Activated charcoal is indicated in paracetamol overdose
Date First Published:
March 1, 2000
Last Updated:
May 24, 2001
Report by:
Katrina Richell-Herren, Research Fellow (Manchester Royal Infirmary)
Search checked by:
Magnus Harrison, Manchester Royal Infirmary
Three-Part Question:
In [patients poisoned with paracetamol] does [activated charcoal alone or in combination with other treatments] reduce [hepatotoxicity]?
Clinical Scenario:
A 23 year old woman attends the Emergency Department having taken 60 500mg paracetamol tablets 2 hours prior to presentation. You wonder whether she should receive activvated charcoal.
Search Strategy:
Medline 1966-03/00 using the OVID interface.
Search Details:
[({acetaminophen.mp OR paracetamol.mp} AND {exp poisoning OR poisoning.mp OR exp overdose OR overdose.mp}) AND {exp charcoal OR charcoal.mp} LIMIT to human AND english.
Outcome:
71 papers found of which 68 were irrelevant or of insufficient quality. The remaining 3 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetamol overdose. Underhill TJ, Greene MK, Dove AF. 1990, UK | 60 patients who had taken 5 gm or more of paracetamol within 4 hours of attendance. Gastric lavage (14) vs ipecacuana (21) vs activated charcoal (20) vs nothing (5) | RCT | Plasma concentrations at 0, 60, 90 and 150 minutes post treatment | Activated charcoal group had significantly better fall in paracetamol concentration at 150 min | Small study |
| A prospective evaluation of the effect of activated charcoal before oral N acetylcysteine in acetaminophen overdose. Spiller HA, Krenzelok EP, Grande GA et al. 1994, USA | 122 patients with paracetamol overdose within the previous 12 hours. Activated charcoal (40) vs activated charcoal and N acetylcysteine (57) vs activated charcoal and high dose N acetyl cysteine (25) | Observational study | Hepatotocxicity (defined as SGOT over 125 units/l) | Significantly less (5% vs 20%) in groups receiving activated charcoal | Spectrum is of patients contacting a poisons centre. No power study. |
| Activated charcoal reduces the need for N-acetylcysteine treatment after acetaminophen (paracetamol) overdose. Buckley NA, Whyte IM, O'Connell DL et al. 1999, Australia | 981 consecutive paracetamol poisonings. Gastric lavage and charcoal vs charcoal alone vs nothing | Observational study | Risk of "high risk" concentrartion | Significantly less change of toxic level if activated charcoal given (Odds Ratio 0.36 {0.23 - 0.58}) |
Author Commentary:
There are no high quality studies in this area. In particular there is no data to indicate how long after poisoning activated charcoal remains effective.
Bottom Line:
Activated charcoal should be given to all patients with significant paracetamol poisoning who present acutely.
References:
- Underhill TJ, Greene MK, Dove AF.. A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetamol overdose.
- Spiller HA, Krenzelok EP, Grande GA et al.. A prospective evaluation of the effect of activated charcoal before oral N acetylcysteine in acetaminophen overdose.
- Buckley NA, Whyte IM, O'Connell DL et al.. Activated charcoal reduces the need for N-acetylcysteine treatment after acetaminophen (paracetamol) overdose.