Home administration of charcoal: can mothers administer a therapeutic dose?

This study evaluated whether children under 3 years of age would drink a therapeutic dose of activated charcoal (AC) in a simulated home environment. Children 13 to 35 months participated with their mothers. Children were randomly assigned to receive AC mixed with regular cola or with diet cola. Maximum time allowed to drink the AC was 30 min. A therapeutic dose was defined as 1 gm/kg or 15 g (the entire bottle) if the child weighed >15 kg. Fifteen children participated; eight received AC with regular cola; seven received AC with diet cola. Ages ranged from 13 to 30 months (average 19 months; SD 4.5 months). Eleven of 15 (73%) drank <1/2 (60 mL) of the AC. Nine of 15 (60%) drank <1/4 of the AC (30 mL). None of these children ingested a therapeutic dose. Three of the 15 (20%) drank > or =100 mL equaling a therapeutic dose. All three were in the group receiving regular cola; 62.5% (five of the eight) who had AC mixed with regular cola did not drink a therapeutic dose. The potential for failure of home AC administration needs to be considered when making the decision to recommend home stocking of AC. Mixing AC with cola does not ensure successful administration. Diet cola does not appear to be an alternative.

Copperhead snakebites: clinical severity of local effects.

STUDY OBJECTIVE: We sought to evaluate the type and extent of local reactions after copperhead snakebites. METHODS: We performed a retrospective evaluation of copperhead snakebites in West Virginia between January 1, 1995, and September 30, 1999. A local effect scoring system was used to define a clinically significant local reaction. A bite was considered clinically significant if the bitten individual's average local effect score was 3 to 4 (range, 0 to 4). RESULTS: Ninety-two patients met the inclusion criteria; an average local effect score of 3 to 4 was documented in 33% (n=30). The foot was the most common bite location (46% of all bites); 87.5% of bites to the finger (n=8) resulted in a score of 3 to 4. Eight (36%) of 22 patients who presented to the emergency department within 2 hours of a bite and whose highest local effect score was 3 to 4 did not have their highest score until greater than 4 hours after the bite. The average length of stay (score 3 to 4) was 3.4 days compared with 1.1 days for those with a score of 3 or less. CONCLUSION: Clinically significant local effects (eg, pain requiring parenteral analgesics, ecchymosis, swelling of over one half of the bitten extremity) occurred in one third of patients in our study. The generalization of copperhead snakebites as mild or of benign clinical significance should be reconsidered.

Single dose pharmacokinetics of syrup of ipecac.

Syrup of ipecac (SI) has been used medicinally since the 1500s; however, little is known about the pharmacokinetics in humans of SI's active ingredients, emetine and cephaeline. The objective of this study was to evaluate the rate of absorption and the rate of elimination of emetine and cephaeline. Ten healthy, adult, human volunteers between 18 and 45 years of age who were of ideal body weight (body mass index 20-25) completed this study. After an overnight fast, 30 mL SI were ingested. Blood samples were collected 30, 45, 60, 90, 120, 150, and 180 minutes post-ingestion and urine was collected throughout the study period. Plasma and urine concentrations of emetine and cephaeline were measured by reverse-phase HPLC with fluorescence detection. In virtually all subjects, emetine and cephaeline were detected within 5-10 minutes of dosing with the time to maximum concentration being approximately 20 minutes. The mean areas under the concentration-time curve (AUC) for both emetine and cephaeline were similar; however, the ratio of mean cephaeline maximum concentration (Cmax) to emetine Cmax was approximately 1.5. Four of the ten subjects exhibited a type of concentration-time profile in which the levels of cephaeline were substantially higher than those of emetine and the levels of cephaeline were substantially higher than noted for the other six subjects. In these remaining six subjects, the levels of emetine and cephaeline were lower than 10 ng/mL at all time-points. An initial elimination phase was noted in some subjects but not in others. Individuals in whom an initial elimination phase was not observed also exhibited low levels of both alkaloids as compared with the other subjects suggestive of a slower distribution phase. Less than 0. 15% of the administered emetine and cephaeline was recovered in the urine at 3 hours. No relationship between vomiting episodes and peak concentrations of emetine or cephaeline was found. Administration of SI results in rapid appearance and disappearance of emetine and cephaeline in plasma becoming almost undetectable at 3 hours. Very little of either alkaloid is eliminated in the urine within this time period, suggesting extensive distribution. The length of time that an administered dose of SI can result in the detection of emetine and/or cephaeline in the urine has not been determined; future studies in humans are required.

Accidental intranasal administration of phenol.

A 79-y-old man developed erythema and superficial sloughing of the turbinate following accidental intranasal administration of 89.2% phenol solution. Previous documented reports of phenol exposure include exposures via dermal and oral routes, but no reports of nasal phenol administration were found.

Emergency physicians perceptions of drug screens at their own hospitals.

Previous studies evaluated the prudent use and potential over use of drug screens in clinical decision making. However, the percentage of emergency physicians who can correctly identify which drugs are found on their hospital's basic drug screens has not been established. Results of physician closed-ended questionnaires were compared to the results of a telephone survey with each physician's individual hospital laboratory. Eighty-one (35.7%) of 227 emergency physicians responded. Four (4.9%) correctly identified what was on their individual institution's urine drug screens and 17 (21%) correctly identified what was on serum screens. In other results, 74.3% erroneously relayed that all benzodiazepines can be found on urine drug screens and 46.3% incorrectly answered that acetaminophen would be found on basic quantitative serum screens. Drug screen results can be misinterpreted if the drugs the physician expects to be screened for, and what is actually screened for, are not the same. Pharmacy and laboratory personnel have a responsibility to keep the physician informed of drug screen issues. They should be proactive in advising physicians of changes in drug testing and new drug screening methods or by providing reports on the occurrence of false positive results.

Use of ondansetron and other antiemetics in the management of toxic acetaminophen ingestions.

BACKGROUND: Patients presenting with acetaminophen toxicity and vomiting are often treated with antiemetics so that orally administered N-acetylcysteine can be retained. The policy at the West Virginia Poison Center is to reserve ondansetron, an antiemetic with a higher cost than other antiemetics, as a second line agent for patients presenting within 8 hours of an acetaminophen ingestion. METHODS: A retrospective study of cases between January 1993 and December 1995, in which the primary or secondary drug ingested was an adult-strength, acetaminophen-only formulation and the ingestion resulted in vomiting. Seventy-eight patients with laboratory-verified acetaminophen toxicity and vomiting were evaluated for the type of antiemetics used and the antiemetic's effectiveness. RESULTS: Of the 78 acetaminophen toxic patients with vomiting, 17/51 patients (33.3%) who received a nonondansetron antiemetic failed therapy and required IV ondansetron. Of the 24 patients who received ondansetron, 4 patients (16.7%) failed therapy. All four patients who failed ondansetron therapy had previously failed other antiemetic therapy. DISCUSSION: Although ondansetron had a lower failure rate than nonondansetron antiemetics, almost two-thirds of acetaminophen toxic patients with vomiting did not require ondansetron to control their vomiting. Health care costs would have been higher had these patients received ondansetron as their initial therapy. Antiemetics were found to be highly effective as only 3/78 patients (4%) required IV N-acetylcysteine secondary to antiemetic failure. CONCLUSIONS: Ondansetron should be utilized as a second-line agent in the management of acetaminophen toxic patients with vomiting. Because of its lower failure rate, ondansetron should be administered as a first-line agent in patients with a delay in N-acetylcysteine administration approaching 8 or more hours.

Methods used to decrease lithium absorption or enhance elimination.

OBJECTIVE: To review current methods, well documented and investigational, being used to decrease lithium absorption or enhance lithium elimination. METHODS: The basic science and clinical literature on lithium were reviewed by a comprehensive Medline search from 1984 to 1996. Additional references were identified by reviewing the reference citations from the results of the Medline search. RESULTS: Prevention of Absorption: Whole bowel irrigation has been demonstrated to be an effective means of enhancing lithium removal from the gastrointestinal tract. Sodium polystyrene sulfonate resin administration has been shown to be effective in binding lithium elimination in animal and human models. However, the lower limits of effective sodium polystyrene sulfonate dosing and the extent of potassium lowering in humans are questions that need to be answered before sodium polystyrene sulfonate resin can be recommended for routine, use. Enhancement of Elimination: Saline or forced diuresis is not effective in enhancing lithium elimination unless the patient is volume or sodium depleted. The use of continuous arteriovenous hemodiafiltration or low dose dopamine to enhance lithium elimination has only been documented in case reports. Intravenous aminophylline (theophylline) is not consistently effective and its risks outweigh possible benefits. The literature supports hemodialysis as a well documented and effective means of enhancing lithium elimination. Controversy exists over the appropriate indications for its initiation. DISCUSSION: Given the wide interpatient variability in lithium pharmacokinetics, single case reports do not provide sufficient evidence of the effectiveness of a given method to enhance

A sodium rodizonate lead testing kit for home use--valid for paint and soil samples?

BACKGROUND: The presence of lead in consumer products has become an important health issue. Lead Check is a home test kit promoted to detect lead on any surface at government action levels with 96.6% accuracy. Validation of this kit's sensitivity and specificity is necessary because false negatives may give the user a false sense of security, while false positives may result in unnecessary concern. METHODS: Aliquots of paint and soil samples submitted to a county health department were collected. Lead Check kits were used to analyze these samples in accordance with manufacturer's instructions. Each sample was tested with three reagent swabs; one stored at 56 degrees C (room temperature), and one swab each stored at 22 degrees C (cold) and 92 degrees C (hot) for 24 hours. Results were compared to quantitative results obtained from the health department's lead testing laboratory. RESULTS: The sensitivity of the swabs for testing lead in paint was 91.7% for all three temperatures with a specificity of 88.9% (22 degrees C), 77.8% (56 degrees C), and 88.9% (92 degrees C). The sensitivity of the swabs for testing lead in soil was significantly less: 28.6% at 22 degrees C, 28.6% at 56 degrees C (room temperature) and 85.7% at 110 degrees C. The specificity for testing lead in soil was 100% for all temperatures. CONCLUSIONS: The claim that Lead Check can detect lead in paint at government action levels (0.5% lead) appears to be accurate; however, the claim that this kit can reliably detect lead in soil at 1000 ppm was not verified. The swabs were found to maintain their ability to detect lead even if not stored under ideal conditions.

Nursing attitudes towards charcoal administration--impact on patient care.

In 1990, the American Association of Poison Control Centers identified that for the first time activated charcoal (AC) use had surpassed that of syrup of ipecac. As nurses are given the primary responsibility for AC administration, it was important to determine how AC was being administered, as well as nursing attitudes towards AC that have an impact on patient care. Surveys were mailed to the Emergency Departments (EDs) of 60 hospitals served by the Pittsburgh Poison Center (PPC); 6 nurses/ED, 2 from each shift, were asked to respond. Forty-four EDs responded (73.3%) providing 237 surveys. Eighty-two percent of nurses stated they disliked administering AC for the following reasons: Patients did not like AC (64.4%); AC soiled clothing (54.7%); and AC took too long to give (35.5%). Prior to administration, 70.9% of the nurses responded that they shook the AC a minimum of 20 times; 9.3% commented that AC still failed to resuspend. Specific administration techniques included attempts to mask the appearance the the AC (67.1%) and attempts to increase AC's palatability by adding a flavoring agent (37.6%) or by using AC with sorbitol instead of aqueous AC (25.7%). Of note was that the flavoring agents used were those known to decrease AC's ability to adsorb toxins. As the majority of problems with AC involved its poor resuspendibility and palatability, an AC fact sheet was developed and mailed to EDs to provide suggestions on AC resuspension and means of enhancing patient acceptance without compromising AC's adsorptive capacity. By surveying nursing attitudes toward AC and the administration techniques being utilized, the PPC was able to identify specific problems and address nursing concerns in a way that positively impacts patient care.

Efficiency of whole bowel irrigation with and without metoclopramide pretreatment.

Whole bowel irrigation (WBI) with a polyethylene glycol electrolyte lavage solution (PEG-ELS) is a gastrointestinal (GI) decontamination procedure used after selected ingestions of toxic substances. The purpose of this study was to evaluate the ability of WBI, with and without metoclopramide pretreatment, to clear the GI tract of foreign bodies using previously established WBI end points, ie, the presence of a clear effluent or the administration of 2 L/h PEG-ELS for 5 hours. Eleven healthy, adult, male volunteers participated in this controlled, two-phase, blinded, crossover study. Ten fluorescent coffee beans were ingested after an overnight fast followed 1 hour later by 10 mg of metoclopramide syrup or an equivalent volume of placebo; 30 minutes later, WBI with PEG-ELS was begun at 2 L/h. All volunteers received 10 L of PEG-ELS during a 5-hour period. No statistically significant difference (P > .05) was found between the two pretreatments. For the metoclopramide group, the mean number of beans passed was equal to 3.8 (+/- 2.5 standard deviation [SD]; 1 to 8 R); the mean number at clear effluent was equal to 2.3. For the placebo group, the mean number of beans passed was equal to 3.5 (+/- 1.9 SD; 2 to 7 R), and the mean number at clear effluent was equal to 2.3. In conclusion, the presence of a clear effluent or the administration of 10 L of PEG-ELS are not valid markers for the termination of WBI if complete elimination of a foreign body is required. Pretreatment with 10 mg of oral metoclopramide does not enhance the efficiency of WBI.