentrations and thus may reduce the need for treatment and hospital stay.     

Comparison of the Adsorption Capacities of an Activated-Charcoal–Yogurt Mixture Versus Activated-Charcoal–Water Slurry In Vivo and In Vitro

Background. An activated charcoal–yogurt mixture was evaluated in vivo to determine the effect on the gastrointestinal absorption of paracetamol, as compared to activated-charcoal–water slurry. The potential advantage of the activated-charcoal–yogurt mixture is a better palatability and general acceptance by the patients without loss of efficacy. In addition, paracetamol adsorption studies were carried out in vitro to calculate the maximum adsorption capacity of paracetamol to activated-charcoal–yogurt mixture. Methods. In vivo: A randomized crossover study on 15 adult volunteers, using paracetamol 50 mg/kg as a simulated overdose. Each study day volunteers were given a standard meal 1 h before paracetamol, then 50 g activated charcoal 1 h later in either of two preparations: standard water slurry or mixed with 400 mL yogurt. Paracetamol serum concentrations were measured using HPLC. The areas under the concentration-time curve (AUC) of the two preparations were compared and used to estimate the efficacy of each preparation. The palatability of both preparations was evaluated using a visual-analogue scale where the volunteers were asked to evaluate the appearance, smell, flavor, texture, ability to swallow, and overall impression of the mixtures. The time spent to consume the activated charcoal was also registered. In vitro: Activated charcoal, simulated gastric (pH 1.2) or intestinal (pH 7.2) fluid, and paracetamol were mixed with yogurt followed by 1 h incubation. The maximum adsorption capacity of paracetamol to activated charcoal was calculated using Langmuir's adsorption isotherm. Paracetamol concentration was analyzed using HPLC. Results. In vivo there was no significant difference (p > 0.05) in the AUC of paracetamol between the two activated-charcoal preparations. Geometric mean values and 95% CI for the AUCs were (in mg/l · min): 6307 (4932–8065) for the activated charcoal–water slurry and 6525 (5111–8330) for the activated charcoal–yogurt mixture. The palatability study showed significant difference (p < 0.05) only in duration of administration, in favor of the activated charcoal-water slurry. In vitro the maximum adsorption capacity of activated charcoal with added yogurt was 544 mg paracetamol/g activated charcoal (pH 1.2), and 569 mg paracetamol/g activated charcoal (pH 7.2). Conclusion. The two activated-charcoal preparations showed equal (NS) absorption reduction of paracetamol in vivo. Mixing activated charcoal with yogurt rather than water prolonged the ingestion time, but did not improve the palatability in adults. The presence of yogurt reduced the adsorption capacity in vitro by 9–13% (p < 0.05) compared to control without yogurt (previous study with the same setup).     

Age-Specific and Age-Adjusted Penetrance as Poison Center Outcome Measures

Abstract

The effect of the type of carboxymethylcellulose (CMC) and amount of CMC used in preparing antidotal activated charcoal formulations on the in vitro kinetics of sodium salicylate adsorption from simulated gastric fluid was assessed in agitated vessels of two designs. Mixtures made with low, medium, and high viscosity CMC were tested. Additionally, the effects of the charcoal and water contents of these mixtures on adsorption kinetics were considered. The results suggest that charcoal mixtures which are fluid enough to be pourable (hence, drinkable) are strongly to be preferred from the standpoint of rate of adsorption. More particularly, gel-like formulations should be avoided because they disperse poorly and result in rather slow rates of drug uptake.     

不同清洁肠道药物降低肝癌术后高胆红素血症发生率的临床研究

目的探讨可降低原发性肝癌术后高胆红素血症发生率的术前清洁肠道药物。方法将240例原发性肝癌患者随机分为A、B、C、D 4组,每组60例,分别采用25%硫酸镁(A组)、磷酸钠盐口服溶液(B组)、聚乙二醇电解质散(C组)、乳果糖口服溶液(D组)作为口服清洁肠道药物,于术后第1、3日检测血清胆红素值,比较各组高胆红素血症的发生率。结果使用4种药物的肠道清洁程度和术后肠功能恢复时间的差异无统计学意义(P>0.05);A组、C组高胆红素血症发生率显著低于B组、D组,差异有统计学意义(P<0.001);C组药物口感、接受度明显优于A组(P<0.05)。结论术前应用硫酸镁和聚乙二醇电解质散清洁肠道均可降低原发性肝癌术后高胆红素血症的发生率,聚乙二醇电解质散的口感和患者的接受度优于硫酸镁。     

Activated charcoal alone and followed by whole-bowel irrigation in preventing the absorption of sustained-release drugs

OBJECTIVE: Our objective was to study the effect of activated charcoal on the absorption of sustained-release drugs ingested 1 hour earlier and to examine whether whole-bowel irrigation affects the efficacy of charcoal. METHODS: In this randomized, 3-phase crossover study, 9 healthy subjects received, at the same time, 200 mg carbamazepine, 200 mg theophylline, and 120 mg verapamil. All drugs were given as sustained-release tablets. One hour after taking the tablets, the subjects were assigned to one of the following treatments: 25 g activated charcoal as a suspension, 25 g activated charcoal as a suspension followed by whole-bowel irrigation with polyethylene glycol (PEG) electrolyte lavage solution, or 200 mL water (control). The absorption of the drugs was characterized by using the area under the plasma drug concentration-time curve from time zero to 24 hours [AUC(0-24)], peak plasma concentration (C(max)), C(max) minus the plasma concentration at 1 hour (C(Delta)), and time to peak (t(max)). RESULTS: Activated charcoal alone given 1 hour after drug intake significantly (P <.001) reduced the absorption [AUC(0-24)] of all 3 drugs (by 62%-75%). Also the C(max) and C(Delta) values of these drugs were significantly reduced by charcoal alone. Whole-bowel irrigation did not increase significantly the effect of charcoal on any absorption parameters of the 3 drugs studied. On the contrary, whole-bowel irrigation significantly (P <.01) decreased the efficacy of charcoal with respect to carbamazepine. CONCLUSIONS: Activated charcoal alone given 1 hour after intake of sustained-release drugs was effective in preventing the absorption of all 3 drugs studied. Whole-bowel irrigation may even decrease the efficacy of charcoal if the drug is well adsorbable onto charcoal. However, our study was performed with therapeutic drug doses only. In overdoses their possible effects on gastrointestinal motility may modify the efficacy of decontamination methods.     

Gastric decontamination--a view for the millennium

The management of acute poisoning remains an important part of accident and emergency (A&E) care. Three gastric decontamination procedures have been widely used: gastric lavage, ipecac, and activated charcoal. Their role has recently been reviewed and position statements developed by working groups of the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. These have important implications for A&E, as they indicate that activated charcoal is now the agent of choice for most poisons, but than in most situations it is probably only effective if given within an hour of overdose. Ipecac is effectively obsolete and gastric lavage has a narrow range of indications, principally for potentially serious amounts of agents not adsorbed by charcoal. Protocols for care of overdose patients should be modified accordingly.     

Gastric decontamination--a view for the millennium.

The management of acute poisoning remains an important part of accident and emergency (A&E) care. Three gastric decontamination procedures have been widely used: gastric lavage, ipecac, and activated charcoal. Their role has recently been reviewed and position statements developed by working groups of the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. These have important implications for A&E, as they indicate that activated charcoal is now the agent of choice for most poisons, but than in most situations it is probably only effective if given within an hour of overdose. Ipecac is effectively obsolete and gastric lavage has a narrow range of indications, principally for potentially serious amounts of agents not adsorbed by charcoal. Protocols for care of overdose patients should be modified accordingly.     

口服泻药结合甘油剂灌肠在提高糖尿病患者肠道清洁度中的作用

目的探讨口服聚乙二醇电解质散结合甘油剂灌肠在提高糖尿病患者肠道清洁度中的作用效果。方法将110例行结肠镜检查的糖尿病患者随机分为实验组和对照组,每组各55例。在结肠镜检查前,给予对照组患者口服聚乙二醇电解质散清洁肠道,实验组在此基础上采用甘油剂进行灌肠。比较两组患者肠道清洁度的差异。结果实验组患者肠道清洁度(96.4%)优于对照组(78.2%),两组比较,χ2=8.91,P<0.05,差异具有统计学意义。结论口服聚乙二醇电解质散结合甘油剂灌肠的方法,可提高糖尿病患者的肠道清洁度,使结肠镜检查能顺利进行,值得临床推广应用。     

A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetamol overdose.

The aim of this prospective trial was to compare the efficacy of gastric lavage, activated charcoal and ipecacuanha at limiting the absorption of paracetamol in overdose and to assess the significance of the continued absorption of paracetamol following treatment. Patients aged 16 and over who had ingested 5 gms or more of paracetamol within 4h of admission were entered into the trial. The percentage fall in plasma paracetamol level was used as the measure of the success of a treatment at limiting absorption. The mean percentage fall was 39.3 for gastric lavage, 52.2 for activated charcoal and 40.7 for ipecacuanha, with a significant difference between the treatment methods (p = 0.03). Activated charcoal was more effective at limiting the absorption of paracetamol following overdose than either gastric lavage or ipecacuanha induced emesis. In treated patients continuing paracetamol absorption is not significant if more than 2h have elapsed since ingestion.     

PEG-ELS在老年人结肠镜检查肠道准备应用的护理

目的观察聚乙二醇电解质散（polyethylene glycol—electrolyte lavage solution,PEG-ELS）在老年人结肠镜检查前肠道准备中应用的效果和护理要点。方法97例老年结肠镜检查患者用抽签法随机分为研究组和对照组,分别给予PEG-ELS和50％硫酸镁溶液进行肠道准备,比较两种方法准备完成时间,询问患者的主观口感,并观察肠道准备效果和不良反应。结果两组间肠道准备完成时间无显著性差异（P〉0．05）,PEG-ELS口感优于50％硫酸镁溶液（P〈O．05）,研究组和对照组肠道清洁度满意率分别为69．4％和56．3％,差异无统计学意义（P〉0．05）,两组间疗效差异也无统计学意义（P〉0．05）,两组不良反应发生率分别为14．3％和18．8％,差异无统计学意义（P〉0．05）。结论PEG-ELS应用于老年人结肠镜检查中的肠道准备,肠道清洁效果与50％硫酸镁溶液相当,但是主观口感要优于50％硫酸镁溶液,提示它更容易被患者接受。     

Absence of ice‐cream interference with the adsorption of paracetamol onto activated charcoal

Aims : To measure the extent to which the addition of ice‐cream to activated charcoal interferes with its ability to adsorb paracetamol. Method : Activated charcoal, ice‐cream and both charcoal and ice‐cream were added to stock solutions of paracetamol at both simulated gastric and intestinal pH at charcoal : paracetamol ratios of 3:1, 5:1 and 10:1. The samples were centrifuged and the supernatant assayed for paracetamol concentration. Results : When the charcoal : paracetamol ratio was 3:1, charcoal alone adsorbed 65% of the available paracetamol, and charcoal with ice‐cream adsorbed 57%. When the ratio was 5:1, charcoal alone adsorbed 92% of the available paracetamol and charcoal with ice‐cream 90%. When the ratio was 10:1, charcoal alone adsorbed 100% of the available paracetamol and charcoal with ice‐cream 99%. The results were independent of pH. Conclusions : The practice of adding ice‐cream to activated charcoal to improve palatability does not decrease the ability of the charcoal to adsorb paracetamol in vitro, especially if charcoal : drug ratios are above 5:1.     

Safety and effectiveness of large-volume enema solutions

The effectiveness and side effects of three types of enema solutions were compared in healthy subjects. Using a repeated-measures, double-blind design, the three different enemas (soapsuds, tap water, and polyethylene glycol-electrolyte solution) were given at 1-week intervals to 24 healthy volunteers. Soapsuds and tap water enemas produced significantly greater returns than polyethylene glycol electrolyte solution (PEG-ES) and were also more uncomfortable. Rectal biopsies showed surface epithelium loss after soapsuds and tap water but not after PEG-ES enemas. Before recommending changes in nursing practice, further research is needed to determine the mechanism for the surface epithelium damage and to determine if this damage produces a stronger defecation stimulus and discomfort.     

Repetitive Doses of Activated Charcoal in Dapsone Poisoning in a Child

Abstract

A case of Dapsone poisoning, treated by repetitive dosing with activated charcoal, is reported. This 18-month-old child showed remarkably rapid resolution of his symptoms with this mode of therapy, becoming symptom free in 64?h. This rapid improvement is attributed to interruption by activated charcoal of the entero-hepatic circulation of Dapsone. This mode of therapy may be indicated for other compounds having an enterohepatic circulation.

Activated charcoal is a generally well-accepted agent for gastrointestinal decontamination in the treatment of oral poisoning in childhood. It is considered a secondary method to induced emesis or gastric lavage for this purpose. Activated charcoal adsorbs a variety of compounds, thereby preventing their systemic adsorption until the charcoal and adsorbed material are excreted by fecal elimination. It is usually recommended that the charcoal be administered in a water slurry as a single dose approximately 10 times that of the ingested toxic material [1]. Several investigators have suggested that repetitive administration of activated charcoal may enhance the clearance of compounds that undergo enterogastric or enterohepatic recirculation or are very slowly adsorbed [2, 3].

Suggestive cases that support this concept have been reported in exposure of adult patients to nortriptyline and Dapsone [3]. To our knowledge there have been no reports of management of such cases in the pediatric literature.

Our case illustrates the use of this mode of therapy in a child.     

Esophageal laceration and charcoal mediastinum complicating gastric lavage

A 19-year-old woman underwent multiple attempts at orogastric lavage before success 5 h after ingesting approximately 24 grams of ibuprofen in a suicide attempt. Activated charcoal was administered via the lavage tube. She vomited charcoal shortly after administration and began experiencing difficulty breathing and an increase in the pitch of her voice. A chest X-ray study showed a widened mediastinum, pneumopericardium, and subcutaneous emphysema consistent with esophageal perforation that was confirmed by computed tomography scan. Surgical exploration revealed a tear in the proximal posterior esophagus with charcoal in the posterior mediastinum. She remained intubated for 7 days and was discharged 14 days after admission. This is a report of esophageal perforation with activated charcoal contamination of the mediastinum after gastric lavage. The risks and benefits of this procedure should be carefully considered in each patient prior to its use. Awake patients should be cooperative with the procedure to minimize any risk of trauma to the oropharynx or esophagus.