Introduction

Adsorbent and antidote; destructive distillation residue of organic materials with small particle size, treated to increase adsorptive power.

Uses for Charcoal, Activated

Poisonings

May be used for treatment (GI decontamination) in most oral poisonings except those involving corrosive agents (e.g., strong acids or alkalis) or substances for which its absorptive capacity is too low to be clinically useful (e.g., iron salts, lithium, boric acid, arsenic, malathion, or organic solvents such as methanol, ethanol, or ethylene glycol).

Most commonly used agent for GI decontamination in poisoned patients; however, routine administration in poisoned patients is not recommended by American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists (AACT/EAPCCT). Controlled studies demonstrating reduced morbidity and mortality generally are lacking. (See General: Poisonings, under Dosage and Administration.)

Hemoperfusion

Hemoperfusion through columns of activated charcoal to remove endogenous or exogenous toxins in uremia, hepatic failure, or acute toxicity associated with overdose of certain drugs.

GI Disorders

Adsorption of intestinal gases in the treatment of flatulence, intestinal distention, and dyspepsia; FDA classified as lacking substantial evidence of efficacy as antiflatulent or digestive aid.

Has been used alone or combined with kaolin in the management of diarrhea, but value has not been established.

Wounds and Ulcers

Has been used in dressings for suppurating wounds or ulcers to decrease odor and promote healing.

Charcoal, Activated Dosage and Administration

General

Poisonings

• Most effective when administered early, preferably within 30–60 minutes of poison ingestion.

• Multiple-dose regimens may be considered for drugs that undergo enterohepatic or enteroenteric circulation, those with a small volume of distribution, those that are not extensively protein bound, and those with a low endogenous clearance. Also may be considered for life-threatening ingestions of phenobarbital, carbamazepine, quinine, dapsone, theophylline, paraquat, or Amanita phalloides.

• Tablets or granules of activated charcoal are less effective than powder and should not be used in the treatment of poisonings.

• If help from a poison control center (800-222-1222), emergency medical facility (911), or other qualified health professional cannot be obtained quickly by medically unsupervised individuals attempting to manage acute poisoning, follow directions on the container of activated charcoal.

Administration

Oral Administration

Administer activated charcoal powder orally or via nasogastric or orogastric tube as extemporaneously prepared slurry or suspension or commercially available suspension.

Continuous nasogastric infusion or division of the total dose into smaller amounts given more frequently may improve tolerance of large doses.

If an antiemetic is required to successfully administer high dosages, a serotonin type 3 ( 5-HT₃) receptor antagonist (e.g., ondansetron) or metoclopramide may be preferred.

Sorbitol may be administered with single-dose activated charcoal or with first dose of multiple-dose regimen for palatability and laxative action; additional suspending and flavoring agents generally not recommended.

Reconstitution

Extemporaneously, mix powder with sufficient tap water (e.g., 20–30 g in at least 240 mL) to form a slurry.

Dosage

Pediatric Patients

Poisonings

Oral

Adults

Poisonings

Oral

Single dose: 25–100 g or 0.5–1 g /kg; for massive ingestion of a highly toxic substance or if limited adsorption of a lethal substance may provide substantial clinical benefit, 1.5–2 g/kg may be given.

Multiple doses: 50–100 g, then 12.5 g every hour, 25 g every 2 hours, or 50 g every 4 hours. Alternatively, 0.5–1 g/kg every 4–6 hours for lower-risk ingestions and larger doses (e.g., 1–1.5 g/kg per hour) for more serious ingestions (e.g., life-threatening ingestion of extended-release theophylline). Continue multiple-dose therapy until patient recovers or major toxicity resolves.

GI Disorders

Oral

0.6–5 g as a single dose or 0.975–3.9 g 3 times daily after meals.

Contraindications

• Before endoscopy after ingestion of corrosive agents, unless necessary to adsorb another ingested toxin; may obscure endoscopic evaluation of gastroesophageal lesions.

• Patients with an unprotected airway, a GI tract that is not anatomically intact, and where risk or severity of aspiration may be increased (e.g., hydrocarbon ingestions).

• Multiple-dose regimen in presence of ileus or bowel obstruction.

Warnings/Precautions

Warnings

Petroleum Distillates Ingestion

Do not use for ingestion of petroleum distillates (e.g., gasoline, kerosene); limited efficacy, and toxicity other than aspiration is rare.

Sorbitol and Cathartics

Sorbitol, present in many commercial preparations, should be administered only with a single dose of activated charcoal or the first dose of multiple-dose activated charcoal; no more than 1 or 2 doses of sorbitol or another cathartic (if required) should be used in a 24-hour period because of potential for dehydration, hypotension, electrolyte disturbances (e.g., hypernatremia) associated with excessive catharsis.

If sorbitol is used with an initial dose of activated charcoal, a second cathartic generally should not be administered.

Use sorbitol with caution in children and geriatric patients; monitor hydration and electrolytes.

General Precautions

GI Effects

May cause vomiting, constipation, diarrhea, and GI obstruction or fecal impaction in dehydrated patients.

Generally should not be used when decreased peristalsis present (reduced or absent bowel sounds); if risk of GI obstruction, perforation, or hemorrhage exists; if surgery has occurred recently; or if electrolyte imbalance or volume depletion exists.

Pulmonary Effects

Aspiration of activated charcoal may lead to more severe complications than aspiration of gastric contents alone. Aspiration from vomiting or misdirected nasogastric catheter has resulted in granulomatous reactions, bronchiolitis obliterans, tissue reaction to suspension agents (sorbitol, povidone), increased lung permeability, and rarely, death.

Take measures to reduce the risk of aspiration (e.g., placement of a cuffed endotracheal tube in patients with impaired laryngeal reflexes).

Use of Fixed Combination

When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

Common Adverse Effects

Vomiting, diarrhea, constipation, black stools.

General

Poisonings

• Most effective when administered early, preferably within 30–60 minutes of poison ingestion.

• Multiple-dose regimens may be considered for drugs that undergo enterohepatic or enteroenteric circulation, those with a small volume of distribution, those that are not extensively protein bound, and those with a low endogenous clearance. Also may be considered for life-threatening ingestions of phenobarbital, carbamazepine, quinine, dapsone, theophylline, paraquat, or Amanita phalloides.

• Tablets or granules of activated charcoal are less effective than powder and should not be used in the treatment of poisonings.

• If help from a poison control center (800-222-1222), emergency medical facility (911), or other qualified health professional cannot be obtained quickly by medically unsupervised individuals attempting to manage acute poisoning, follow directions on the container of activated charcoal.

Administration

Oral Administration

Administer activated charcoal powder orally or via nasogastric or orogastric tube as extemporaneously prepared slurry or suspension or commercially available suspension.

Continuous nasogastric infusion or division of the total dose into smaller amounts given more frequently may improve tolerance of large doses.

If an antiemetic is required to successfully administer high dosages, a serotonin type 3 ( 5-HT₃) receptor antagonist (e.g., ondansetron) or metoclopramide may be preferred.

Sorbitol may be administered with single-dose activated charcoal or with first dose of multiple-dose regimen for palatability and laxative action; additional suspending and flavoring agents generally not recommended.

Reconstitution

Extemporaneously, mix powder with sufficient tap water (e.g., 20–30 g in at least 240 mL) to form a slurry.

Dosage

Pediatric Patients

Poisonings

Oral

Adults

Poisonings

Oral

Single dose: 25–100 g or 0.5–1 g /kg; for massive ingestion of a highly toxic substance or if limited adsorption of a lethal substance may provide substantial clinical benefit, 1.5–2 g/kg may be given.

Multiple doses: 50–100 g, then 12.5 g every hour, 25 g every 2 hours, or 50 g every 4 hours. Alternatively, 0.5–1 g/kg every 4–6 hours for lower-risk ingestions and larger doses (e.g., 1–1.5 g/kg per hour) for more serious ingestions (e.g., life-threatening ingestion of extended-release theophylline). Continue multiple-dose therapy until patient recovers or major toxicity resolves.

GI Disorders

Oral

0.6–5 g as a single dose or 0.975–3.9 g 3 times daily after meals.

May decrease absorption of and therapeutic response to other orally administered drugs. Drugs other than those used for GI decontamination or antidotes for ingested toxins should not be given within 2 hours of activated charcoal; if necessary, concomitant drug therapy can be given parenterally.

Specific Drugs