Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial

Abstract

Background: The case-fatality for intentional self-poisoning in the rural developing world is 10-50-fold higher than that in industrialised countries, mostly because of the use of highly toxic pesticides and plants. We therefore aimed to assess whether routine treatment with multiple-dose activated charcoal, to interrupt enterovascular or enterohepatic circulations, offers benefit compared with no charcoal in such an environment.

Methods: We did an open-label, parallel group, randomised, controlled trial of six 50 g doses of activated charcoal at 4-h intervals versus no charcoal versus one 50 g dose of activated charcoal in three Sri Lankan hospitals. 4632 patients were randomised to receive no charcoal (n=1554), one dose of charcoal (n=1545), or six doses of charcoal (n=1533); outcomes were available for 4629 patients. 2338 (51%) individuals had ingested pesticides, whereas 1647 (36%) had ingested yellow oleander (Thevetia peruviana) seeds. Mortality was the primary outcome measure. Analysis was by intention to treat. The trial is registered with controlled-trials.com as ISRCTN02920054.

Findings: Mortality did not differ between the groups. 97 (6.3%) of 1531 participants in the multiple-dose group died, compared with 105 (6.8%) of 1554 in the no charcoal group (adjusted odds ratio 0.96, 95% CI 0.70-1.33). No differences were noted for patients who took particular poisons, were severely ill on admission, or who presented early.

Interpretation: We cannot recommend the routine use of multiple-dose activated charcoal in rural Asia Pacific; although further studies of early charcoal administration might be useful, effective affordable treatments are urgently needed.

Figure 1

Trial profile *The proportion of patients who did not receive their intervention is an estimate derived from a prospective study of compliance in 1649 participants.

Figure 2

Forest plot of mortality for multiple-dose activated charcoal versus no activated charcoal MDAC=multiple-dose activated charcoal. AC=activated charcoal. OP=organophosphorus. GCS=Glasgow comma score. *Test for trend.

Figure 3

Forest plot of mortality for single-dose activated charcoal versus no activated charcoal SDAC=single-dose activated charcoal. AC=activated charcoal. OP=organophosphorus. GCS=Glasgow comma score. *Test for trend.

Figure 4

Cumulative percentage—for days to death (A) and to first intubation (B) (A) For the purpose of survival analysis, the clock was started at randomisation and stopped either at death or discharge (assumed to be 35 days if discharged alive sooner than 35 days). (B) For the purpose of survival analysis, the clock was started either at randomisation or, in the case of those who were intubated at randomisation, when the patient was first extubated. The clock stopped either at the first postrandomisation intubation or at death or discharge (assumed to be 8 days if discharged without intubation after less than 8 days). MDAC=multiple-dose activated charcoal. AC=activated charcoal. SDAC=single-dose activated charcoal.

Figure 5

Forest plot of effect of time to recruitment on mortality for multiple-dose or single-dose activated charcoal versus no activated charcoal, with detailed breakdown of less than 4 h AC=activated charcoal.