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TERPIN HYDRATE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Terpin hydrate is used as an expectorant, but is NO longer approved for this indication in the United States.
    B) Terpin hydrate with codeine: see also opioids management for specific information on codeine.
    C) Terpin Hydrate with Dextromethorphan: See also dextromethorphan management.

Specific Substances

    1) 4-Hydroxy-alpha,alpha,4-trimethylcyclohexane-
    2) methanol monohydrate
    3) cis-Dipenteneglycol hydrate
    4) p-Menthane-1,8-diol monohydrate
    5) Terpene hydrate
    6) Terpine
    7) Terpinol
    8) Molecular Formula: C10-H20-2.H20
    9) CAS 80-53-5 (anhydrous)
    10) CAS 2451-01-6 (monohydrate)
    1.2.1) MOLECULAR FORMULA
    1) C10-H20-O2.H20

Available Forms Sources

    A) FORMS
    1) USP required that each 100 mL contain not less than 1.53 grams and not more than 1.87 grams of terpin hydrate and an alcohol content of 39% to 44%. .
    2) Terpin hydrate with codeine contained 10 mg codeine/5 mL.
    3) Terpin hydrate with dextromethorphan contained 10 mg of dextromethorphan per 5 mL (teaspoonful).
    B) USES
    1) It is no longer approved for use as an expectorant in the United States.

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) WITH POISONING/EXPOSURE
    1) Toxic effects of terpin hydrate are not well studied. It is most commonly found in cough syrups, along with ethanol (42% in commercial preparations), dextromethorphan (some commercial preparations), or codeine (prescription). Terpin hydrate is no longer approved for use as an expectorant in the United States.
    2) Effects of ethanol, opiods or opiod antagonists and dextromethorphan should also be considered when managing terpin hydrate intoxication.
    0.2.7) NEUROLOGIC
    A) WITH THERAPEUTIC USE
    1) Drowsiness may occur from ethanol or codeine content of terpin hydrate preparations.
    0.2.8) GASTROINTESTINAL
    A) WITH THERAPEUTIC USE
    1) Gastric irritation may occur following ingestion of terpin hydrate on an empty stomach; diarrhea, constipation, and flatulence have been reported during prolonged use.
    0.2.9) HEPATIC
    A) WITH POISONING/EXPOSURE
    1) Liver cirrhosis was reported in a single patient following prolonged high-dose use of up to 20 ounces of terpin hydrate with codeine per day.
    0.2.10) GENITOURINARY
    A) WITH THERAPEUTIC USE
    1) A diuretic effect may occur after terpin hydrate doses of 200 to 400 mg.
    2) Albuminuria and hematuria have not been reported in humans. Large doses have caused these effects in dogs.
    0.2.20) REPRODUCTIVE
    A) There was no specific information available for terpin hydrate.

Laboratory Monitoring

    A) Liver function tests and blood alcohol concentrations may be of value.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) Most preparations containing terpin hydrate will also contain CNS depressants such as ethanol or opioids; therefore emesis is NOT recommended.
    B) GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in the head down left lateral decubitus position or by endotracheal intubation. Control any seizures first.
    1) CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.
    C) 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.
    D) Terpin hydrate elixir contains 42% ethanol. Observe patient for signs of ethanol toxicity.
    E) Following an ingestion of terpin hydrate with codeine, observe patient for signs of codeine toxicity. Treatment with naloxone could be necessary.
    F) Patients ingesting terpin hydrate with dextromethorphan in amounts exceeding 10 mg/kg of dextromethorphan should be evaluated for ethanol and dextromethorphan intoxication.
    G) No serious toxicity has been reported from terpin hydrate alone.
    0.4.4) EYE EXPOSURE
    A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

    A) Doses of up to 4 grams/day in an adult produced a tendency toward constipation.
    B) As little as 10 mL of terpin hydrate elixir in a 10 kg child may produce a toxic estimated blood alcohol level (50 mg/dL).
    C) A 5 mL dose of terpin hydrate with codeine may produce toxicity (1 milligram codeine/kg) in a 10 kg child.
    D) Ingestion of 17 mg/kg dextromethorphan by a 3-month-old child over 24 hours resulted in symptoms of toxicity.

Clinical Effects

Summary Of Exposure

    A) WITH POISONING/EXPOSURE
    1) Toxic effects of terpin hydrate are not well studied. It is most commonly found in cough syrups, along with ethanol (42% in commercial preparations), dextromethorphan (some commercial preparations), or codeine (prescription). Terpin hydrate is no longer approved for use as an expectorant in the United States.
    2) Effects of ethanol, opiods or opiod antagonists and dextromethorphan should also be considered when managing terpin hydrate intoxication.

Neurologic

    3.7.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Drowsiness may occur from ethanol or codeine content of terpin hydrate preparations.

Gastrointestinal

    3.8.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Gastric irritation may occur following ingestion of terpin hydrate on an empty stomach; diarrhea, constipation, and flatulence have been reported during prolonged use.
    3.8.2) CLINICAL EFFECTS
    A) DIARRHEA
    1) WITH THERAPEUTIC USE
    a) Diarrhea has been described in humans after prolonged use (Lepine, 1887).
    B) FLATULENCE/WIND
    1) WITH THERAPEUTIC USE
    a) Indigestion and flatulence may occur following prolonged use (Lepine, 1887).
    C) CONSTIPATION
    1) WITH THERAPEUTIC USE
    a) Constipation was reported following doses of 4 grams per day (Matzel, 1905).
    D) GASTRITIS
    1) WITH THERAPEUTIC USE
    a) Irritation may occur if terpin hydrate is ingested on an empty stomach (Sumner, 1968).

Hepatic

    3.9.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Liver cirrhosis was reported in a single patient following prolonged high-dose use of up to 20 ounces of terpin hydrate with codeine per day.
    3.9.2) CLINICAL EFFECTS
    A) CIRRHOSIS OF LIVER
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Faierman & Jacobs (1973) reported a 20-year-old man who consumed up to 20 ounces per day of terpin hydrate with codeine elixir and presented with liver cirrhosis not consistent with ethanol or codeine abuse. These authors suggested that terpin hydrate may have been the causative agent, but no cause and effect relationship could be established.

Genitourinary

    3.10.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) A diuretic effect may occur after terpin hydrate doses of 200 to 400 mg.
    2) Albuminuria and hematuria have not been reported in humans. Large doses have caused these effects in dogs.
    3.10.2) CLINICAL EFFECTS
    A) POLYURIA
    1) WITH THERAPEUTIC USE
    a) Lepine (1887) reported that terpin hydrate doses of 200 to 400 mg have a diuretic effect.
    3.10.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HEMATURIA
    a) DOGS: Albuminuria and hematuria have occurred in dogs following large doses of terpin hydrate (Lepine, 1887). This has not been reported in humans for doses up to 4 grams daily (Matzel, 1905).

Reproductive

    3.20.1) SUMMARY
    A) There was no specific information available for terpin hydrate.
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) BREAST MILK
    1) There was no specific information on terpin hydrate.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Liver function tests and blood alcohol concentrations may be of value.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Liver function tests may be of value for those patients with prolonged exposure to high doses of terpin hydrate preparations.
    2) Blood alcohol concentration may be of value in the terpin hydrate intoxicated patient.

Methods

    A) CHROMATOGRAPHY
    1) Terpin hydrate has been detected by gas chromatography (Kurlansik et al, 1967a; Kurlansik et al, 1967b; Wesselman, 1968) and gas-liquid chromatography (Kubiak, 1968).

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) Patients acutely ingesting large amounts of terpin hydrate should be observed for 6 hours for signs and symptoms of toxicity.
    B) Patients ingesting large amounts of terpin hydrate elixir and terpin hydrate with codeine elixir should be admitted to a health care facility and evaluated for signs of ethanol and codeine toxicity.
    C) Patients ingesting terpin hydrate with dextromethorphan (terpin hydrate DM) in amounts exceeding 10 milligrams/ kilogram of dextromethorphan should be admitted to a health care facility and evaluated for ethanol and dextromethorphan intoxication.

Monitoring

    A) Liver function tests and blood alcohol concentrations may be of value.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) EMESIS/NOT RECOMMENDED -
    1) Most preparations containing terpin hydrate will also contain CNS depressants such as ethanol or opioids; therefore emesis is NOT recommended.
    B) 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) EMESIS/NOT RECOMMENDED
    1) Most preparations containing terpin hydrate will also contain CNS depressants such as ethanol or opioids; therefore emesis is NOT recommended.
    B) GASTRIC LAVAGE
    1) INDICATIONS: Consider gastric lavage with a large-bore orogastric tube (ADULT: 36 to 40 French or 30 English gauge tube {external diameter 12 to 13.3 mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a potentially life threatening ingestion if it can be performed soon after ingestion (generally within 60 minutes).
    a) Consider lavage more than 60 minutes after ingestion of sustained-release formulations and substances known to form bezoars or concretions.
    2) PRECAUTIONS:
    a) SEIZURE CONTROL: Is mandatory prior to gastric lavage.
    b) AIRWAY PROTECTION: Place patients in the head down left lateral decubitus position, with suction available. Patients with depressed mental status should be intubated with a cuffed endotracheal tube prior to lavage.
    3) LAVAGE FLUID:
    a) Use small aliquots of liquid. Lavage with 200 to 300 milliliters warm tap water (preferably 38 degrees Celsius) or saline per wash (in older children or adults) and 10 milliliters/kilogram body weight of normal saline in young children(Vale et al, 2004) and repeat until lavage return is clear.
    b) The volume of lavage return should approximate amount of fluid given to avoid fluid-electrolyte imbalance.
    c) CAUTION: Water should be avoided in young children because of the risk of electrolyte imbalance and water intoxication. Warm fluids avoid the risk of hypothermia in very young children and the elderly.
    4) COMPLICATIONS:
    a) Complications of gastric lavage have included: aspiration pneumonia, hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or stomach, fluid and electrolyte imbalance (Vale, 1997). Combative patients may be at greater risk for complications (Caravati et al, 2001).
    b) Gastric lavage can cause significant morbidity; it should NOT be performed routinely in all poisoned patients (Vale, 1997).
    5) CONTRAINDICATIONS:
    a) Loss of airway protective reflexes or decreased level of consciousness if patient is not intubated, following ingestion of corrosive substances, hydrocarbons (high aspiration potential), patients at risk of hemorrhage or gastrointestinal perforation, or trivial or non-toxic ingestion.
    C) 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) TERPIN HYDRATE
    1) Treatment of terpin hydrate alone is symptomatic and supportive. There is no specific antidote.
    2) TERPIN HYDRATE ELIXIR
    a) Terpin hydrate elixir contains about 42 percent ethanol. Observed toxicity may be due to the ethanol content.
    3) TERPIN HYDRATE WITH CODEINE ELIXIR
    a) Observed toxicity may be a combination of codeine and ethanol toxicity. Treatment with naloxone could be necessary.
    4) TERPIN HYDRATE WITH DEXTROMETHORPHAN ELIXIR
    a) Observed toxicity may be a combination of terpin hydrate, ethanol, and dextromethorphan.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

Summary

    A) Doses of up to 4 grams/day in an adult produced a tendency toward constipation.
    B) As little as 10 mL of terpin hydrate elixir in a 10 kg child may produce a toxic estimated blood alcohol level (50 mg/dL).
    C) A 5 mL dose of terpin hydrate with codeine may produce toxicity (1 milligram codeine/kg) in a 10 kg child.
    D) Ingestion of 17 mg/kg dextromethorphan by a 3-month-old child over 24 hours resulted in symptoms of toxicity.

Therapeutic Dose

    7.2.1) ADULT
    A) SUMMARY
    1) This agent is no longer available for use in the US; no current dosage information is available.

Minimum Lethal Exposure

    A) SUMMARY
    1) A lethal dose in humans has been estimated to be 0.5 to 5 g/kg, based on laboratory determinations of mean lethal (LD50) single doses taken by mouth or gavage in small laboratory animals (Gosselin et al, 1984).

Maximum Tolerated Exposure

    A) ADULT
    1) Up to 4 grams/day in an adult was well tolerated (Matzel, 1905).
    B) PEDIATRIC
    1) As little as 10 milliliters of terpin hydrate elixir in a 10 kilogram child may produce a toxic estimated blood alcohol level (50 milligrams/deciliter).
    2) A 5 milliliter dose of terpin hydrate with codeine may produce toxicity (1 milligram codeine/kilogram in a 10 kilogram child).
    C) INFANT
    1) Ingestion of 17 milligrams/kilogram dextromethorphan by a 3-month-old child over 24 hours resulted in symptoms of toxicity.

Serum Plasma Blood Concentrations

    7.5.2) TOXIC CONCENTRATIONS
    A) TOXIC CONCENTRATION LEVELS
    1) GENERAL
    a) No data are available for toxic serum/blood concentrations of terpin hydrate.

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Terpin hydrate is reported to act by a direct stimulation of the respiratory tract secretory glands resulting in an increased output of respiratory tract fluid (Tyler et al, 1988).

Physicochemical

Physical Characteristics

    A) White powder or glistening, colorless crystals with slightly aromatic odor and bitter taste (JEF Reynolds , 2000)

Ph

    A) 1% solution in hot water: neutral to litmus (JEF Reynolds , 2000)

Molecular Weight

    A) 190.28 (Budavari, 1996)

References

General Bibliography

    1) 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.
    2) Budavari S: The Merck Index, 12th ed, Merck & Co, Inc, Whitehouse Station, NJ, 1996.
    3) Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.
    4) Caravati EM, Knight HH, & Linscott MS: Esophageal laceration and charcoal mediastinum complicating gastric lavage. J Emerg Med 2001; 20:273-276.
    5) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    6) 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.
    7) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    8) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    9) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    10) Gosselin RE, Smith RP, & Hodge HC: Clinical Toxicology of Commercial Products, 5th ed, Williams & Wilkins, Baltimore, MD, 1984.
    11) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    12) 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.
    13) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    14) JEF Reynolds : Martindale: The Extra Pharmacopoeia (CD-ROM Version). The Pharmaceutical Press. London, England (Internet Version). Edition expires 5/31/2000; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    15) Kubiak EJ: Determination of terpin hydrate by gas-liquid chromatography. J Pharm Sci 1968; 57:473-475.
    16) Lepine: Therapeut Monatshefte 1887; 309-311.
    17) Matzel R: Zur pharmakologie der atherischen oele. Arch Internat de Pharmacodynamie et de Therapie 1905; 14:321-354.
    18) Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.
    19) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    20) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    21) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    22) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    23) Spiller HA & Rogers GC: Evaluation of administration of activated charcoal in the home. Pediatrics 2002; 108:E100.
    24) Sumner ED: Terpin hydrate preparations. J Am Pharm Assoc 1968; 8:250-254.
    25) Thakore S & Murphy N: The potential role of prehospital administration of activated charcoal. Emerg Med J 2002; 19:63-65.
    26) Tyler VE, Brady LR, & Robbers JE: Pharmacognosy, 9th ed, Lea & Febiger, Philadelphia, PA, 1988.
    27) Vale JA, Kulig K, American Academy of Clinical Toxicology, et al: Position paper: Gastric lavage. J Toxicol Clin Toxicol 2004; 42:933-943.
    28) Vale JA: Position Statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997; 35:711-719.