The general approach to the poisoned patient

The Use of Activated Charcoal for Acute Poisonings

“…Evaluation of the intoxicated patient should start with initial supportive measures and management of the Circulation, Airway, Breathing (CAB's), a history and physical examination, toxidrome recognition, diagnostic testing and then start considering whether or not to administer decontamination measures, enhanced elimination measures or antidotes and consult toxicologists or regional poison control center. 42,5,43 Subsequently, the physician should assess the risks, consider the possible clinical course and potential complications for the patient, as well as the risks and benefits of giving therapies to prevent absorption, increase elimination or indications for antidotes. Therefore, the decision to give a patient activated charcoal should be undertaken using the principles of evidence-based medicine where the clinician should make a value-based judgement on each individual patient.…”

“…14,44 Some authors suggest that the preferred method for gastrointestinal decontamination in awake patients with intact airway is AC. 5 For this process one must consider: the agent, dose, time from ingestion, current clinical presentation and individual patient factors. This process involves factors specific to the physician (experience, knowledge) and the patient (medical conditions, information provided).…”

“…1,2,4 Despite intoxications being among the first causes of accidental death, medical toxicology remains a small subspecialty of emergency medicine and knowledge of these topics among physicians in general can be limited. 5 Here we present a review of the use of activated charcoal for acute poisonings with a practical approach. The MEDLINE, EMBASE and Current Contents/Science Edition databases were searched mainly with the MeSH terms "Charcoal" and free text "Activated Charcoal", "gastrointestinal decontamination" and relevant articles selected based on the title and abstract.…”

Flumazenil, naloxone and the ‘coma cocktail’

“…These factors, as well as a QRS interval greater than 100 ms by itself, should be considered contraindications to its use . Notwithstanding expert recommendations against its liberal use, in actual practice flumazenil is undoubtedly being used more often . For example, the vast majority of poisoned patients given flumazenil identified in the UK database over a 2 year period were deemed to have either no indication or a contraindication to its use on expert review, yet complications are uncommon .…”

“…Flumazenil, on the other hand, carries a ‘black box’ warning in the United States . Experts recommend against widespread use, restricted to very narrow indications or only on the recommendation of a medical toxicologist while discouraging empirical administration as part of a ‘coma cocktail’ . To understand this discordant practice requires understanding how these antidotes differ, and the modern approach to the unconscious overdose patient.…”