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Generic names (Common brand names):

In the U.S.:
Actidose with Sorbitol
CharcoAid 2000
Insta-Char Aqueous
Insta-Char with Sorbitol
Liqui-Char with Sorbitol
Pediatric Aqueous Insta-Char

In Canada:
Aqueous Charcodote
Charac-tol 50
Charcodote TFS-25
Charcodote TFS-50
Insta-Char Aqueous
Pediatric Aqueous Charcodote
Pediatric Charcodote

It can be obtained as a powder, as capsules or as tablets, the powdered form being by far the most effective.
Activated charcoal capsules are twice as strong as the tablets, although chewing the tablets before swallowing them increases their effectiveness. The tablets and capsules are used mainly for gas and indigestion.

The average adult dose is either 1 tablespoonful of charcoal powder stirred in enough water to make a thick soup-like mixture, or 6 to 8 tablets or 4 capsules twice a day. The charcoal should be kept tightly sealed in a glass or metal container. It is best not to take charcoal when there is food in the stomach if it can possibly be avoided, as the food interferes with its action.

In case of poisoning, take five times the weight of charcoal as the estimated weight of the ingested poison. If there is food in the stomach, 8 to 10 times the weight of the poison should be given in the form of finely powdered charcoal. One tablespoonful of charcoal equals about 10 grams. The sooner the charcoal can be taken after the poison is ingested, the more effective it will be.

Systems Affected:
Digestion, intestines, and stomach.

Bodily Influences:
Antidote (adsorbent)-Activated Charcoal USP; Activated Charcoal Oral Suspension;
Antidote (adsorbent)-laxative-Activated Charcoal and Sorbitol Oral Suspension;
Antidiarrheal (adsorbent)-Activated Charcoal Capsules;
Antiflatulent-Activated Charcoal Capsules; Activated Charcoal Tablets;
Sorbitol: Laxative, hyperosmotic: Hygroscopic action results in increased water in the large intestine and increased intraluminal pressure, thus stimulating catharsis.

Biochemical Constitutions:
Activated charcoal is a black, shiny, odorless and tasteless substance made by burning certain types of wood under controlled conditions so that a very large adsorptive surface is produced. All impurities are removed so that it is 100 percent pure vegetable mattel.

When examined under the microscope, it is seen to be extremely porous, having the appearance of a sponge with rigid walls. Charcoal is adsorptive in its action, rather than being absorptive like a sponge; that is, it acts like a magnet, attracting substances to itself and holding them tightly on its surface.

The surface area of all the particles in a small piece of charcoal only 2/5 of an inch square would cover an area more than 33 yards square. It has a strong affinity for adsorbing impure and toxic gasses which makes it a wonderful remedy for use when fermentation occurs in the intestinal tract with the production of excessive gas, bad breath, heartburn, nausea, sour stomach, and headache.

It also adsorbs many poisonous chemicals, drugs, and toxins, such as opium, cocaine, morphine, nicotine, salicylates, strychnine, kerosene, barbiturates, and antidepressant pills, to name but a few.

It is of little or no value in lye and caustic alkalis, alcohol, mineral acids, iron, and cyanides; in fact, cyanide actually interferes with the normal adsorptive properties of charcoal. Charcoal can adsorb up to 250 to 350 times its own weight. One quart of charcoal can adsorb nearly 90 quarts of ammonia gas.


Its use dates back at least to the time of Hippocrates, who lived from 460 to 370 B.C.

A dramatic demonstration, conducted in 1813 by the French chemist Bertrand, vividly demonstrated the almost miraculous adsorptive properties of charcoal when he drank five grams of arsenic trioxide mixed with charcoal and survived.

A few years later, about 1830, a pharmacist by the name of P. F. Touery, attempting to prove that charcoal was an excellent antidote, took a massive dose of strychnine (ten times the usual lethal dose) with 15 grams (half an ounce) of activated charcoal before the French Academy of Medicine in Paris and suffered no apparent ill effects. But for anyone to try such an experiment today would be considered very foolhardy and dangerous!

During World War 1, charcoal was used as an adsorbent in gas masks to protect the soldiers from poisonous gas. Following the war, the use of charcoal in the United States was largely neglected. Two factors that may have contributed to this lack of interest were: (1) the use of burnt toast as a home remedy for poisoning in the place of charcoal gave disappointing results; and (2) the use of the so-called "universal antidote." This consisted of two parts charcoal, one part magnesium oxide, and one part tannic acid. Because of the added substances, it was usually not as effective as using charcoal by itself.

No home should be without charcoal and the knowledge of how to use it effectively. It is a marvelous antidote for many kinds of poisons and is excellent to use for infections. Charcoal is also an excellent air deodorizer when placed in a dish in the refrigerator or anywhere that unpleasant odors are present. It may be used either internally or externally. Charcoal has been found to be harmless when ingested or when used on the skin and may be applied in powdered form directly to skin ulcers or wounds, specially if they are infected.

To obtain the maximum effect, it must be ingested before the poison is absorbed from the intestinal tract. As John Holt, M.D., makes clear in the
Journal of Pediatrics: "It is shown that this agent [charcoal], presently somewhat neglected, has a wide spectrum of activity and when properly used is probably the most valuable single agent we possess ... as an emergency antidote for the treatment of ingested poisons... A bottle of charcoal on every medicine shelf would go a long way to combat serious poisonings in the home." An even more convenient way to have a charcoal mixture ready right when you need it is to purchase a suspension of 30 grams of activated charcoal in four ounces of water already mixed and sealed in a plastic container. All you have to do when it is needed is to shake the carton a few times, remove the lid and drink the contents. It should be kept in the home emergency medical kit in a conspicuous place.

For a long time there has been some difference of opinion as to whether or not charcoal will adsorb necessary nutrients as well as poisons. Dr. Holt states: "It is now very clear that activated charcoal will adsorb not only poisons but also vitamins, digestive enzymes, amino acids, and other valuable nutrients from the gut. Such losses if continued will seriously affect health, but are of no importance in situations of acute poisoning."

Monkeys on the African island of Zanzibar have learned that ingesting charcoal will counteract the adverse affects of toxic substances in their diet, say
Duke University and University of Wyoming
scientists. UW Professor David Cooney, a chemical engineer with extensive research on the medical uses of activated charcoal, says he was asked to test samples collected in a study by Duke scientist Thomas Struhsaker, who observed the unusual habit of Zanzibar red colobus monkeys eating charcoal.

Struhsaker was familiar with Cooney's research and with his recent book, "
Activated Charcoal in Medical Applications
." He sent Cooney leaf samples of the monkey's main dietary source, Indian almond and mango leaves, which are potentially toxic. He also sent charcoal taken from burned trees and charcoal lying near kilns, where it was produced for cooking. Cooney studied the adsorption ability of five charcoals from Zanzibar in hot water extracts steeped from the Indian almond and mango leaves. Absorption is the ability of substances, in this case the toxins, to stick to the surface of a solid, such as charcoal. "For comparison, we also evaluated three commercial powdered activated charcoals," he says. "As expected, these charcoals acted best, yet the African kiln charcoals adsorbed surprisingly well. The findings support the hypothesis that the monkeys eat charcoal to reduce the harmful compounds, which have the potential to be toxic or interfere with digestion." Struhsaker says the young leaves of exotic trees, consumed by the monkeys living in gardens in this area of Zanzibar, are also high in protein and highly digestible. "This may explain why the birth rates and population densities of the colobus living in the Indian almond and mango habitat adjacent to the Jozani Forest are significantly higher than those in the ground water forest," he says.

Cooney's book, "
Activated Charcoal in Medical Applications ," was published in 1995 as a comprehensive reference of research on medical uses of activated charcoal. His and other studies describe activated charcoal's effectiveness in treating overdoses and poisonings in humans and animals. The collaborative work by Cooney and Struhsaker has been published in two papers appearing in the
International Journal of Primatology.

MOPP stands for Mission Oriented Protective Posture. Charcoal is used in the linning of the MOPP or chemical warfare gear that the U.S. military issues its troops even to this day. MOPP would be the entire ensemble (suit, gloves, rubber boots and mask), but it is the suit (blouse and trousers) that has the charcoal in the lining. Not sure but charcoal is not used in the masks anymore. MOPP gear comes in 4 levels depending on how serious the chemical/bio threat is...Level IV being the most serious and this would be mask, rubber gloves, Rubber booties and suit. This information was related to me via correspondence-Shannon Younger.

There are 1363 references to the term activated charcoal, many patents refer to it as a filtering agent, such as gas mask, water, air conditioning, etc., as a deodorizer, a foam that is useful in removing from the soil residual toxic herbicides and pesticides which can cause significant damage to a sensitive succeeding crop.

Here are a few abstracts:
US4238521: Process for the removal of antibiotics from milk:
Inventor(s): Charm; Stanley E. , Newton, MA
Applicant(s): Penicillin Assays, Inc., Boston, MA
Issued/Filed Dates: Dec. 9, 1980 / Sept. 18, 1979
Application Number: US1979000076600

Abstract: A method of removal of penicillin from penicillin-contaminated milk, which method comprises contacting the contaminated milk with activated charcoal and recovering a penicillin-free milk product.

US5795586: Toxin decontaminant food product and method of forming same.
Inventor(s): Stang; Michael A. , Pikesville, MD Zeak; Jeffrey Alan , Manhattan, KS Strouts; Brian Lee , Manhattan, KS
Applicant(s): De Novo, Inc., Baltimore, MD
Issued/Filed Dates: Aug. 18, 1998 / Aug. 7, 1996
Application Number: US1996000692239

Abstract: An antidotal food product containing activated charcoal is provided for ingestion into the gastro-intestinal tract of a user. The antidotal food product is orally administered having the visual appearance and physical properties which enables the desire on the part of young children to chew and ingest the food product. The food product in a preferred embodiment includes a substantially dry friable wafer which is adapted to be chewed by the user for ingestion. The dry friable wafer has a wafer mixture composition formed by blending a first predetermined weight of sorbent particulate composition having an initial adsorption value with respect to a toxin to a second predetermined weight of a substantially non-interfering flavored binding composition which provides for a creamy and sweet tasting food product. The initial adsorption value of the sorbent particulate composition maintains a high adsorption value in the wafer mixture composition for maximizing the adsorption value of the composition to combat toxins which have been ingested by the user.

US5370891: Production of vodka

Inventor(s): Fillipova; Irina V. , Bethlehem, PA
Applicant(s): RTD Corporation, Bethlehem, PA
Issued/Filed Dates: Dec. 6, 1994 / June 28, 1993
Application Number: US1993000083979

Abstract: A method of treating a mixture of ethyl alcohol and water for the reduction of impurities comprising the steps of: a) mixing ethyl alcohol and water at a temperature of from about 5C. to about 10C. to obtain a mixture; b) flowing the mixture at a temperature of from about 5C. to about 20C. through three layers of an activated charcoal adsorber having surface activities of 1) from about 0.6 to about 0.8 mg-equivalent/liter, 2) from about 0.8 to about 1.0 mg-equivalent/liter, and 3) from about 1.0 to about 1.4 mg-equivalent/liter respectively, and a total pore volume of from about 1.4 to 1.6 cm3 /g; c) allowing the mixture to contact the activated charcoal adsorber for about 2 to 15 minutes, preferably for about 5 to 10 minutes; and d) recovering the initial capacity of the activated charcoal adsorber by flowing a stream of dry air, having a temperature of from about 100C. to about 400C., through the activated charcoal adsorber.

US4928681: Wound dressing
Inventor(s): Langston; Richard D. , Wokingham, United Kingdom Webb; Frances C. , Maidenhead, United Kingdom McBeath; Simon C. , Poole, United Kingdom
Applicant(s): Charcoal Cloth Limited, Berkshire, United Kingdom
Issued/Filed Dates: May. 29, 1990 / June 30, 1988

Abstract: A wound dressing which comprises, in order: a layer of a permeable material suitable for putting in contact with the wound; a layer of a charcoal fabric; an absorbent pad; and one or more layers which protect and substantially prevent liquid strike-through.

US4181712: Tooth paste composition
Inventor(s): Rialdi; Giorgio , I-16131 Genova, Italy
Applicant(s): none
Issued/Filed Dates: Jan. 1, 1980 / Aug. 31, 1978
Application Number: US1978000938493

Abstract: A tooth paste composition comprising, in combination with a detergent base, a mixture of micronized colloidal silica gel and activated charcoal.

Other Uses:

Aluminum Air Battery:
A simple battery can be made from aluminum foil, salt water and activated charcoal that will make 1 volt and 100 milliamps.


Charcoal might be good at reducing cholesterol has been suggested by a preliminary study of seven patients with hypercholes-terolemia or high levels of cholesterol in the blood.

When given 8 grams of activated charcoal three times daily for a month, these subjects exhibited an average 25 percent reduction in total cholesterol and an average 41 percent reduction in the particularly harmful LDL cholesterol Meanwhile, their good cholesterol, HDL, went up an average of 8 percent. The only side effect was black stools.

Activated charcoal as a potential radioactive marker for gastrointestinal studies.
Mullan BP, Camilleri M, Hung JC
Nucl Med Commun 1998 Mar;19(3):237-40
Nuclear Medicine, Department of Diagnostic Radiology, Mayo Clinic, Rochester, MN 55905, USA.
The scintigraphic measurement of colonic transit is currently performed using 111In ion exchange resin pellets delivered to the colon in a capsule coated with a pH sensitive polymer, methacrylate, which dissolves in the distal ileum. However, in the USA, this requires an investigational drug permit. Our aim was to evaluate the in vitro binding characteristics of activated charcoal in milieus that mimicked gastric and small intestinal content. The in vitro incubation of activated charcoal was performed with Na99Tc(m)O4, 99Tc(m)-DTPA, 111InCl3, 111In-DTPA, 201TlCl and 67Ga-citrate in the pH range 2-4 and pH 7.2 at 37 degrees C. We estimated the association of radiopharmaceuticals with the activated charcoal over a 3 h in vitro incubation. With the exception of 67Ga-citrate, the association of activated charcoal with the other radiopharmaceuticals was approximately 100% throughout the 3 h incubation.

In conclusion, activated charcoal appears to adsorb avidly with common radioisotopes, and appears promising as an alternative to resin ion exchange pellets used for the measurement of gastrointestinal transit by scintigraphy.

"Turista" or even baby's diarrhea is not repressed by charcoal, but it does aid the body in getting rid of noxious substances. When these are captured, the body no longer has the need to hurry the bowels.

Flatulence Relief, Intestinal Gases and Discomfort:
Each particle of activated charcoal contains many small chambers and cavities that will bind up unwanted toxins and gases from the stomach and intestines. They are then taken safely through the digestive system.

Made from pure carbon, activated charcoal has been chemically treated (activated) to soak up gas.

Charcoal works by trapping gases before they escape from the intestines.

Carbon will not absorb air in the stomach, intestinal gas is usually hydrogen, methane or carbon dioxide (and sometimes ammonia and hydrogen sulfide) and these will be "absorbed" by charcoal.
The body normally gets rid of most of its intestinal gas by diffusion through the intestinal wall where it is taken by the blood to the lungs to be expelled. An inflamed or toxic coating of the intestinal wall can prevent this process, allowing a buildup of painful and noxious gas.

Activated charcoal will not only remove the gas, but often can also remove the toxic irritant causing it.

One fairly recent double-blind, placebo-controlled study found activated charcoal to be
more effective that the drug simethicone when it comes to quelling flatulence, bloating and the irritable bowel syndrome. This confirmed an earlier double-blind study.

Charcoal was a popular remedy for gas more than a century ago. But then, with the advent of antacids and simethicone, it fell out of fashion.


Previous studies have shown that oral activated charcoal can be useful in the long-term management of kidney patients who are at particular risk of developing high cholesterol levels and atherosclerosis.
High doses of charcoal (20 to 50 grams daily) have helped many kidney patients excrete wastes their failing kidneys would otherwise have difficulty handling, and reductions in cholesterol of up to 43 percent and reductions in triglycerides (blood fats) of up to 76 percent have been reported in kidney patients thus treated.

Charcoal also is used to relieve itching associated with kidney dialysis treatment and to treat overdoses of other medicines.

Pesticide Deactivation:
L. B. McCarty
Occasionally an accidental spill will occur that must be cleaned up to continue growing grass. Or in a combination weed control and grass seeding program, it is necessary to stop the activity of an applied herbicide to successfully seed a grass. Charcoal is a very porous, soft, black substance made by heating, in a restricted amount of air, substances containing carbon. This is most often derived from hardwood trees and coconut shells. Charcoal adsorbs 100 to 200 times its own weight. The adsorption capacity is developed by activating the charcoal by heating.

Activated charcoal comes in handy for binding, thus, deactivating some herbicides. Activated charcoal will reduce the available level of most organic pesticides in the soil; however, it is considered ineffective for inorganic pesticides such as arsenates, lead compounds, sodium chlorate, sulfur, borax, etc., and water-soluble organic pesticides such as, but not limited to, aminotriazole, MSMA, and DSMA.

In order to have effective application of activated charcoal, it is important to have the spraying equipment clean and in good operating condition. It is a good idea to keep a bag or two of activated charcoal in stock at all times when managing fine turf so it can be applied almost immediately instead of having to wait several days for delivery after an accidental spill or application.

General Mixing Instructions:
For application convenience, it is recommended that activated charcoal be applied as a water slurry. To minimize dusting, always add activated charcoal to water slowly, keeping the bag as close to the water surface as possible.

Spray Application:
Make sure spray equipment, tubing, and nozzles are completely clean. Screens should be removed if practical.

The final spray mixture should contain one to two lbs of charcoal per gallon of water.Add sufficient water to begin moderate agitation. Simultaneously add the balance of required water and charcoal. Continue agitation until a uniform mixture is obtained. Maintain moderate agitation while spraying.

Activated charcoal is a poison antidote,
when vomiting should not be induced.

Medical researchers acknowledge that charcoal is probably the best known antidote for poison. And charcoal is rated safe and effective for acute toxic poisoning by the FDA. It should be administrated within 30 minutes of poisoning.

The so-called Universla Antidote (e.g., Res-Q) contains 2 parts activated charcoal, 1 part antacid, such as magnesium oxide, and 1 part tannic acid (which is potentially hepatotoxic). It is reportedly not as effective as
activated charcoal. It it often used with a laxative to promote elimination.

Data Assessment for a Patient in Referrence to Poisoning:

*blood pressure
*vital signs
*neurological examination
*level of respiratory effort
*breath sounds
*careful visual inspection (including nose and mouth)
*blood gases
*renal function studies
*patient weight

A detailed patient history from the patient and or family member about the suspected toxic agents, including (as appropriate) amount, how long ago substance was ingested, efforts made by family and friends to induce vomiting or dilute the substance, patient age and coexisting medical problems. Any samples of the toxic substances should be carefully saved and labeled and sent to the lab for analysis. It is a common practice to administer a single dose of activated charcoal simultaneously with a laxative, such as magnesium citrate, magnesium sulfate, sodium sulfate, to hasten drug elimination, and to prevent constipation and possible impaction.

Record appearance, color, consistency, frequency, and relative amount of stools. Inform patient that activated charcoal will color feces black. Activated charcoal can be swallowed or given throught a nasogastric tube.
If administered too rapidly patient may vomit. Activated charcoal slurry can be made more acceptable to the patient if it is administered through a straw, from a covered opaque container, so the patient canot see it.

Factors that may reduce the effectiveness ot activated charcoal include the presence of food or alcohol in stomach or reduced GI motility.

Some of the Substances "Absorbed" by Activated Charcoal:

Acetaminophen, Aconitine, Alcohol, Amphetamine, Antimony, Antipyrine, Arsenic, Aspirin, Atropine, Barbital, Barbiturates, Camphor, Chlordane, Chloroquine, Chlorpheniramine, Chlorproma, Cocaine, Colchicine, Cyanide, Delphinium, Dichlorophenoxyacetic acid, Digitalis, Diphenylhydantoin, Diphenoxylates, Ergotamine, Ethclilorvynol, Gasoline, Glutethimide, Hemlock, Hexachlorophene, Imipramine, Iodine, Ipecac, Isoniazid, Kerosene, Lead acetate, Malathion, Mefenamic acid, Mepfobamate, Methylene blue, Methyl salicylate, Morphine, Muscarin, Narcotics, Neguvon, Nicotine, Nortriptyline, Opium, Parathion, Penicillin, Pentobarbital, Pesticides, Phenobarbital, Phenolphthalein, Phenol, Phenylpropanolamine, Potassium, Primaquine, Propantheline, Propoxyphene, Quianacrine, Quinidine, Quinine, Radioactive substances, Salitylamide, Salicylates, Secobarbital, Selenium, Silver, Stramonium, Strychnine, Sulfonamides, Veratrine.

Some of the Substances 'Not Absorbed' by Activated Charcoal:
Caustic materials like lye are probably not readily absorbed" and in these cases very large quantities of charcoal should be used. Salts such as sodium chloride and potassium nitrate are also poorly 'absorbed,' including iodine and mercuric chloride. But simple acids and bases are easily absorbed." There is also a question about its power to remove alcohol from the body.

In Dr. Christopher's book, he mentions that charcoal can be used for offensive gangrenous wounds or sores as an antiseptic poultice. This poultice is also mentioned by Jethro Kloss.

Mix slippery elm powder with activated charcoal; mix this with hot water or with an infusion of wormwood to a paste like consistency; then apply over the affected area and cover.

Other poultices recommended by Kloss:

Charcoal and hops poultice: This will relieve gallstone pain quickly.

Charcoal and smartweed poultice: Excellent for inflammation of the bowels or inflammation in other parts of the body. When used for old and inflamed ulcers and sores, add powdered echinacea, golden seal, myrrh, or a small amount of the three.

Poultices made of charcoal are excellent for insect bites, stings, poison oak, inflammation around the ears and eyes, to dress and disinfect wounds, cellulitis, boils, carbuncles, and abdominal pain. They also act as a deodorant and antiseptic.

How to make a charcoal poultice:

1. Place equal parts of pulverized charcoal and flaxseed in a pot. Grinding the flaxseed into a fine powder first will make the mixture form a paste faster. This can be done in a blender.

2. Add enough water to form a thick paste and bring it slowly to a boil while stirring.

3. Spread the paste as rapidly as possible on a piece of cotton or muslin of sufficient size to completely cover the area to be treated.

4. The paste should be spread about one-quarter-inch thick and kept about one inch in from the edges of the cloth.

5. Cover this with another cloth of the same size and then place the poultice on the area of the skin to be treated.

6. Cover this with a piece of plastic at least one inch larger on all sides than the poultice.

7. Place a towel over the entire poultice and hold it in place with a roller bandage, strips from an old sheet or towel, an Ace bandage, etc. Pin securely in place with safety pins.

8. Leave on overnight or for 8 to 10 hours during the day.

9. After removing the poultice, rub the skin with a cold cloth.

The amount of material needed for the poultice will depend on the size of the area to be covered. A large area will require about 3 tablespoonsful of charcoal and flaxseed. For small areas, such as a bee sting or spider bite, use only charcoal to make the paste.
Charcoal can be very messy, so be careful as you assemble the poultice.

I have found one reference that care should be used when applying charcoal to open wounds, as some of the black powder may get trapped as the area heals, giving a tattoo effect!

Some Articles on the Effects of Activated Charcoal on Poisoning:
Accidental ingestion of cigarettes by children.[Article in Dutch]
Hulzebos CV, Walhof C, de Vries TW
Ned Tijdschr Geneeskd 1998 Nov 21;142(47):2569-71
Academisch Ziekenhuis, Beatrix Kinderkliniek, Groningen.

Accidental ingestion of cigarettes (and butts) is mainly seen in young children. Nicotine in tobacco products is easily absorbed by the oral mucosa and intestines; absorption depends on nicotine content and pH of tobacco. Symptoms are caused by the nicotine component and usually develop rapidly (< 4 hours). The most common symptom is vomiting. Although cigarettes are potentially toxic, their ingestion by children is generally benign. Decontamination of the mouth with water may be useful. Induction of emesis is not advised. Gastric lavage is not needed in asymptomatic patients (with an unreliable history) or after vomiting. Children who ingested cigarettes should receive medical observation for four hours after ingestion. Children with significant symptoms should be admitted and eventually treated by supportive care. In symptomatic children or children with a reliable history of ingestion of large quantities who have not vomited gastric lavage with administration of activated charcoal has to be performed. When after vomiting other symptoms persist activated charcoal can be given via a nasogastric tube.

Amanita phalloides Mushroom Poisoning
-- Northern California, January 1997
The popular interest in gathering and eating uncultivated mushrooms has been associated with an increase in incidents of serious mushroom-related poisonings. From December 28, 1996, through January 6, 1997, nine persons in northern California required hospitalization after eating Amanita phalloides (i.e., "death cap") mushrooms; two of these persons died. Risks associated with eating these mushrooms result from a potent hepatotoxin. This report describes four cases of A. phalloides poisoning in patients admitted to a regional referral hospital in northern California during January 1997 and underscores that wild mushrooms should not be eaten unless identified as nonpoisonous by a mushroom expert.

Case 1. A 32-year-old man gathered and ate wild mushrooms that he believed were similar to other mushrooms he had previously gathered and eaten. Eight hours later, he developed vomiting and profuse diarrhea; he was admitted to a hospital 19 hours after ingestion.

On admission, he was dehydrated, and laboratory findings included an aspartate aminotransferase (AST) level of 81 U/L (normal: 0-48 U/L), prothrombin time (PT) of 12.3 seconds (normal: 11.0-12.8 seconds), and bilirubin level of 0.9 mg/dL (normal: 0-0.3 mg/dL).

He received intravenous fluids, intravenous penicillin, repeated oral doses of activated charcoal, and oral N-acetylcysteine. Although the diarrhea resolved after 24 hours, his PT and AST and bilirubin levels continued to rise. On the third day after eating the mushrooms, abnormal findings included an AST level of 2400 U/L, alanine aminotransferase (ALT) level of 4100 U/L (normal: 0-53 U/L), PT of greater than 60 seconds, and total bilirubin level of 11 mg/dL. Six days after eating the mushrooms, his bilirubin level was 16 mg/dL, and his AST level had decreased to 355 U/L; he developed metabolic acidosis and hypotension. Seven days after eating the mushrooms, he developed hepatic encephalopathy, oliguric renal failure, and adult respiratory distress syndrome requiring intubation and mechanical ventilation. He died from multiple organ failure 9 days after eating the mushrooms. One mushroom cap remaining after the meal was identified as A. phalloides.

Case 2. A 42-year-old man developed vomiting and diarrhea 11 hours after eating wild mushrooms, and he was admitted to a hospital 14 hours after eating the mushrooms. His transaminase levels were elevated 24 hours after ingestion (AST and ALT levels both at 100 U/L); his PT was 12.1 seconds, and his bilirubin level was 0.2 mg/dL. His PT became prolonged the next day and peaked at 35 seconds on the fourth day. His transaminase levels also peaked on the fourth day (AST level of 3000 U/L and ALT level of 6000 U/L); his bilirubin level was 7.8 mg/dL.

He was given repeated doses of activated charcoal and oral N-acetylcysteine. His transaminase levels and PT gradually decreased, and he was discharged on the seventh day after eating the mushrooms without sequelae.

Case 3. A 30-year-old man used a guidebook to assist in the collection of wild mushrooms. Twelve hours after eating the mushrooms he had gathered, he developed vomiting and severe diarrhea.

He was admitted to a hospital 17 hours after ingestion because of orthostatic hypotension and dehydration. Abnormal laboratory findings indicated an AST level of 75 U/L, blood urea nitrogen level of 22 mg/dL (normal: 6-20 mg/dL), and creatinine level of 2.8 mg/dL (normal: 0.6-1.3 mg/dL).

He was treated with intravenous fluids. Although renal function indicators were within normal limits 1 day after admission, his liver enzyme and PT levels began to increase; on the fourth day, transaminase levels peaked (AST level of 1900 U/L and ALT level of 2800 U/L), total bilirubin level was 1.6 mg/dL, and PT was 18 seconds. His clinical status continued to improve, and he was discharged 7 days after eating the mushrooms.
Case 4. A 68-year-old man ate mushrooms he had collected on a golf course.

Two days after eating the mushrooms, he was admitted to a hospital because of diarrhea and weakness. His AST level was 630 U/L, and he had renal failure. On the third day after eating the mushrooms he required hemodialysis, and his transaminase levels and his PT continued to increase; on the fifth day, his AST level was 3500 U/L; ALT level, 4600 U/L; PT, 34 seconds; and bilirubin, 9.7 mg/dL.
He developed hepatic encephalopathy and died 6 days after eating the mushrooms.

Anticholinergic Poisoning Associated with an Herbal Tea
-- New York City, 1994
Inadvertent anticholinergic poisoning can result from consumption of foods contaminated with plants that contain belladonna alkaloids.

During March 1994, the New York City Department of Health (NYCDOH) investigated seven cases of anticholinergic poisoning in members of three families; three of the seven ill persons required emergency treatment for characteristic manifestations.

For all cases, manifestations occurred within 2 hours after drinking tea made from leaves purchased commercially and labeled as Paraguay tea -- an herbal tea derived from the plant Ilex paraguariensis, which is native to South America. This report summarizes the investigation of these cases.

On March 20, a 39-year-old man and his 38-year-old wife shared a pot of Paraguay tea. Within 30 minutes after drinking the tea, both developed acute symptoms (including agitation and flushed skin). They were transported by ambulance to a local hospital. In the emergency department, the man was disoriented and agitated.

Findings on examination included fever (101.2 F {38.4 C}), dilated and nonreactive pupils, and dry skin and oral mucous membranes; bowel sounds were absent. Anticholinergic poisoning was diagnosed based on clinical findings, and the New York City Poison Center (NYCPC) was notified.

After treatment with two doses of intravenous physostigmine (2 mg each over 5 minutes), signs and symptoms completely resolved. Findings on examination of the woman included fever (100.8 F {38.2 C}), dilated and nonreactive pupils, and dry skin and oral mucosa. Her symptoms resolved without treatment.

On March 21, a 20-year-old woman drank approximately 1 cup of Paraquay tea; approximately 1 hour later, she presented to a local emergency department with agitation, disorientation, and aphasia that progressed to stupor.

Findings on examination included increased pulse (120 beats per minute), oral temperature of 98.2 F (36.8 C), dilated pupils, dry skin, and absent bowel sounds. Anticholinergic syndrome was diagnosed, and the NYCPC was notified.

She received gastric lavage, activated charcoal, and a cathartic. Her mental status gradually improved, and she was discharged after 10 hours of observation.

Aspiration of Activated Charcoal Elicits an Iincrease in Lung Microvascular Permeability:

Arnold TC, Willis BH, Xiao F, Conrad SA, Carden DL
Department of Emergency Medicine, Louisiana State University Medical Center, Shreveport 71130, USA. TArnold@ems.lsumc.edu

Gastric decontamination with orally administered activated charcoal is the recommended treatment for many poisonings. However, ingestion of central nervous system depressants resulting in loss of protective airway reflexes may result in pulmonary aspiration of activated charcoal.

Although activated charcoal has been reported to be an inert substance, evidence suggests that pulmonary aspiration of charcoal is associated with lung edema formation and pulmonary compromise. This study tested the hypothesis that intratracheal instillation of activated charcoal disrupts the integrity of the lung microvascular barrier.

The capillary filtration coefficient (Kf,c), a sensitive measure of lung microvascular permeability, was determined isogravimetrically prior to and after intratracheal instillation of activated charcoal 0.04 g/kg (12% weight/vol solution, pH 7.4) or an equal volume of sterile water in isolated, perfused rat lungs. Arterial blood gas analysis was determined prior to and after tracheal instillation of activated charcoal or sterile water in a separate group of animals.

Intratracheal instillation of activated charcoal resulted in a significant increase in pulmonary microvascular permeability compared to lungs treated with sterile water or control lungs (delta Kf,c = +0.21 +/- 0.076; -0.014 +/- 0.04; and -0.041 +/- 0.02 mL/min/cm H2O/100 g lung tissue, respectively, p < 0.05 ANOVA). There was no significant difference in baseline blood gases in the 3 experimental groups. There was a significant decrease in arterial Po2, bicarbonate, and pH in animals administered activated charcoal compared to time-matched controls and animals administered sterile water.

Intratracheal instillation of activated charcoal is associated with a significant increase in lung microvascular permeability and arterial blood gas derangements. The effects of activated charcoal on pulmonary microvascular barrier integrity may contribute to the lung edema formation and pulmonary compromise observed following clinical aspiration of activated charcoal.

Camphor toxicity:
Emery DP, Corban JG
J Paediatr Child Health 1999 Feb;35(1):105-6
Department of Paediatrics, Memorial Hospital Hastings, Hawkes Bay, New Zealand. gowan@clear.net.nz
Camphor ingestion led to status epilepticus in a 20-month-old girl who required intubation and ventilation.

She was treated with intravenous valium and phenobarbitone, and nasogastric activated charcoal. She made a complete neurological recovery. A number of products containing a high concentration of camphor were found to be available in the local community.

Epidemiologic Notes and Reports Jimson Weed Poisoning - Texas, New York, and California, 1994 :
Ingestion of Jimson weed (Datura stramonium), which contains the anticholinergics atropine and scopolamine, can cause serious illness or death. Sporadic incidents of intentional misuse have been reported throughout the United States, and clusters of poisonings have occurred among adolescents unaware of its potential adverse effects.

This report describes incidents of Jimson weed poisoning that occurred in Texas, New York, and California during June-November 1994.

On June 19, 1994, the El Paso City-County Health and Environmental District was notified of two male adolescents (aged 16 and 17 years) who had died from D. stramonium intoxication. On June 18, the decedents and two other male adolescents had consumed tea brewed from a mixture of roots from a Jimson weed plant and alcoholic beverages, then fell asleep on the ground in the desert. Family and police found the decedents the following afternoon. The other two adolescents reported drinking only small amounts of the tea: one experienced hallucinations; the other had no signs or symptoms. Neither was treated, nor were biologic specimens collected. Screening of a toxicologic postmortem blood sample from one decedent detected atropine (55 ng/mL) and a blood alcohol concentration (BAC) of 0.03 g/dL (in Texas, intoxication is defined as a BAC greater than or equal to 0.1 g/dL). Analysis of the tea identified atropine, ethanol, and scopolamine.

On the morning of October 9, 1994, an 18-year-old man from Long Island was brought to an emergency department (ED) by his mother after she found him in his bedroom unclothed and hallucinating. Reports from friends indicated he had ingested 50 Jimson weed seeds and had used controlled substances (i.e., cocaine, "ecstacy," and marijuana) at a party the previous night. On evaluation, the patient was hallucinating and had fully dilated pupils, dry mouth, and decreased bowel sounds. He became progressively agitated and was sedated with intravenous diazepam and alprazolam. Hallucinations continued for 36 hours. On October 11, he was discharged for psychiatric counseling. He had a history of chronic substance abuse.

New York
During October 8-November 15, a regional poison-control center was contacted about this case and for information about 13 other identified cases of Jimson weed intoxication. The mean age of the 14 patients was 16.8 years (range: 14-21 years), and eight were male. In the five incidents for which quantity of Jimson weed exposure was reported, ingestion ranged from 30 to 50 seeds per person. Manifestations included visual hallucinations (12 persons), mydriasis (10), tachycardia (six), dry mouth (five), agitation (four), nausea and vomiting (four), incoherence (three), disorientation (three), auditory hallucinations (two), combativeness (two), decreased bowel sounds (two), slurred speech (two), urinary retention (one), and hypertension (one). Four patients were treated and released from EDs, six were hospitalized, three were admitted to an intensive-care unit (ICU), and one refused medical care. Five of these patients were treated with activated charcoal, one was administered gastric lavage, and none received physostigmine.

On October 22, 1994, two male and four female adolescents (aged 15-17 years) with a history of drinking Jimson weed tea were transported to an ED. Two persons were discharged from the ED; four were admitted to the ICU because of symptoms that included headache, fatigue, disorientation, fixed or sluggish dilated pupils, tachycardia (heart rates greater than 120 beats per minute), and hallucinations. These four patients were monitored with electrocardiograms, treated with physostigmine and activated charcoal, and discharged on October 23. The Los Angeles County Forestry Division reported that fires in the Los Angeles area may have promoted regrowth of Jimson weed in defoliated areas.

Epidemiologic Notes and Reports Jin Bu Huan Toxicity in Children
-- Colorado, 1993
The consumption of traditional ethnic remedies can have adverse health effects, especially among children (1,2). Life-threatening bradycardia with rapid onset and central nervous system (CNS) and respiratory depression developed in three unrelated children in Colorado during 1993 following ingestion of Jin Bu Huan tablets, a Chinese herbal medicine used for relieving pain. This report summarizes the investigations of these cases.

Patient 1
A 13-month-old boy was lethargic and breathing abnormally when found by his mother approximately 20 minutes after he ingested approximately 60 Jin Bu Huan tablets. His initial vital signs measured by an emergency medical team included a blood pressure of 75/50 mm Hg, pulse of 100, and a respiratory rate of 28. The child exhibited CNS depression and was responsive only to painful stimuli. In the emergency department, he was lethargic, with hypotonia, and had a respiratory rate of 44 and transient bradycardia (pulse mid 40s). He was unresponsive to naloxone (3.8 mg), a fingerstick glucose test measured 110 mg/dL, and an extensive toxicologic screen was negative.

He was treated with activated charcoal through an orogastric tube. He became more alert during the next 10 hours until his physical examination and mental status were completely normal. Follow-up indicated no permanent sequelae.

Patient 2
A 2 1/2-year-old girl was lethargic and breathing abnormally when found by her mother 30-60 minutes after she ingested approximately 17 Jin Bu Huan tablets. Paramedics found the child unresponsive with respiratory depression. An acute episode of bradycardia (pulse 30-35) was successfully treated with atropine. Initial examination in the emergency department indicated miotic pupils (2 mm and equal), CNS depression, and a disconjugate gaze. Blood pressure was palpated at 100 mm Hg systolic; pulse, 100; and respiratory rate, 24. She was unresponsive to naloxone (0.8 mg). The patient's respiratory rate diminished, requiring intubation within 20 minutes after arrival to the emergency department. During the next hour, the child's condition improved, and during an episode of vomiting, she extubated herself.

Gastrointestinal decontamination treatment included performing gastric lavage and administering activated charcoal and a cathartic. She remained intermittently lethargic with diffuse muscle weakness until approximately 8 hours following ingestion. Urine and serum toxicologic screens were negative for more than 30 substances including beta-blockers, clonidine, and opiates. She was discharged the following day after a complete recovery. Follow-up indicated no permanent sequelae.

Patient 3
A 23-month-old girl was lethargic when found by her parents within 1 hour after she ingested approximately seven Jin Bu Huan tablets. The child was transported to an emergency department 1 1/4 hours following ingestion. Her blood pressure was 94/64 mm Hg and pulse 130. Gastrointestinal decontamination consisted of performing gastric lavage (resulting in recovery of pill fragments) and administering activated charcoal and a cathartic. Approximately 2 hours after ingestion, the child was awake and talkative. She was observed in the emergency department until 5 hours following ingestion and was discharged. Follow-up indicated no permanent sequelae.

Follow-up investigation:
Analysis of Jin Bu Huan tablets retrieved from the parents of the three children was performed at Colorado State University using nuclear magnetic resonance and gas chromatography/mass spectroscopy; the tablets were 36% concentrated weight-by-weight levo-tetrahydropalmatine (L-THP), a substance present in the plant genus Stephania but not in the genus Polygala- -the plant of origin indicated on the product package insert (2-4). Each tablet contained 28.8 mg L-THP; no other plant alkaloids were present in tablets tested from multiple bottles of Jin Bu Huan. Extensive toxicologic analysis of the Jin Bu Huan tablets and of urine and serum from patients 1 and 2 did not detect other drugs or pharmaceutical products.

As a result of this investigation, Jin Bu Huan anodyne tablets and their active ingredient (L-THP) were entered into the update of Poisindex Registered, an international toxicologic data base.

Incidence of Aspiration Pneumonia in Intubated Patients Receiving Activated Charcoal:

Moll J, Kerns W 2nd, Tomaszewski C, Rose RJ Emerg Med 1999 Mar Apr;17(2):279-83
Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA.

Several case reports and animal studies raise concerns over the risk of aspiration pneumonia when administering activated charcoal (AC) to intubated patients.

Therefore, we sought to determine the incidence of aspiration pneumonia in intubated overdose patients who then received AC. We conducted a retrospective review from January 1994 to April 1997 of intubated patients who then received AC.

Patients were transferred to, or primarily treated at, an 843-bed tertiary medical center with an annual emergency department volume of 100,000 patients. Objective evidence of infiltrate on chest radiograph during initial 48 h of hospitalization was used to determine the incidence of aspiration pneumonia. Patients with known preexisting pneumonia or with administration of AC before intubation were excluded. There were 64 patients identified. Fourteen were excluded for clinical aspiration before intubation, receiving activated charcoal before intubation, or abnormal immediate post-intubation chest radiographs. The remaining 50 patients, ages 1-64 years, 33% male, overdosing on a large variety of substances, required acute intubation and then received AC.

Only two patients of these 50 (4%) with initial negative radiographs developed a new infiltrate after intubation and AC. Administration of AC to intubated overdose patients is associated with a low incidence of aspiration pneumonia.

Lead Ingestion Associated with Ceramic Glaze - Alaska, 1992
In August 1992, a physician notified the Alaska Division of Public Health (ADPH) that three patients at a psychiatric hospital had consumed ceramic glaze during ceramic therapy (i.e., recreation therapy involving the production of ceramic ware), and two of these patients had elevated blood lead levels (BLLs).
This report summarizes the ADPH's investigation of these ingestions.

Patient 1
On August 18, an 11-year-old patient, admitted for conduct disorder, consumed approximately 2 fluid ounces of ceramic glaze. The patient was taken immediately to the emergency room of a nearby hospital and was treated by gastric lavage and activated charcoal administered by mouth. Because ceramic glaze can contain lead, a blood sample was obtained to be tested for lead and zinc protoporphyrin (ZPP) levels. The BLL obtained approximately 1 hour after ingestion of the glaze was 163 ug/dL; ZPP level was 25 ug/dL (normal: less than 35 ug/dL). However, the BLL was not known until August 21. Repeat tests for BLL on August 21 and 28 and September 9 were 61 ug/dL, 45 ug/dL, and 35 ug/dL, respectively. Chelation therapy was not given, and the patient remained asymptomatic.

Patient 2
On August 18, a 13-year-old patient, admitted for conduct disorder and depression, consumed a small amount of liquid ceramic glaze. A BLL obtained approximately 1 hour after ingestion of the glaze was less than 5 ug/dL; ZPP was 54 ug/dL. A repeat BLL on August 21 was less than 5ug/dL.

Patient 3
On August 15, a 58-year-old patient, admitted for psychosis with suicidal ideation, consumed approximately 4 fluid ounces of ceramic glaze. The next day, the patient complained of abdominal pain. A BLL obtained on September 1 was 61 ug/dL; ZPP was 105 ug/dL.
No treatment was given, and the patient had no additional gastrointestinal symptoms.

Follow-up Investigation :
The glazes consumed by patients 1 and 3 were 25%-29% and 43% lead by weight, respectively. Soluble lead accounted for up to 32% of the total weight of both of these glazes. The glaze consumed by patient 2 was less than 0.06% lead by weight and was considered "lead-free."

At the time of these episodes, two large psychiatric facilities in Alaska offered ceramic-therapy programs that used lead-based glaze. Approximately 1400 patients participated in ceramic-therapy programs at these two facilities. In addition, of 15 nursing homes in Alaska contacted by the ADPH, four had used lead-based glaze in ceramic therapy.

Following these ingestions, the ADPH requested that psychiatric facilities and nursing homes discontinue use of lead-based glaze in ceramic therapy.

Editorial Note:
During 1991, the American Association of Poison Control Centers received reports of 318 incidents of ceramic glaze ingestion in the United States (1), of which nine (2.8%) were intentional; 307 (96.5%), unintentional; and two (0.6%), of unknown intent.

From 1984 through 1990, the Fresno County (California) Regional Poison Control Center received reports of 75 persons who ingested lead-based ceramic glaze (2); of these, 34 (45.3%) occurred in extended-care facilities and for 32 (42.7%) persons, impaired mental status was known before ingestion.

Nursing home patients who developed lead poisoning after ingesting lead-based glaze while participating in ceramic therapy include four persons (one of whom died of lead encephalopathy) in Pennsylvania (R. Roberge, University of Pittsburgh Medical Center, personal communication, September 24, 1992) and one person in Maryland (P. McLaine, Division of Lead Poisoning Prevention, Maryland Department of the Environment, Baltimore, personal communication, September 30, 1992).

In 1988, following a series of lead poisonings among patients who ingested ceramic glaze, Arizona banned the use of lead-based glaze in nursing homes (3).

Since 1990, all arts and crafts products sold in the United States are required to be labeled in conformance with Standard D-4236 of the American Society for Testing and Materials (ASTM).* Under this standard, toxic products, including lead-based glazes, must be marked with a signal word such as "warning" or "caution," a list of ingredients, instructions for safe use of the product, and a statement that the product is inappropriate for use by children. Additional labeling such as "safe for food containers" or "food-safe" indicates that lead from a correctly fired piece of pottery will not leach; unfired glaze, however, may contain lead that can be absorbed if ingested.

In 1987, the Art and Craft Materials Institute (ACMI), a nonprofit association that sponsors a certification program of arts and crafts products to document conformance with labeling laws, informed nursing homes and occupational therapists nationally of the hazards associated with using toxic materials in institutional settings. ACMI recommends that in situations where supervision is required (e.g., elementary schools, hospitals, nursing homes, and psychiatric institutions) only "lead-free" glaze be used (4). ACMI also supports additional product labeling that specifically cautions against the use of toxic materials in these facilities. Glazes distributed after 1990 that are labeled "conforms to ASTM D-4236" and have no health warnings are considered nontoxic.

Scombroid Fish Poisoning
- New Mexico, 1987
In July 1987, state and local public health officials in New Mexico investigated two cases of scombroid fish poisoning (histamine poisoning) in persons living in Albuquerque.

The New Mexico Health and Environment Department was initially consulted by an Albuquerque physician regarding two patients, a husband and wife, who had become ill within 45 minutes after eating dinner. Their symptoms included nausea, vomiting, diarrhea, headache, fever, flushing, and rapid pulse rate.

An investigation by the Albuquerque Environmental Health Department found that the couple had shared a meal of grilled mahi mahi, pasta, salad, water, and wine. Their dog had eaten some of the fish and had vomited; however, their daughter, who had eaten no fish, did not become ill.

Both of the patients had been treated with Benadryl, activated charcoal, and ipecac in a hospital emergency room. Their symptoms resolved within 36 hours of onset of illness.

Samples of the remaining mahi mahi were sent to the Food and Drug Administration laboratory in Seattle. Histamine was detected in the samples at a ratio of 20 mg/100 g, a level sufficient to cause symptoms (1). Samples from a different shipment of fish were obtained from the store in Albuquerque where the mahi mahi was purchased. These samples yielded histamine levels of 3 mg/100 g of sample and were negative for ciguatera toxin.

The fish had been imported from Taiwan through California and shipped frozen to the Albuquerque distributor, where it was thawed and sold from iced refrigerator cases. The patients had frozen the fish after they bought it. Later, they thawed it for 3 hours at room temperature and then grilled the still icy fish.

Tetrodotoxin Poisoning Associated With Eating Puffer Fish Transported from Japan -- California, 1996
MMWR 45(19);389-391 Publication date: 05/17/1996

On April 29, 1996, three cases of tetrodotoxin poisoning occurred among chefs in California who shared contaminated fugu (puffer fish) brought from Japan by a co-worker as a prepackaged, ready-to-eat product. The quantity eaten by each person was minimal, ranging from approximately 1/4 to 1 1/2 oz. Onset of symptoms began approximately 3-20 minutes after ingestion, and all three persons were transported by ambulance to a local emergency department (ED).

This report summarizes the investigation of these cases by the San Diego Department of Environmental Health (SDEH) and the Food and Drug Administration (FDA).

Case 1
A 23-year-old man ate a piece of fugu "the size of a quarter" (approximately 1/4 oz). Approximately 10-15 minutes later, he had onset of tingling in his mouth and lips followed by dizziness, fatigue, headache, a constricting feeling in his throat, difficulty speaking, tightness in his upper chest, facial flushing, shaking, nausea, and vomiting. His legs weakened, and he collapsed.

On examination in the ED, his blood pressure was 150/90 mmHg; heart rate, 117 beats per minute; respiratory rate, 22 per minute; temperature, 99.3 F (37.4 C); and oxygen saturation, 99% on room air.

Case 2.
A 32-year-old man ate three bites of fugu (approximately 1 1/2 oz) over 2-3 minutes. While eating his third bite, he noticed tingling in his tongue and right side of his mouth followed by a "light feeling," anxiety, and "thoughts of dying." He felt weak and collapsed.

At the ED, his blood pressure was 167/125 mmHg; heart rate, 112 beats per minute; respiratory rate, 20 per minute; and oxygen saturation, 96% on room air.

Case 3.
A 39-year-old man ate approximately 1/4 oz of fugu after eating a full meal. Approximately 20 minutes after eating the fugu, he had onset of dizziness and mild chest tightness.

At the ED, his blood pressure was 129/75 mmHg; heart rate, 84 beats per minute; respiratory rate, 22 per minute; temperature, 97.2 F (36.2 C); and oxygen saturation, 97% on room air.

Diagnosis and Treatment:
A presumptive diagnosis of tetrodotoxin poisoning in all three men was based on clinical presentation in the ED and the history of recent consumption of fugu.

All were treated with intravenous hydration, gastric lavage, and activated charcoal. Symptoms gradually resolved, and the men were discharged the following day with no residual symptoms.

Follow-Up Investigation:
The chef who brought the fugu from Japan failed to declare this item through customs. The remaining fugu was obtained for toxin analysis at FDA. SDEH contacted health authorities in Japan and relayed the product label information for identification of the product manufacturer to assist in their local follow-up investigation.

Treatment of Acetaminophen Overdose:

Zed PJ, Krenzelok EP
Am J Health Syst Pharm 1999 Jun 1;56(11):1081-91; quiz 1091-3
CSU Pharmaceutical Sciences, Vancouver Hospital and Health Science Center, Faculty of Pharmaceutical Sciences, University of British Columbia, Canada. zed@interchange.ubc.ca

The therapeutic management of patients with acetaminophen overdose is reviewed.
Acetaminophen overdose results in more calls to poison control centers in the United States than overdose with any other pharmacologic substance. Although the optimal management strategy remains controversial, the literature suggests a general approach that can be followed until there is evidence supporting a different strategy.

A single dose of activated charcoal should be administered within one hour of acetaminophen overdose. Other means of gastric decontamination are not warranted.

Acetylcysteine should be given if the acetaminophen concentration exceeds the treatment line in the Rumack-Matthew nomogram.

If a patient is treated within 10 hours of acetaminophen ingestion, the risk of hepatoxicity is low. In patients 10-24 hours after ingestion, a 72-hour oral or 48-hour i.v. acetylcysteine regimen should be used. Among patients with fulminant hepatic failure, acetylcysteine should be given until recovery or death occurs. In patients who have taken extended-release acetaminophen, the acetaminophen concentration should be measured at four hours and, if this level exceeds the treatment line, acetylcysteine should be started immediately. If the concentration is below the treatment line, a second acetaminophen concentration should be determined four to six hours later. If this level is above the treatment line, acetylcysteine therapy should be started. Cimetidine appears to have no role in the management of acetaminophen overdose.

Children should be diagnosed and treated the same way as adults, and pregnant patients should be managed no differently than nonpregnant patients. An evaluation of the literature on acetaminophen poisoning verifies the usefulness of acetylcysteine as a hepatoprotective agent. A single dose of activated charcoal may also be useful if given within one hour of acetaminophen ingestion.

Water Hemlock Poisoning -- Maine, 1992
On October 5, 1992, a 23-year-old man and his 39-year-old brother were foraging for wild ginseng in the midcoastal Maine woods. The younger man collected several plants growing in a swampy area and took three bites from the root of one plant. His brother took one bite of the same root.

Within 30 minutes, the younger man vomited and began to have convulsions; they walked out of the woods, and approximately 30 minutes after the younger man became ill, they were able to telephone for emergency rescue services. Within 15 minutes of the call, emergency medical personnel arrived and found the younger man unresponsive and cyanotic with mild tachycardia, dilated pupils, and profuse salivation. Severe tonic-clonic seizures occurred and were followed by periods of apnea.

He was intubated and transported to a local emergency department. Physicians performed gastric lavage and administered activated charcoal. His cardiac rhythm changed to ventricular fibrillation, and four resuscitative attempts were unsuccessful. He died approximately 3 hours after ingesting the root.

Although the older brother was asymptomatic when he arrived at the emergency department, he was treated prophylactically with gastric lavage and administered activated charcoal. He began to have seizures and exhibit delirium 2 hours after eating the root; he was stabilized and transferred to a tertiary-care center for observation. No additional adverse effects were reported.

The root ingested by the two brothers was identified as water hemlock (Cicuta maculata). In October 1993, postmortem samples of frozen liver tissue, blood, and gastric contents from the man were analyzed by high-pressure liquid chromatography for cicutoxin, a poisonous substance in water hemlock. Cicutoxin, a neurotoxin, was not detected; however, the toxin is labile and may have degraded during storage.

The Safety Factor:

It is argued that charcoal can take vitamins from the intestinal tract. However, clinical research has rarely shown any ill effects from long-term use of activated charcoal." In experiments with sheep and rats, no significant change in blood chemistry was detected after 6 months of observation," While charcoal "absorbs" extremely well at body temperatures, it loses this quality at higher temperatures.

This medicine
should not be used in poisoning if corrosive agents such as alkalis (lye) and strong acids, iron, boric acid, lithium, petroleum products (e.g., kerosene, gasoline, coal oil, fuel oil, paint thinner, cleaning fluid), ethyl alcohol, or methyl alcohol have been swallowed, since it will not prevent these poisons from being absorbed into the body.

Preparations of activated charcoal with sorbitol are usually not recommended for use in children under 1 year of age because of the risk of excessive catharsis. In older children, the weight of the child must be taken into account to determine a safe dosage of sorbitol, which should not exceed 3 grams per kg of body weight. Children should not receive preparations of activated charcoal with sorbitol unless they are under the direct supervision of a physician, so proper attention may be given to the patients' fluid and electrolyte needs. For antidiarrheal or antiflatulent use (preparations without sorbitol only): When used as an antidiarrheal or antiflatulent, prolonged use of activated charcoal in infants and children under 3 years of age is not recommended since it may possibly interfere with nutrition. In pediatric patients with diarrhea, caution is recommended because of the risk of fluid and electrolyte loss; these patients should be referred to a physician.

For use as an antidote: Although adequate and well-controlled studies have not been done in the geriatric population, caution is recommended when using preparations of activated charcoal with sorbitol because of the increased risk of catharsis, which may result in fluid and electrolyte loss in geriatric patients. For antidiarrheal use (preparations without sorbitol only): In geriatric patients with diarrhea, caution is recommended because of the risk of fluid and electrolyte loss; these patients should be referred to a physician.

The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)-not necessarily inclusive major clinical significance):
Acetylcysteine, oral (effectiveness of orally administered acetylcysteine as antidote in acetaminophen overdose may be decreased because of adsorption by activated charcoal; activated charcoal is recommended if ingestion of other substances [in addition to acetaminophen] is confirmed or suspected, but its removal by gastric lavage may be advisable.

Activated Charcoal