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SCULLCAP

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Scullcap, whose scientific name is Scutellaria laterifolia L., is a member of the mint family and is native to the United States.
    1) A related species, Scutellaria baicalensis Georgii, is commonly called scullcap in Chinese herbal medicine.

Specific Substances

    1) Scutellaria laterifolia L.
    2) Skullcap
    3) Helmetflower
    4) Hoodwort
    5) Mad-dog weed
    6) Madweed
    7) Virginian scullcap
    8) Quaker Bonnet

Available Forms Sources

    A) FORMS
    1) Scullcap is available as the dried plant, liquid extract, and tincture (Wong et al, 1998; (Newall et al, 1996).
    B) SOURCES
    1) Scullcap consists of the dried aerial parts of the Scutellaria lateriflora L. gathered during the late flowering period (Anon, 1993).
    C) USES
    1) Scullcap is used as a sedative and an anticonvulsant (Wong et al, 1998).
    2) In the 18th century, scullcap was promoted as an effective treatment for the management of hydrophobia (rabies) (Anon, 1993).

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) Human overdose information is limited. Reported overdose effects, following scullcap (S. lateriflora) administration, have included giddiness, stupor, confusion, and seizures.
    B) Hepatotoxicity has been associated with therapeutic ingestions of scullcap-containing products.
    1) There have been reports of hepatotoxicity associated with herbal products that were labeled as containing scullcap, but actually contained germander.
    0.2.7) NEUROLOGIC
    A) Scullcap overdose effects may include giddiness, stupor, confusion, and seizures.
    0.2.9) HEPATIC
    A) Hepatotoxicity, including hepatic failure, has been associated with therapeutic ingestions of scullcap-containing products.
    0.2.20) REPRODUCTIVE
    A) Limited information is known regarding the toxicity of scullcap during pregnancy. Reportedly, scullcap has been used traditionally to eliminate a mother's afterbirth and to promote menstruation, therefore scullcap is not recommended for use during pregnancy.

Laboratory Monitoring

    A) Monitor serum liver enzyme levels in symptomatic patients.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) Most cases of toxicity reported have involved chronic ingestion of scullcap. It is not known if gastric decontamination will be useful in acute ingestions.
    B) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
    C) EMESIS: Ipecac-induced emesis is not recommended because of the potential for CNS depression and seizures.
    D) Treatment is SYMPTOMATIC and SUPPORTIVE.
    E) SEIZURES: Administer a benzodiazepine; DIAZEPAM (ADULT: 5 to 10 mg IV initially; repeat every 5 to 20 minutes as needed. CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed) or LORAZEPAM (ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist. CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue).
    1) Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years).
    2) Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.

Range Of Toxicity

    A) A toxic dose has not been established.

Clinical Effects

Summary Of Exposure

    A) Human overdose information is limited. Reported overdose effects, following scullcap (S. lateriflora) administration, have included giddiness, stupor, confusion, and seizures.
    B) Hepatotoxicity has been associated with therapeutic ingestions of scullcap-containing products.
    1) There have been reports of hepatotoxicity associated with herbal products that were labeled as containing scullcap, but actually contained germander.

Neurologic

    3.7.1) SUMMARY
    A) Scullcap overdose effects may include giddiness, stupor, confusion, and seizures.
    3.7.2) CLINICAL EFFECTS
    A) SEIZURE
    1) Some sources report that seizures may occur following overdose ingestions of scullcap, but these events are not well documented (Newall et al, 1996) Wong et al, 1998).
    B) STUPOR
    1) Some sources report that overdose ingestions of scullcap may result in the occurrence of stupor, but this is not well documented (Newall et al, 1996).
    C) CLOUDED CONSCIOUSNESS
    1) Some sources state that giddiness and confusion have been reported following scullcap overdose ingestions, but this information is not well documented (Newall et al, 1996) Wong et al, 1998).

Hepatic

    3.9.1) SUMMARY
    A) Hepatotoxicity, including hepatic failure, has been associated with therapeutic ingestions of scullcap-containing products.
    3.9.2) CLINICAL EFFECTS
    A) HEPATIC FAILURE
    1) CASE REPORT - A 28-year-old male had ingested scullcap, 6 tablets daily, and pau d'arco, an herbal preparation, and, six months later, presented with jaundice and mild right upper-quadrant tenderness. Laboratory testing revealed elevated liver enzyme levels, an elevated bilirubin level of 29 mg/dL, and a prothrombin time of 20 seconds. Over the next 5 weeks, the patient developed progressive liver failure with hypoglycemia, hepatorenal syndrome, encephalopathy, gastrointestinal bleeding, ascites, and sepsis. The patient died shortly after receiving a liver transplant. Examination of the explant liver showed hepatic necrosis associated with fibrous stenosis and extensive perivenular fibrosis, and bridging indicative of veno-occlusive disease (Hullar et al, 1999).
    a) The authors speculated that the patient's scullcap preparation was contaminated with a pyrrolizidine alkaloid thereby causing the hepatotoxicity resulting in the development of veno-occlusive disease.
    B) TOXIC HEPATITIS
    1) Three patients ingested Kalms tablets, an herbal product, for approximately 2 to 8 weeks, and subsequently developed hepatotoxicity. Each patient presented with jaundice, dark urine, pale stools, and elevated liver enzyme levels. In two of the patients, the liver biopsy showed acute hepatitis. The hepatotoxicity resolved in all three patients after discontinuation of the tablets (MacGregor et al, 1989).
    a) Prior to 1984, Kalms tablets were reported to contain scullcap only, and after 1984 the ingredients included valerian, asafetida, hops, and gentian. It is unknown which formulation was ingested by the patients, but the authors speculated that scullcap and valerian were the most likely hepatotoxic components.
    2) Perharic et al (1994) reported the occurrence of jaundice and hepatitis following chronic ingestions of herbal combination products containing scullcap.
    3) CASE REPORT - A 77-year-old female ingested comfrey- and scullcap-containing herbal products for approximately 6 months and subsequently presented with fatigue, weight loss, dark urine, and jaundice. Lab exams revealed elevated liver enzyme levels. The herbal remedies were discontinued upon admission into the hospital and, two weeks later, the patient's liver enzyme levels had improved significantly (Miskelly & Goodyer, 1992).

Reproductive

    3.20.1) SUMMARY
    A) Limited information is known regarding the toxicity of scullcap during pregnancy. Reportedly, scullcap has been used traditionally to eliminate a mother's afterbirth and to promote menstruation, therefore scullcap is not recommended for use during pregnancy.
    3.20.2) TERATOGENICITY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the teratogenic potential of this agent.
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) Limited information is known regarding the toxicity of scullcap during pregnancy. Reportedly, scullcap has been used traditionally to eliminate a mother's afterbirth and to promote menstruation, therefore scullcap is not recommended for use during pregnancy (Newall et al, 1996).
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects of this agent during lactation.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor serum liver enzyme levels in symptomatic patients.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) Monitor serum liver enzyme levels in symptomatic patients.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY -
    1) Most cases of toxicity reported have involved chronic ingestions of scullcap. It is not known if gastric decontamination will be useful in treating acute scullcap ingestions.
    B) EMESIS/NOT RECOMMENDED -
    1) EMESIS: Ipecac-induced emesis is not recommended because of the potential for CNS depression and seizures.
    C) ACTIVATED CHARCOAL -
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
    2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) 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 occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, 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). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Most cases of toxicity reported have involved chronic ingestion of scullcap. It is not known if gastric decontamination will be useful in acute ingestions.
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) 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 occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, 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). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) SUPPORT
    1) Treatment is SYMPTOMATIC and SUPPORTIVE.
    B) SEIZURE
    1) SUMMARY
    a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
    b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
    c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).
    2) DIAZEPAM
    a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
    b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
    c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .
    3) NO INTRAVENOUS ACCESS
    a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
    b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).
    4) LORAZEPAM
    a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
    b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
    c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2009; Chin et al, 2008).
    5) PHENOBARBITAL
    a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
    b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
    c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
    d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
    e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
    f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).
    6) OTHER AGENTS
    a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):
    1) VALPROATE SODIUM: ADULT DOSE: An initial dose of 20 to 40 mg/kg IV, at a rate of 3 to 6 mg/kg/minute; may give an additional dose of 20 mg/kg 10 minutes after loading infusion. PEDIATRIC DOSE: 1.5 to 3 mg/kg/minute (Brophy et al, 2012).
    2) LEVETIRACETAM: ADULT DOSE: 1000 to 3000 mg IV, at a rate of 2 to 5 mg/kg/min IV. PEDIATRIC DOSE: 20 to 60 mg/kg IV (Brophy et al, 2012; Loddenkemper & Goodkin, 2011).
    3) LACOSAMIDE: ADULT DOSE: 200 to 400 mg IV; 200 mg IV over 15 minutes (Brophy et al, 2012). PEDIATRIC DOSE: In one study, median starting doses of 1.3 mg/kg/day and maintenance doses of 4.7 mg/kg/day were used in children 8 years and older (Loddenkemper & Goodkin, 2011).
    4) TOPIRAMATE: ADULT DOSE: 200 to 400 mg nasogastric/orally OR 300 to 1600 mg/day orally divided in 2 to 4 times daily (Brophy et al, 2012).

Range Of Toxicity

Summary

    A) A toxic dose has not been established.

Therapeutic Dose

    7.2.1) ADULT
    A) GENERAL
    1) DRIED HERB - 1 to 2 teaspoonfuls infused, by boiling water, for 10 to 15 minutes, then ingested three times daily or as needed (DL Hoffman , 1999).
    2) LIQUID EXTRACT (1:1 in 25% alcohol) - 2 to 4 milliliters three times daily (Newall et al, 1996).
    3) TINCTURE (1:5 in 45% alcohol) - 1 to 2 milliliters three times daily (Newall et al, 1996).
    7.2.2) PEDIATRIC
    A) GENERAL
    1) Doses for the pediatric population have not been established.

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Various species of Scutellaria contain several flavonoid pigments, including baicalein, scutellarein, and wogonin, which may contribute to the herb's anti- spasmodic effects, although tests in mice have shown that baicalein had no detectable antispasmodic activity and wogonin had very slight antispasmodic activity (Tyler, 1993).

References

General Bibliography

    1) AMA Department of DrugsAMA Department of Drugs: AMA Evaluations Subscription, American Medical Association, Chicago, IL, 1992.
    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: Scullcap monograph in Olin BR (Ed): The Lawrence Review of Natural Products, Facts and Comparisons, St Louis, MO, 1993.
    4) Brophy GM, Bell R, Claassen J, et al: Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17(1):3-23.
    5) Chamberlain JM, Altieri MA, & Futterman C: A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Ped Emerg Care 1997; 13:92-94.
    6) Chin RF , Neville BG , Peckham C , et al: Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study. Lancet Neurol 2008; 7(8):696-703.
    7) Choonara IA & Rane A: Therapeutic drug monitoring of anticonvulsants state of the art. Clin Pharmacokinet 1990; 18:318-328.
    8) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    9) DL Hoffman : Herbal Materia Medica: scutellaria laterifolia. HealthWorld Online, Inc. Los Angeles, CA. 1999. Available from URL: http://www.healthy.net/library/books/hoffman/materiamedica/SKULLCAP.HTM.
    10) Dagnone D, Matsui D, & Rieder MJ: Assessment of the palatability of vehicles for activated charcoal in pediatric volunteers. Pediatr Emerg Care 2002; 18:19-21.
    11) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    12) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    13) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    14) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    15) Guenther Skokan E, Junkins EP, & Corneli HM: Taste test: children rate flavoring agents used with activated charcoal. Arch Pediatr Adolesc Med 2001; 155:683-686.
    16) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    17) Hegenbarth MA & American Academy of Pediatrics Committee on Drugs: Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008; 121(2):433-443.
    18) Hullar TE, Sapers BL, & Ridker PM: Herbal toxicity and fatal hepatic failure (letter). Amer J Med 1999; 106:267-268.
    19) Hvidberg EF & Dam M: Clinical pharmacokinetics of anticonvulsants. Clin Pharmacokinet 1976; 1:161.
    20) Loddenkemper T & Goodkin HP: Treatment of Pediatric Status Epilepticus. Curr Treat Options Neurol 2011; Epub:Epub.
    21) MacGregor FB, Abernethy VE, & Dahabra S: Hepatotoxicity of herbal remedies. Br Med J 1989; 299:1156-1157.
    22) Manno EM: New management strategies in the treatment of status epilepticus. Mayo Clin Proc 2003; 78(4):508-518.
    23) Miskelly FG & Goodyer LI: Hepatic and pulmonary complications of herbal medicines (letter). Postgrad Med J 1992; 68:935.
    24) Newall CA, Anderson LA, & Phillipson JD: Herbal Medicine: a Guide for Health-Care Professionals, Pharmaceutical Press, London, UK, 1996.
    25) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    26) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    27) Product Information: diazepam IM, IV injection, diazepam IM, IV injection. Hospira, Inc (per Manufacturer), Lake Forest, IL, 2008.
    28) Product Information: lorazepam IM, IV injection, lorazepam IM, IV injection. Akorn, Inc, Lake Forest, IL, 2008.
    29) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    30) Scott R, Besag FMC, & Neville BGR: Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomized trial. Lancet 1999; 353:623-626.
    31) Spiller HA & Rogers GC: Evaluation of administration of activated charcoal in the home. Pediatrics 2002; 108:E100.
    32) Sreenath TG, Gupta P, Sharma KK, et al: Lorazepam versus diazepam-phenytoin combination in the treatment of convulsive status epilepticus in children: A randomized controlled trial. Eur J Paediatr Neurol 2009; Epub:Epub.
    33) Thakore S & Murphy N: The potential role of prehospital administration of activated charcoal. Emerg Med J 2002; 19:63-65.
    34) Tyler VE: The Honest Herbal: A Sensible Guide to the Use of Herbs and Related Remedies, Pharmaceutical Products Press, New York, NY, 1993.