Ray paints a fairly classic story of a tca od who
deteriorates rapidly after arrival. This backed up by
the Callaham study of 18 tca fatalities.
The charcoal issue is not quite straightforward: if
intubated soon after arrival, the best course of
action for a toxic tca od, then charcoal is safe and
probably effective up to 4 hours post ingestion -
though no real evidence.
Theorectically repeat doses may be helpful
(enterohepatic circulation) To give it to an
unintubated patient who may become profoundly
unconscious and fit in an ambulance sounds risky to me
- aspirating charcoal causes severe and potentially
fatal pneumonitis, I understand.
It appears from my reading that the evidence that
charcoal is beneficial in tca od is purely
theoretical, other than one volunteer study using 75mg
nortripiline, and thus the risk outweighs the
potential benefit in unintubated patients.
Would any of the lurking toxicologists like to
comment?
Steve Meek
Bath
--- Ray McGlone <[log in to unmask]> wrote:
> We had a patient from the Windermere area recently
> who had taken 28 x 10 mg Amytriptyline tablets. On
> arrival in A&E at Lancaster it was over 2 hours
> since the ingestion so a little late for charcoal to
> make any difference (he walked in.... but within 20
> mins was delirious... eventually intubated on ITU).
>
> I was wondering about the possibility of paramedics
> giving charcoal, when the travelling distance is
> prolonged it makes sense if they could start
> treatment. The evidence is that it should be given
> within 1 hour to make a difference, perhaps up to 2
> hrs if a significant tricyclic overdose
> (ref:TOXBASE). Paramedics are advised not to take
> tricyclic overdoses to Kendal hospital (no
> anaesthetics on site)... the above case explains
> why.
>
> The problem with charcoal would be if they vomited
> in the back of the ambulance!
>
> I'm advised that Charcoal is in the list to be
> considered in the next years work of the national
> guidelines review (JRCALC).
>
> Ray McGlone
>
> A&E Consultant
> Royal Lancaster Infirmary / Westmorland General
> Hospital
>
>
http://www.mbha.nhs.uk/morecambe_bay_hospitals_trust.htm
>
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