Contact Us    Contact Us     |     Feedback
MOBILE VIEW  | 

ACTIVATED CHARCOAL

Export To Excel

Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Activated charcoal is obtained by selective oxidation of organic material, such as wood pulp to produce a highly porous material with a large surface area. It adsorbs many drugs and chemicals to reduce the amount of the agent available for absorption.

Specific Substances

    1) Activated carbon
    2) Active carbon
    3) Adsorbent charcoal
    4) Carbo Activatus
    5) Carbo medicinalis
    6) Carbon active
    7) Carbon attivo
    8) Charcoal, activated
    9) Decolorising charcoal
    10) Medicinal charcoal
    11) CAS 16291-96-6 (charcoal)

Available Forms Sources

    A) FORMS
    1) Activated charcoal is available in the United States as 260 mg oral capsules, 250 mg oral tablets, 25 g/120 mL and 15 g/72 mL oral suspension, and 25 g/29.4 g oral powder for suspension (Prod Info activated charcoal oral capsules, 2005; Prod Info Actidose-Aqua(TM), , 2004; Prod Info CharcoCaps(R), , 2003; Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998).
    B) SOURCES
    1) Activated charcoal is obtained by destructive distillation or pyrolysis of organic material, such as wood pulp, which is activated by exposing it to an oxidizing gas compound at high temperatures, resulting in the production of increased surface area from the creation of pores. The adsorption of a chemical is limited by the number and size of these pores, or internal surface area (Prod Info Actidose-Aqua(TM), , 2004; Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998; Perry & Shannon, 1996). A larger surface area has been shown to be more effective in preventing the adsorption of some compounds (eg, theophylline, acetaminophen, and aspirin) (Van de Graaff et al, 1982; Park et al, 1984; Chung et al, 1982; Roberts et al, 1997).
    2) Activated charcoal is most effective in absorbing compounds with a molecular weight range of 100 to 1000 Daltons. Charcoal-drug ratio, pH, gastric contents, and adsorption kinetics may also influence the adsorptive capacity of activated charcoal (Prod Info Actidose-Aqua(TM), , 2004; Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998; Perry & Shannon, 1996). Other factors that may influence the effectiveness of charcoal products include mineral content, preservatives and palatability enhancers (Neuvonen, 1982; Krenzelok & Heller, 1987), and the relative solubility of the drug at a specified pH (Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998).
    3) SURFACE AREA: The surface area of USP activated charcoal is 1000 to 1500 m(2)/g. Superactivated charcoal has a surface area of 3000 m(2)/g. A 50 g dose of activated charcoal has a surface area approximately equal to 10 football fields (Perry & Shannon, 1996).
    4) Some charcoal preparations having equal surface areas; however, they have not shown identical adsorption capacity (Watson, 1987).
    C) USES
    1) Activated charcoal is used in the treatment of acute oral poisoning (Prod Info activated charcoal oral capsules, 2005; Prod Info Actidose-Aqua(TM), , 2004; Prod Info CharcoCaps(R), , 2003; Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998).
    2) SUMMARY: Activated charcoal should not be used routinely in all poisoned patients. It is most effective when administered within one hour of ingestion and should be administered as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    3) SINGLE DOSE
    a) In 2005, the AACT and EAPCCT published a position paper regarding the use of single dose activated charcoal in human poisonings. The recommendations were that activated charcoal not be used routinely in all poisoned patients. It should be considered in patients who have ingested a potential toxic amount of a poison which is known to be adsorbed to activated charcoal up to one hour previously. There is insufficient data to support or exclude the administration of activated charcoal longer than one hour after overdose. There is no evidence that activated charcoal improves clinical outcome after overdose. Activated charcoal is contraindicated in patients who do not have an intact or protected airway, patients with a nonfunctioning gastrointestinal tract, and after the ingestion of most hydrocarbons (aspiration risk) (Chyka et al, 2005).
    4) MULTIPLE DOSE
    a) Although additional binding may be accomplished with multiple dose charcoal (MDC), clinical practice may alter one's decision to use this regimen. Vomiting charcoal intolerance, decreased bowel motility, and possible aspiration may limit MDC usefulness (Tenenbein, 1991).
    b) In 1999, the AACT and EAPCCT published a position statement and practice guideline on the use of multiple dose activated charcoal in the poisoned patient. Although there are a number of studies demonstrating that multiple dose activated charcoal increases the clearance of a variety of substances, it has never been shown in a controlled study in poisoned patients to affect outcome. The current recommendation is that multiple dose activated charcoal be considered in the treatment of patients who have ingested a life threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline (Anon, 1999).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Activated charcoal is used in the treatment of acute oral poisoning. However, it should not be used routinely in all poisoned patients. Activated charcoal is most effective when administered within one hour of ingestion and should be administered as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway.
    B) PHARMACOLOGY: Activated charcoal is obtained by destructive distillation or pyrolysis of organic material, such as wood pulp, which is activated by exposing it to an oxidizing gas compound at high temperatures, resulting in the production of increased surface area from the creation of pores. The adsorption of a chemical is limited by the number and size of these pores, or internal surface area. A larger surface area has been shown to be more effective in adsorbing xenobiotics. Activated charcoal is most effective in absorbing compounds with a molecular weight range of 100 to 1000 Daltons. Charcoal-drug ratio, pH, gastric contents, and adsorption kinetics may also influence the adsorptive capacity of activated charcoal. Other factors that may influence the effectiveness of charcoal products include mineral content, preservatives and palatability enhancers, and the relative solubility of the drug at a specified pH.
    C) EPIDEMIOLOGY: Activated charcoal overdose and serious complications from its appropriate use are rare.
    D) WITH THERAPEUTIC USE
    1) Vomiting, constipation, black stools, gastrointestinal obstruction, acute pancreatitis, corneal abrasions, aspiration pneumonitis and empyema have been reported in patients receiving activated charcoal. Aspiration may be complicated by acute respiratory failure, acute respiratory distress syndrome (ARDS), bronchiolitis obliterans or chronic lung disease. Severe diarrhea, hypokalemia, hypernatremia, hypermagnesemia, and metabolic acidosis have been reported when activated charcoal was co-administered with cathartics.
    E) WITH POISONING/EXPOSURE
    1) TOXICITY: Charcoal impaction and bowel obstruction have been reported with multiple dose charcoal.
    0.2.20) REPRODUCTIVE
    A) There are no adequate and well-controlled studies of activated charcoal use in pregnancy; however, as activated charcoal is not systemically absorbed it is highly unlikely to have any adverse effects on the fetus. In animal studies, no teratogenic effects were observed in rats and rabbits administered activated charcoal.

Laboratory Monitoring

    A) Monitor fluid and electrolyte status as indicated in a patient with persistent vomiting or diarrhea.
    B) Assess bowel function in all patients following an overdose; monitor for abdominal pain or distention, vomiting, constipation, or evidence of bowel obstruction.
    C) Aspiration pneumonitis has been reported in patients receiving activated charcoal. Monitor arterial blood gases, pulse oximetry, and pulmonary function tests, and obtain a chest x-ray in any patient with respiratory symptoms.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. Assess bowel function in all patients following an overdose; monitor for abdominal pain or distention, vomiting, constipation, or evidence of bowel obstruction. Manual disimpaction and/or enemas may be useful to relieve activated charcoal. Aspiration pneumonitis has been reported in patients receiving activated charcoal. Monitor arterial blood gases, pulse oximetry, and pulmonary function tests, and obtain a chest x-ray in any patient with respiratory symptoms. Bronchoscopy may be necessary in patients with severe charcoal aspiration.
    C) AIRWAY MANAGEMENT
    1) Endotracheal intubation and mechanical ventilation may be required in a patient with aspiration pneumonia. Bronchoscopy may be necessary in patients with severe aspiration.
    D) ANTIDOTE
    1) None.
    E) PATIENT DISPOSITION
    1) OBSERVATION CRITERIA: Symptomatic patients should be sent to a healthcare facility for evaluation and treatment as necessary.
    2) ADMISSION CRITERIA: Symptomatic patients (eg, bowel obstruction, aspiration pneumonia) should be admitted.
    3) CONSULT CRITERIA: Consult a pulmonologist for assistance in managing patients with aspiration pneumonia.
    F) PITFALLS
    1) Alteration in bowel function and fluid balance may occur following activated charcoal, monitor the patient closely. A patient should only be discharged when bowel assessment is normal and patient is able to tolerate fluids, and vital signs are stable.
    G) PHARMACOKINETICS
    1) Activated charcoal is not absorbed via the gastrointestinal tract. Activated charcoal is excreted in the feces.
    H) DIFFERENTIAL DIAGNOSIS
    1) Includes other agents that may cause bowel obstruction (eg, cholestyramine) or aspiration pneumonitis (eg, hydrocarbon).

Range Of Toxicity

    A) TOXICITY: A toxic dose has not been established.
    B) THERAPEUTIC DOSES: DILUTION: Use a minimum of 240 mL of water per 30 g of activated charcoal as an aqueous slurry.
    C) ADULTS: SINGLE DOSE: The optimum dose has not been established. The recommended dose is 25 to 100 g in adults and adolescents. MULTIPLE DOSE: After an initial dose of 50 to 100 g activated charcoal, administer subsequent doses at 1 to 4 hour intervals at a rate equivalent to 12.5 g/hr. Continue until clinical and laboratory parameters are improving.
    D) CHILDREN: SINGLE DOSE: 13 YEARS AND OLDER: The recommended dose is 25 to 100 g in adults and adolescents. 1 TO 12 YEARS: The recommended dose is 25 to 50 g (or 0.5 to 1 g/kg body weight). INFANTS UP TO 1 YEAR: The recommended dose is 0.5 to 1 g/kg. MULTIPLE DOSE: 13 YEARS AND OLDER: After an initial dose of 50 to 100 g activated charcoal, administer subsequent doses at 1 to 4 hour intervals at a rate equivalent to 12.5 g/hr. Continue until clinical and laboratory parameters are improving. 1 TO 12 YEARS: After an initial dose of 25 to 50 g of activated charcoal, administer subsequent doses at 1 to 4 hr intervals at a rate equivalent to 6.25 g/hr. Continue until clinical and laboratory parameters are improving.
    E) CATHARTICS: The routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasional hypotension.

Clinical Effects

Summary Of Exposure

    A) USES: Activated charcoal is used in the treatment of acute oral poisoning. However, it should not be used routinely in all poisoned patients. Activated charcoal is most effective when administered within one hour of ingestion and should be administered as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway.
    B) PHARMACOLOGY: Activated charcoal is obtained by destructive distillation or pyrolysis of organic material, such as wood pulp, which is activated by exposing it to an oxidizing gas compound at high temperatures, resulting in the production of increased surface area from the creation of pores. The adsorption of a chemical is limited by the number and size of these pores, or internal surface area. A larger surface area has been shown to be more effective in adsorbing xenobiotics. Activated charcoal is most effective in absorbing compounds with a molecular weight range of 100 to 1000 Daltons. Charcoal-drug ratio, pH, gastric contents, and adsorption kinetics may also influence the adsorptive capacity of activated charcoal. Other factors that may influence the effectiveness of charcoal products include mineral content, preservatives and palatability enhancers, and the relative solubility of the drug at a specified pH.
    C) EPIDEMIOLOGY: Activated charcoal overdose and serious complications from its appropriate use are rare.
    D) WITH THERAPEUTIC USE
    1) Vomiting, constipation, black stools, gastrointestinal obstruction, acute pancreatitis, corneal abrasions, aspiration pneumonitis and empyema have been reported in patients receiving activated charcoal. Aspiration may be complicated by acute respiratory failure, acute respiratory distress syndrome (ARDS), bronchiolitis obliterans or chronic lung disease. Severe diarrhea, hypokalemia, hypernatremia, hypermagnesemia, and metabolic acidosis have been reported when activated charcoal was co-administered with cathartics.
    E) WITH POISONING/EXPOSURE
    1) TOXICITY: Charcoal impaction and bowel obstruction have been reported with multiple dose charcoal.

Heent

    3.4.3) EYES
    A) WITH THERAPEUTIC USE
    1) CORNEAL ABRASIONS: McKinney et al (1993) reported 2 cases of corneal abrasions in combative patients whose eyes became contaminated with charcoal bits while being given activated charcoal (McKinney et al, 1993).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) ASPIRATION PNEUMONITIS
    1) WITH THERAPEUTIC USE
    a) Several cases of aspiration pneumonitis (some fatal) have been reported in patients after receiving activated charcoal (Sabga et al, 1997; Givens et al, 1992; Harris & Filandrinos, 1993; Benson et al, 1989; Elliott et al, 1989; Weber & Santiago, 1989; Menzies et al, 1988; Dammann et al, 1988; Harsch, 1986; Justiniani et al, 1985; Pollack et al, 1981).
    b) Aspiration may be complicated by acute respiratory failure, acute respiratory distress syndrome (ARDS), bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002).
    c) The suspending agent, povidone, in the charcoal product has been previously implicated in pneumonitis and may have contributed to the severity in one case (Menzies et al, 1988).
    d) CASE SERIES: In a retrospective study of 64 intubated patients who received activated charcoal for treatment of drug overdose, 14 aspirated before intubation and 2 had abnormal chest radiographs immediately after intubation. Of the remaining 50 patients, 2 (4%) developed radiographic evidence of aspiration during the initial 48 hours of hospitalization, suggesting aspiration of activated charcoal and gastric contents after intubation (Moll et al, 1999).
    e) LONG-TERM EFFECT: A 38-year-old woman with a history of aspiration pneumonitis after receiving activated charcoal at the age of 3, presented with recurrent pneumothorax. A chest x-ray showed pulmonary lesions, highly suggestive of lymphangioleiomyomatosis (LAM). Histopathologic examination revealed pneumoconiotic lesions, characterized by prominent black pigmented deposits with foreign-body granuloma formation and minimal fibrosis. The black particles were found to be carbon-rich charcoal material (Huber et al, 2006).
    f) CASE REPORT: A 45-year-old man with a history of respiratory failure, pneumonia, and pneumothorax after receiving activated charcoal 2 years before admission, presented with a spiculated right-lower-lobe lung mass. A biopsy revealed anthracotic material, with surrounding granulomatous inflammation. A charcoal concretion was observed during the gross examination of the mass (Seder et al, 2006).
    B) EMPYEMA
    1) WITH THERAPEUTIC USE
    a) A charcoal-containing empyema resulted when an obtunded patient received activated charcoal and gastric lavage. The esophagus was probably perforated by the Ewald tube, resulting in leakage of gastric contents into the pleural space. The patient also had evidence of aspiration pneumonitis (Justiniani et al, 1985).
    b) CASE REPORT: Aspiration pneumonitis and sterile empyema developed in a 51-year-old man after receiving activated charcoal directly into the right lung and pleural cavity by nasogastric tube (Sabga et al, 1997).
    C) OBSTRUCTION OF LARYNX
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 2-year-old girl developed obstructive laryngitis after receiving a single dose of activated charcoal. Fiberbronchoscopy revealed edema and a large amount of charcoal particles on the epiglottis, arytenoids, and arytenoepiglottic folds. She recovered following the removal of charcoal particles (Donoso et al, 2003).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) VOMITING
    1) WITH THERAPEUTIC USE
    a) Vomiting was reported in 12.5% of poisoned patients receiving activated charcoal, and in 15.5% of those receiving a charcoal/sorbitol combination (Minocha et al, 1986).
    b) In another study, vomiting occurred in one patient who received activated charcoal alone, and in 13.3% who received activated charcoal following gastric lavage (Watson et al, 1986).
    c) The ingestion of large volumes of water following the charcoal slurry may precipitate vomiting in children. In 35 children receiving activated charcoal with sorbitol at home, 11 vomited within 30 minutes of administration (Dockstrader et al, 1986).
    B) GASTROINTESTINAL OBSTRUCTION
    1) WITH THERAPEUTIC USE
    a) Several cases of gastrointestinal obstruction have been reported in patients after receiving activated charcoal (with or without cathartics) (Chan et al, 2005; Merriman & Stokes, 1995; Goulbourne & Cisek, 1994; Ray et al, 1988; Watson et al, 1986).
    b) CASE REPORTS
    1) Small-bowel obstruction and charcoal bezoar were described in a 21-year-old comatose man following an amitriptyline overdose, who received 30 to 60 g of activated charcoal via a nasogastric tube. Concomitant cathartics were not given (Ray et al, 1988).
    2) Small bowel obstruction developed in a 17-year-old man who received two doses (50 g) of activated charcoal without a cathartic 4 hours apart. The patient had a history of anorexia nervosa, malnutrition and a previous gastric reduction surgery (Merriman & Stokes, 1995).
    3) A 64-year-old woman developed a small bowel obstruction after receiving a 50 g dose of activated charcoal with sorbitol followed by six subsequent doses of 50 g activated charcoal alone every 2 hours for treatment of theophylline toxicity (Goulbourne & Cisek, 1994).
    4) A 30-year-old woman experienced abdominal pain, nausea, and charcoal-stained vomiting several days after receiving activated charcoal, 350 g via a nasogastric tube over 25 hours, following a drug overdose involving carbamazepine and alprazolam. A Gastrografin meal showed complete small bowel obstruction and a laparotomy revealed a 2.5 x 5 cm bezoar located in the distal small bowel. The patient recovered following manual fragmentation of the bezoar. In this patient, the parasympatholytic properties of the ingested carbamazepine and alprazolam may have contributed or precipitated a paralytic ileus, thereby allowing the activated charcoal to accumulate, forming the bezoar (Chan et al, 2005).
    C) PERFORATION OF INTESTINE
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 39-year-old woman developed intestinal perforation due to a 120-g charcoal stercolith after receiving multidose charcoal (50 g orally every 4 hours for 2 doses) for an amitriptyline overdose (Gomez et al, 1994).
    b) CASE REPORTS: A 49-year-old woman with preexisting undiagnosed diverticular disease, developed bowel perforation after receiving 50 g of activated charcoal (Green & McCauley, 2006).
    D) CONSTIPATION
    1) WITH THERAPEUTIC USE
    a) Decreased gastrointestinal transit time, resulting in constipation, has been reported rarely (Chyka et al, 2005; Cooney, 1995).
    b) Large doses of activated charcoal can result in constipation, particularly in nonambulatory patients (Anon, 1999a).
    E) ULCER OF RECTUM
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 42-year-old woman treated with multidose activated charcoal (50 grams every 4 to 6 hours via a nasogastric tube for 50 hours) for a fenitrothion ingestion developed a rectal ulcer associated with massive rectal bleeding secondary to passing several large, hard, charcoal stools (Mizutani et al, 1991).
    F) DARK STOOLS
    1) WITH THERAPEUTIC USE
    a) Black stools occur frequently. It may be diarrhetic secondary to concomitant cathartic administration (Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998).
    G) DIARRHEA
    1) WITH THERAPEUTIC USE
    a) Severe diarrhea has been reported in patients receiving activated charcoal with sorbitol (Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998).
    H) ACUTE INTESTINAL PSEUDO-OBSTRUCTION
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 45-year-old man developed intestinal pseudo-obstruction (Ogilvie's syndrome) after receiving activated charcoal (50 g orally every hour for 20 doses) for theophylline overdose (Brubacher et al, 1996).
    b) CASE REPORT: Intestinal pseudo-obstruction was reported in a 57-year-old man treated with multiple dose charcoal (50 g orally every hour for 4 doses) after an overdose involving theophylline, aspirin and acetaminophen, and in a 35-year-old man treated with multidose activated charcoal (50 g orally every hour for 4 doses) for a theophylline overdose (Longdon & Henderson, 1992).
    I) ACUTE APPENDICITIS
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: Acute appendicitis developed in a 55-year-old woman, 4 days after receiving multiple doses of activated charcoal (total doses 840 g). After an appendectomy, pathologic examination of the specimen revealed particles of activated charcoal within the dilated part of the appendicular lumen (Eroglu et al, 2003).
    J) CHARCOAL ACTIVATED ADVERSE REACTION
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: Charcoal peritoneum was described in a patient following lavage and administration of 50 g of activated charcoal via an orogastric tube. At laparotomy, charcoal was found throughout the peritoneal cavity which proved to be refractory to removal by standard peritoneal irrigation and resulted in significant morbidity (Mariani & Pook, 1993).

Reproductive

    3.20.1) SUMMARY
    A) There are no adequate and well-controlled studies of activated charcoal use in pregnancy; however, as activated charcoal is not systemically absorbed it is highly unlikely to have any adverse effects on the fetus. In animal studies, no teratogenic effects were observed in rats and rabbits administered activated charcoal.
    3.20.2) TERATOGENICITY
    A) LACK OF EFFECT
    1) In animal studies, no teratogenic effects were observed in rats and rabbits administered activated charcoal (Prod Info Actidose-Aqua(TM), , 2004).
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) There are no adequate and well-controlled studies of activated charcoal use in pregnancy; however, as activated charcoal is not systemically absorbed it is highly unlikely to have any adverse effects on the fetus. Due to the lack of human safety information, activated charcoal should be used in pregnant women only if the potential benefit outweighs the potential risk to the fetus (Prod Info Actidose-Aqua(TM), , 2004).
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) LACK OF INFORMATION
    1) Lactation studies using activated charcoal have not been conducted in humans; however, as activated charcoal is not systemically absorbed it is highly unlikely to have any adverse effects on the breast feeding infant. Due to the lack of human safety information, activated charcoal should be used in lactating women only if the potential benefit outweighs the potential risk to the infant (Prod Info Actidose-Aqua(TM), , 2004).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor fluid and electrolyte status as indicated in a patient with persistent vomiting or diarrhea.
    B) Assess bowel function in all patients following an overdose; monitor for abdominal pain or distention, vomiting, constipation, or evidence of bowel obstruction.
    C) Aspiration pneumonitis has been reported in patients receiving activated charcoal. Monitor arterial blood gases, pulse oximetry, and pulmonary function tests, and obtain a chest x-ray in any patient with respiratory symptoms.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Symptomatic patients (eg, bowel obstruction, aspiration pneumonia) should be admitted.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a pulmonologist for assistance in managing patients with aspiration pneumonia.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Symptomatic patients should be sent to a healthcare facility for evaluation and treatment as necessary.

Monitoring

    A) Monitor fluid and electrolyte status as indicated in a patient with persistent vomiting or diarrhea.
    B) Assess bowel function in all patients following an overdose; monitor for abdominal pain or distention, vomiting, constipation, or evidence of bowel obstruction.
    C) Aspiration pneumonitis has been reported in patients receiving activated charcoal. Monitor arterial blood gases, pulse oximetry, and pulmonary function tests, and obtain a chest x-ray in any patient with respiratory symptoms.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Activated charcoal is not absorbed in the gastrointestinal tract; therefore, decontamination measures are not indicated following an overdose.
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) Monitor fluid and electrolyte status as indicated in patients with persistent vomiting or diarrhea.
    2) Assess bowel function in all patients following an overdose; monitor for abdominal pain or distention, vomiting, constipation, or evidence of bowel obstruction.
    3) Aspiration pneumonitis has been reported in patients receiving activated charcoal. Monitor arterial blood gases, pulse oximetry, and pulmonary function tests, and obtain a chest x-ray in any patient with respiratory symptoms.

Range Of Toxicity

Summary

    A) TOXICITY: A toxic dose has not been established.
    B) THERAPEUTIC DOSES: DILUTION: Use a minimum of 240 mL of water per 30 g of activated charcoal as an aqueous slurry.
    C) ADULTS: SINGLE DOSE: The optimum dose has not been established. The recommended dose is 25 to 100 g in adults and adolescents. MULTIPLE DOSE: After an initial dose of 50 to 100 g activated charcoal, administer subsequent doses at 1 to 4 hour intervals at a rate equivalent to 12.5 g/hr. Continue until clinical and laboratory parameters are improving.
    D) CHILDREN: SINGLE DOSE: 13 YEARS AND OLDER: The recommended dose is 25 to 100 g in adults and adolescents. 1 TO 12 YEARS: The recommended dose is 25 to 50 g (or 0.5 to 1 g/kg body weight). INFANTS UP TO 1 YEAR: The recommended dose is 0.5 to 1 g/kg. MULTIPLE DOSE: 13 YEARS AND OLDER: After an initial dose of 50 to 100 g activated charcoal, administer subsequent doses at 1 to 4 hour intervals at a rate equivalent to 12.5 g/hr. Continue until clinical and laboratory parameters are improving. 1 TO 12 YEARS: After an initial dose of 25 to 50 g of activated charcoal, administer subsequent doses at 1 to 4 hr intervals at a rate equivalent to 6.25 g/hr. Continue until clinical and laboratory parameters are improving.
    E) CATHARTICS: The routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasional hypotension.

Therapeutic Dose

    7.2.1) ADULT
    A) SINGLE DOSE
    1) DILUTION: Use a minimum of 240 mL of water per 30 g of activated charcoal as an aqueous slurry (FDA, 1985).
    2) The optimum dose has not been established. The recommended dose is 25 to 100 g in adults and adolescents (Chyka et al, 2005; Prod Info Actidose-Aqua(TM), , 2004).
    B) MULTIPLE DOSE
    1) After an initial dose of 50 to 100 g activated charcoal, administer subsequent doses at 1 to 4 hour intervals at a rate equivalent to 12.5 g/hr. Continue until clinical and laboratory parameters are improving (Vale et al, 1999).
    C) CONTRAINDICATIONS
    1) Activated charcoal should not be administered to patients with an unprotected airway. It should not be administered if its use may increase the risk/severity of aspiration (eg hydrocarbons). It is generally not indicated for ingestion of corrosives as it does not prevent toxicity and may interfere with endoscopic evaluation of burns. Patients with underlying pathology that places them at risk for GI hemorrhage or perforation, or recent GI surgery, are at greater risk for complications. Activated charcoal should not be administered routinely, and should be avoided if the ingestion is non- toxic or minimally toxic (Chyka et al, 2005)
    D) CATHARTICS
    1) The routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasional hypotension (None Listed, 2004; Vale et al, 1999).
    E) ADMIXTURE INCOMPATIBILITIES
    1) There are some studies that suggest that administering activated charcoal along with other substances (primarily to improve palatability) may affect its absorptive capacity, although it is not clear that these differences are clinically important.
    2) ICE CREAM: Ice cream mixed with activated charcoal interfered with the adsorptive capacity of the activated charcoal for aspirin in 5 subjects (Levy et al, 1975).
    3) ETHANOL: When given simultaneously with activated charcoal, ethanol interfered with the efficacy of the charcoal (Olkkola, 1984).
    4) MILK: An in vitro study demonstrated that the presence of milk interfered with the adsorptive capacity of activated charcoal for aspirin (DeNeve, 1976).
    5) SIMPLE SYRUP: An in vitro study demonstrated that the presence of simple syrup interfered with the adsorptive capacity of activated charcoal for aspirin (DeNeve, 1976; Navarro et al, 1980).
    6) COCOA POWDER: An in vitro study demonstrated that the addition of 1 gram of cocoa powder to an aqueous acidified suspension of activated charcoal decreased the adsorptive capacity for aspirin (DeNeve, 1976).
    7) MILK CHOCOLATE: A mixture of milk chocolate and Superchar(R) had less adsorptive capacity for aspirin than Superchar(R) alone in a crossover human volunteer study (AUC was 574, 310, and 188 mg/L/hr, respectively for aspirin alone, milk chocolate/charcoal, and Superchar(R) alone) (Eisen et al, 1987).
    8) SALINE CATHARTICS: In a variety of in vivo and in vitro studies, saline cathartics were shown to either have no effect or to actually enhance the adsorptive properties of activated charcoal (Ryan et al, 1980; Chin et al, 1981; Easom et al, 1982; Cooney & Wijaya, 1986; Gaudreault et al, 1985; Akintonwa & Orisakwe, 1988).
    7.2.2) PEDIATRIC
    A) SINGLE DOSE
    1) 13 YEARS AND OLDER: The recommended dose is 25 to 100 g in adults and adolescents (Chyka et al, 2005; Prod Info Actidose-Aqua(TM), , 2004).
    2) 1 TO 12 YEARS: The recommended dose is 25 to 50 g (or 0.5 to 1 g/kg body weight) (Chyka et al, 2005; Prod Info Actidose-Aqua(TM), , 2004).
    3) INFANTS UP TO 1 YEAR: The recommended dose is 0.5 to 1 g/kg (Chyka et al, 2005; Prod Info Actidose-Aqua(TM), , 2004).
    4) The routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasional hypotension (None Listed, 2004).
    B) MULTIPLE DOSE
    1) 13 YEARS AND OLDER: After an initial dose of 50 to 100 g activated charcoal, administer subsequent doses at 1 to 4 hour intervals at a rate equivalent to 12.5 g/hr. Continue until clinical and laboratory parameters are improving (Vale et al, 1999).
    2) 1 TO 12 YEARS: After an initial dose of 25 to 50 g of activated charcoal, administer subsequent doses at 1 to 4 hour intervals at a rate equivalent to 6.25 g/hr. Continue until clinical and laboratory parameters are improving (Vale et al, 1999).

Minimum Lethal Exposure

    A) A toxic dose has not been established.

Maximum Tolerated Exposure

    A) A toxic dose has not been established.

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Activated charcoal is obtained by destructive distillation or pyrolysis of organic material, such as wood pulp, which is activated by exposing it to an oxidizing gas compound at high temperatures, resulting in the production of increased surface area from the creation of pores. The adsorption of a chemical is limited by the number and size of these pores, or internal surface area. A larger surface area has been shown to be more effective in preventing the adsorption of some compounds (eg, theophylline, acetaminophen, and aspirin) (Prod Info Actidose-Aqua(TM), , 2004; Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998; Perry & Shannon, 1996; Roberts et al, 1997; Van de Graaff et al, 1982; Park et al, 1984; Chung et al, 1982).
    B) Activated charcoal is most effective in absorbing compounds with a molecular weight range of 100 to 1000 Daltons. Charcoal-drug ratio, pH, gastric contents, and adsorption kinetics may also influence the adsorptive capacity of activated charcoal (Prod Info Actidose-Aqua(TM), , 2004; Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998; Perry & Shannon, 1996). Other factors that may influence the effectiveness of charcoal products include mineral content, preservatives and palatability enhancers (Neuvonen, 1982; Krenzelok & Heller, 1987), and the relative solubility of the drug at a specified pH (Prod Info ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, 1998).
    C) MULTIPLE DOSE
    1) Multiple doses of activated charcoal can increase the elimination of compounds through several mechanisms (Pond, 1986).
    a) Substances which diffuse passively into the gastrointestinal tract from the blood (lipophilic, uncharged, low protein bound substances) are bound to charcoal and excreted, creating a concentration gradient or "sink" for continued diffusion. The term "gastrointestinal dialysis" has been used to describe this process (Levy, 1982; Watson, 1987).
    b) Substances that diffuse passively meeting the above criteria that are also ion-trapped in the gastrointestinal tract (ie, weak bases) are bound to charcoal in the undissociated form in the gastrointestinal tract and excreted, again providing a concentration gradient.
    c) Substances that are excreted in the bile and undergo enterohepatic circulation can be bound to charcoal as they are secreted into the gastrointestinal tract.
    d) Substances that are actively secreted into the intestine and bound to charcoal can be eliminated in the feces.
    e) A study examining the physicochemical properties of 17 different drugs failed to identify specific predictors of response to repeat-dose activated charcoal. However, the study did suggest that a relationship exists between drugs with a long intrinsic half-life and the effectiveness of repeat-dose activated charcoal (Campbell & Chyka, 1992).
    D) REVERSIBLE ADSORPTION
    1) Adsorption of substances onto charcoal is a reversible process, with rapid adsorption and slow desorption. One method to measure desorption in vivo is to look at changes in apparent volume of distribution of the substance after administration of activated charcoal. If the volume of distribution is unchanged, it can be assumed that the charcoal represents an additional elimination site and that significant desorption has not taken place. This has been demonstrated for theophylline (Mahutte et al, 1983). If the volume of distribution is increased, then the charcoal represents an additional distribution site and may even prolong the biologic half-life of the substance (Huang & Tzou, 1986).

References

General Bibliography

    1) Akintonwa A & Orisakwe OE: The adsorption of metronidazole and tinidazole to activated charcoal and the effect of magnesium sulfate. Vet Hum Toxicol 1988; 30:556-558.
    2) Alaspaa AO, Kuisma MJ, Hoppu K, et al: Out-of-hospital administration of activated charcoal by emergency medical services. Ann Emerg Med 2005; 45:207-12.
    3) Anon: Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Clin Toxicol 1999a; 37(6):731-751.
    4) Anon: Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol 1999; 37:731-751.
    5) Benson B, VanAntwerp M, & Hergott T: A fatality resulting from multiple dose activated charcoal therapy (Abstract 23). Vet Hum Toxicol 1989; 31:335.
    6) Bosse GM, Barefoot JA, & Pfeifer MP: Comparison of three methods of gut decontamination in tricyclic antidepressant overdose. J Emerg Med 1995; 13:203-209.
    7) Brubacher JR, Levine B, & Hoffman RS: Intestinal pseudo-obstruction (Ogilvie's syndrome) in theophylline overdose. Vet Hum Toxicol 1996; 38:368-370.
    8) Campbell JW & Chyka PA: Physicochemical characteristics of drugs and response to repeat-dose activated charcoal. Am J Emerg Med 1992; 10(3):208-210.
    9) Chan JC, Saranasuriya C, & Waxman BP: Bezoar causing small bowel obstruction after repeated activated charcoal administration. Med J Aust 2005; 183(10):537.
    10) Chin L, Picchioni AL, & Gillespie T: Saline cathartics and saline cathartics plus activated charcoal as antidotal treatments. Clin Toxicol 1981; 18:865-871.
    11) Chung DC, Murphy JE, & Taylor TW: In-vivo comparison of the adsorption capacity of "superactive charcoal" and fructose with activated charcoal and fructose. J Toxicol Clin Toxicol 1982; 19:219-224.
    12) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    13) Cooney DO & Wijaya J: Effect of magnesium citrate on the adsorptive capacity of activated charcoal for sodium salicylate. Vet Hum Toxicol 1986; 28:521-526.
    14) Cooney DO: Activated Charcoal in Medical Applications, 2nd ed. Taylor & Francis, New York, NY, 1995, pp -.
    15) Cordonnier J, Van den Heede M, & Heyndrickx A: Activated charcoal and ipecac syrup in prevention in tilidine absorption in man. Vet Hum Toxicol 1987; 29:105-106.
    16) Curtis RA, Barone J, & Giacona N: Efficacy of ipecac and activated charcoal/cathartic. Prevention of salicylate absorption in simulated overdose. Arch Intern Med 1984; 144(1):48-52.
    17) Dammann KZ, Wiley SH, & Tominack RL: Aspiration pneumonia following activated charcoal - A case report (Abstract). Vet Hum Toxicol 1988; 30:353.
    18) Danel V, Glucksman E, & Henry JA: A comparative study of gastric lavage, emesis and activated charcoal in the management of a simulated aspirin overdose. Vet Hum Toxicol 1987; 29:107.
    19) DeNeve R: Antidotal efficacy of activated charcoal in presence of jam, starch and milk. Am J Hosp Pharm 1976; 33:965-966.
    20) Dockstrader LL, Lawrence RA, & Bresnick HL: Home administration of activated charcoal: feasibility and acceptance (abstract). Vet Hum Toxicol 1986; 28:471.
    21) Donoso A , Linares M , Leon J , et al: Activated charcoal laryngitis in an intubated patient. Pediatr Emerg Care 2003; 19(6):420-421.
    22) Easom JM, Caraccio TR, & Lovejoy FH: Evaluation of activated charcoal and magnesium citrate on the prevention of aspirin absorption in humans. Clin Pharmacy 1982; 1:154-156.
    23) Eisen TF, Grbcich PA, & Lacouture PG: The adsorptive capacity of a new milk-chocolate-charcoal mixture (Abstract). Vet Hum Toxicol 1987; 29:487.
    24) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    25) Elliott CG, Colby TV, & Kelly TM: Charcoal lung: bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    26) Eroglu A , Kucuktulu U , Erciyes N , et al: Multiple dose-activated charcoal as a cause of acute appendicitis. J Toxicol Clin Toxicol 2003; 41(1):71-73.
    27) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    28) Farley TA: Severe hypernatremic dehydration after use of an activated charcoal-sorbitol suspension. J Pediatr 1986; 109:719-722.
    29) Fassler CA, Rodriguez M, & Badesch DB: Magnesium toxicity as a cause of hypotension and hypoventilation. Arch Intern Med 1985; 145:1604-1606.
    30) Gaudreault P, Friedman PA, & Lovejoy FH: Efficacy of activated charcoal and magnesium citrate in the treatment of oral paraquat intoxication. Ann Emerg Med 1985; 14:123-125.
    31) Givens T, Holloway M, & Wason S: Pulmonary aspiration of activated charcoal: a complication of its misuse in overdose management. Pediatr Emerg Care 1992; 8(3):137-140.
    32) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    33) Gomez HF, Brent JA, & Munoz DC: Charcoal stercolith with intestinal perforation in a patient treated for amitriptyline ingestion. J Emerg Med 1994; 12:57-60.
    34) Goulbourne KB & Cisek JE: Small-bowel obstruction secondary to activated charcoal and adhesions. Ann Emerg Med 1994; 24:108-110.
    35) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    36) Green JP & McCauley W : Bowel perforation after single-dose activated charcoal. CJEM 2006; 8(5):358-360.
    37) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    38) Harsch HH: Aspiration of activated charcoal. N Engl J Med 1986; 314:318.
    39) Hoffman RS, Chiang WK, & Howland MA: Drug desorption from activated charcoal caused by whole bowel irrigation solution (Abstract 27). Vet Human Toxicol 1989; 31:336.
    40) Hoffman RS, Chiang WK, & Howland MA: Theophylline desorption from activated charcoal caused by whole bowel irrigation solution. J Toxicol Clin Toxicol 1991; 29:191-201.
    41) Huang JD & Tzou MC: The effect of activated charcoal on the volume of distribution of drugs. J Pharm Sci 1986; 75:923-924.
    42) Huber M, Pohl W, Reinisch G, et al: Lung disease 35 years after aspiration of activated charcoal in combination with pulmonary lymphangioleiomyomatosis. A histological and clinicopathological study with scanning electron microscopic evaluation and element analysis. Virchows Arch 2006; 449(2):225-229.
    43) Jones J, Heiselman D, & Dougherty J: Cathartic-induced magnesium toxicity during overdose management. Ann Emerg Med 1986; 15:1214-1218.
    44) Justiniani FR, Hippalgaonkar R, & Martinez LO: Charcoal-containing empyema complicating treatment for overdose. Chest 1985; 87:404-405.
    45) Kirschenbaum LA, Mathews SC, & Sitar DS: Whole-bowel irrigation versus activated charcoal in sorbitol for the ingestion of modified-release pharmaceuticals. Clin Pharmacol Ther 1989; 46:264-271.
    46) Kirshenbaum LA, Sitar DS, & Tenenbein M: Interaction between whole-bowel irrigation solution and activated charcoal: implications for the treatment of toxic ingestions. Ann Emerg Med 1990; 19:1129-1132.
    47) Krenzelok EP & Heller MB: Effectiveness of commercially available aqueous activated charcoal products. Ann Emerg Med 1987; 16:1340-1343.
    48) Kulig K, Bar-Or D, & Cantrill SV: Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985; 14:562-567.
    49) Lapatto-Reiniluoto O, Kivisto KT, & Neuvonen PJ: Effect of activated charcoal alone or given after gastric lavage in reducing the absorption of diazepam, ibuprofen and citalopram. Br J Clin Pharmacol 1999; 48:148-153.
    50) Levy G, Soda DM, & Lampman TA: Inhibition by ice cream of the antidotal efficacy of activated charcoal. Am J Hosp Pharm 1975; 32:289-291.
    51) Levy G: Gastrointestinal clearance of drugs with activated charcoal. N Engl J Med 1982; 307:676.
    52) Longdon P & Henderson A: Intestinal pseudo-obstruction following the use of enteral charcoal and sorbitol and mechanical ventilation with papaveretum sedation for theophylline poisoning. Drug Safety 1992; 7:74-77.
    53) Mahutte CK, True RJ, & Michiels TM: Increased serum theophylline clearance with orally administered activated charcoal. Am Rev Respir Dis 1983; 128:820-822.
    54) Mariani PJ & Pook N: Gastrointestinal tract perforation with charcoal peritoneum complicating orogastric intubation and lavage. Ann Emerg Med 1993; 22:606-609.
    55) McKinney PE, Phillips S, Gomez HF, et al: Corneal abrasions secondary to activated charcoal. Am J Emerg Med 1993; 11(5):562-562.
    56) Menzies DG, Busuttil A, & Prescott LF: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:459-450.
    57) Merigian KS, Woodard M, & Hedges JR: Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990; 8:479-483.
    58) Merriman T & Stokes K: Small bowel obstruction secondary to administration of activated charcoal. Aust NZ J Surg 1995; 65:288-289.
    59) Minocha A, Wiley SH, & Chabbra DR: Superior efficacy of sorbitol cathartics in poisoned patients (abstract). Vet Hum Toxicol 1986; 28:494.
    60) Mizutani T, Naito H, & Oohashi N: Rectal ulcer with massive hemorrhage due to activated charcoal treatment in oral organophosphate poisoning. Hum Exp Toxicol 1991; 10:385-386.
    61) Moll J, Kerns W, & Tomaszewski C: Incidence of aspiration pneumonia in intubated patients receiving activated charcoal. J Emerg Med 1999; 17:279-283.
    62) Navarro R, Navarro K, & Krenzelok EP: Stability, effectiveness, and palatability of three activated charcoal mixtures. Vet Hum Toxicol 1980; 22:6-10.
    63) Neuvonen PJ & Olkkola KT: Activated charcoal and syrup of ipecac in prevention of cimetidine and pindolol absorption in man after administration of metoclopramide as an antiemetic agent. J Toxicol Clin Toxicol 1984; 22(2):103-114.
    64) Neuvonen PJ, Vartiainen M, & Tokola O: Comparison of activated charcoal and ipecac syrup in prevention of drug absorption. Eur J Clin Pharmacol 1983; 24(4):557-62.
    65) Neuvonen PJ: Clinical pharmacokinetics of oral activated charcoal in acute intoxications. Clin Pharmacokinetics 1982; 7:465-489.
    66) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    67) Olkkola KT: Does ethanol modify antidotal efficacy of oral activated charcoal studies in vitro and in experimental animals. Clin Toxicol 1984; 22:425-432.
    68) Park GD, Spector R, & Goldberg MJ: Effect of the surface area of activated charcoal on theophylline clearance. J Clin Pharmacol 1984; 24:289-292.
    69) Perry H & Shannon M: Emergency department gastrointestinal decontamination. Pediatric Ann 1996; 25:19-26.
    70) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    71) Pond SM: Role of repeated oral doses of activated charcoal in clinical toxicity. Med Toxicol 1986; 1:3-11.
    72) Product Information: ACTIDOSE WITH SORBITOL(TM) oral suspension, ACTIDOSE-AQUA(TM) oral suspension, activated charcoal, sorbitol oral suspension, activated charcoal oral suspension. Paddock Laboratories,Inc, Minneapolis, MN, 1998.
    73) Product Information: Actidose-Aqua(TM), , activated charcoal suspension.. Paddock Laboratories, Inc., Minneapolis,, MN, 2004.
    74) Product Information: CharcoCaps(R), , activated charcoal.. Requa, Inc., Bridgeport, CT, 2003.
    75) Product Information: activated charcoal oral capsules, activated charcoal oral capsules. Nature's Sunshine, Phoenix, AZ, 2005.
    76) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    77) Ray MJ, Padin R, & Condie JD: Charcoal bezoar: small-bowel obstruction secondary to amitryptyline overdose therapy. Digest Dis Sci 1988; 33:106-107.
    78) Roberts JR, Gracely EJ, & Schoffstall JM: Advantage of high-surface-area charcoal for gastrointestinal decontamination in a human acetaminophen model. Acad Emerg Med 1997; 4:167-174.
    79) Rosenberg PJ, Livingstone DJ, & McLellan BA: Effect of whole-bowel irrigation on the antidotal efficacy of oral activated charcoal. Ann Emerg Med 1988; 17:681-683.
    80) Ryan CF, Spigiel RW, & Zeldes G: Enhanced adsorptive capacity of activated charcoal in the presence of magnesium citrate, N.F. Clin Toxicol 1980; 17:457-461.
    81) Sabga, Dick A, & Lertzman M: Direct administration of charcoal into the lung and pleural cavity. Ann Emerg Med 1997; 30:695-697.
    82) Seder DB, Christman RA, Quinn MO, et al: A 45-year-old man with a lung mass and history of charcoal aspiration. Respir Care 2006; 51(11):1251-1254.
    83) Smilkstein MJ, Smolinske SC, & Kulig KW: Severe hypermagnesemia due to multiple-dose cathartic therapy (abstract). Vet Hum Toxicol 1986; 28:494.
    84) Spiller HA & Rogers GC: Evaluation of administration of activated charcoal in the home. Pediatrics 2002; 108:E100.
    85) Tenenbein M: Multiple doses of activated charcoal: time for reappraisal?. Ann Emerg Med 1991; 20:529-531.
    86) Tenenbein M: Whole bowel irrigation and activated charcoal (letter). Ann Emerg Med 1989; 18:707.
    87) Thakore S & Murphy N: The potential role of prehospital administration of activated charcoal. Emerg Med J 2002; 19:63-65.
    88) Underhill TJ, Greene MK, & Dove AF: A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetamol overdose. Arch Emerg Med 1990; 7(3):148-154.
    89) Vale JA, Krenzelok EP, & Barceloux GD: Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol 1999; 37:731-751.
    90) Van de Graaff WB, Thompson WL, & Sunshine I: Adsorbent and cathartic inhibition of enternal drug absorption. J Pharmacol Exper Therap 1982; 221:656-663.
    91) Watson WA, Cremer KF, & Chapman JA: Gastrointestinal obstruction associated with multiple-dose activated charcoal. J Emerg Med 1986; 4:401-407.
    92) Watson WA: Factors influencing the clinical efficacy of activated charcoal. Drug Intell Clin Pharm 1987; 21:160-166.
    93) Weber CA & Santiago RM: Hypermagnesemia: A potential complication during treatment of theophylline intoxication with oral activated charcoal and magnesium-containing cathartics. Chest 1989; 95:56-59.