#toxicology/treatments
> [!Key Ponts]
> see [[#Drugs not bound to activated charcoal]]
>
![[Pasted image 20230710190803.png]]
# Single dose activated charcoal
## indications
- ingestion within 2 hours (4 hours if modified release preparations, anticholinergic agents, or massive ingestions)
- drug is bound by activated charcoal
## contraindications
- non-toxic agents
- unprotected airway
- risk of seizures
- ==active vomiting==
**can cause significant pneumonitis if aspirated**
nb: ileus is not a contraindication to single dose activated charcoal
> - NAC is so effective that we tend not to give activated charcoal in paracetamol overdose because benefits don't always outweigh risk
> - but AC is more useful in cases where there is *not* an antidote
## ==Drugs not bound to activated charcoal==
- metals (including lithium)
- toxic alcohols
- corosives (acids, alkalis)
- hydrocarbons (petrol, essential oils, kerosene)
- cyanide
- organophosphates
## Dose
Adults: 50g
Children: 1g/kg up to 50g
(ideal dose is 10:1 AC to drug)
# Multi dose activated charcoal
> mnemonic: **LVACC**
> Lamotrigene
> Valproate
> aminophylline/**aspirin**
> **carbamezapine** or concentration-forming drugs like aspirin
> Colchicine
> dapsone
> quinine
> Theophylline
> barbituates
> digoxin according to Dunn (not austin)
- involved repeated adminisrated of activated charcoal to enhance elimination of drug from body
- should not delay haemodialysis when this is indicated
- can be useful in large ingestions of drugs that delay gastric emptying (eg [[Anticholinergic toxicity]]), modified release preparations, or in cases of possible **parmacobezoar** (eg large [[Aspirin overdose]])
- [[Valproate|sodium valproate]]
> form of elimination because creates a gradient from hepatic to enteric circulation to help with elimination (kinda like "GI dialysis")
```dataview
TABLE WITHOUT ID
file.link AS "Antidote: MDAC" FROM "" WHERE contains(Antidote, "MDAC") SORT file.name ASC
```
## contraindications
- unprotected airway
- bowel obstruciton / ileus
## Drugs for multi-dose activated charcoal
May be helpful for the following drugs:
- [[carbamazepine]]
- lamotrigine
- [[colchicine]]
- [[phenytoin]]
- theophylline
- dapsone
- quinine
- [[Valproate]]
## Dose for MDAC
Adults: initally 50g then repeat 25g Q2H or 50g Q4H
kids: 1g/kg (max 50g) and repeat 0.5g/kg Q4H (or 0.25g/kg Q2H)
> check with clinical toxicologist regarding duration of therapy, depends on specific drug
# Whole bowl irrigation
> Mnemonic: **VPILES**
> - Verapamil/diltazem
> - body packers and potassium
> - iron (metals) → only elemental, not liquid or chewable
> - lithium ,
> - enteric coated drugs
> - sustained release preparation medications eg large venlafaxine od
consider in life-threating ingestions of:
- modified release preparations of [[Calcium channel blocker overdose]] (eg verapamil or diltiazem), venlafaxine
- metals (KCl, iron, lead, [[Lithium Toxicity|lithium]])
- lithium if large overdose of extended release
- symptomatic arsenic trioxide ingestion
- body packers and body stuffers
likely most effective if started within 4 hours of ingestions
## Solutions for WBI
contain poly-ethylene glycol (PEG); use one
- Movicol - 8 sachets in 2L water
- moviprep A & B - in 2L water
- glycoprep 200g - 1 sachet in 3L water
- glyocprep C - 2 sachets in 2L water
- colonLYTELY 2 sachets in 2L water
## Technique
- insert NGT
- 2L of poly-ethylene glycol per hour
- head up 45 deg
- also give maxalon 10-20mg IV Q6H
## Therapeutic endpoint
- rectal effulent is clear (12-24 h)
# Haemodialysis
> mnemonic: **CAVAL**
> - carbamazepine
> - alcohols
> - valproate
> - aspirin
> - lithium
>
> - methanol
> - toxic alcohols (ethylene glycol)
> - isopropanol
> - theyophylline
> - phenobarbitone
- [[Haemoptysis]] enhances elimination of any drug that is:
- small molecule
- small volume of distribution
- rapid redistribution fro tissues and plasma
- slow endogenous elimination
- high solubility in water
## tox indications for haemodialysis:
- Toxic alcohol poisioning
- [[toxic alcohols#Methanol]]
- [[toxic alcohols#Ethylene Glycol]]
- Theophylline
- severe [[Aspirin overdose]]
- severe [[Lithium Toxicity]]
- phenobarbitone coma
- metformin lactic acidosis (?? really)
- massive [[Valproate]] overdose
- massive [[carbamazepine]] overdose
- potassium overdose with life-threatening [[hyperkalemia]]
> note, colchicine may require haemodialysis due to renal failure, but **it does NOT eliminate colchicine**
# urinary alkalinisation
For:
- [[Aspirin overdose]]
- methotrexate
- phenobarbitone
- Start with a 1-2 mEq/kg bolus of [[HCO3 therapy|HCO3]] followed by an infusion at 1.5-2x maintenance
- Goal urine pH should be maintained at 7.5-8.0
- Resultant **hypokalemia** (due to induced alkalosis) must be corrected in order to achieve maximum alkalinization.
> need to have enough potassium to prevent K/H exchange in kidney ; won't work if hypokalemic.
# Enhanced elimination table
![[Pasted image 20230701121933.png]]
# Related Questions
## activated charcoal
- [ ] 1Q: [Polypharmacy overdose](x-devonthink-item://5B3989BE-73BA-4EB6-8D42-758DAA229A56?page=20) -- [Answer](x-devonthink-item://F6B57015-DA53-404D-804A-55DCA60971A6?page=19)
- [ ] 2Q: [Overdose](x-devonthink-item://80040649-2DDB-4266-9A7C-4DE4E6DD4AE6?page=14) -- [Answer](x-devonthink-item://C96EDD2F-137A-43E5-80EE-5F42C5971D55?page=19)
- [ ] 3Q: [Paracetamol Overdose](x-devonthink-item://3D57C3FE-3B52-42E0-9FBD-E4034F60C5B7?page=6) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=22)
## charcoal
- [ ] 8Q: [Altered consciousness and altered ECG](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=5) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=6)