In the rural developing world, patients who have poisoned themselves with toxic pesticides or plants should not be treated with multiple-dose activated charcoal, because it has no effect on the rate of mortality. These results were announced in an Article on February 16, 2008 in The Lancet.

In fact, a major clinical and public health problem in rural Asia is self-poisoning by organophosphorus pesticides. Approximately 500,000 deaths restult in the region from self-inflicted harm, and approximately 60 percent of these are due to pesticide poisoning. Of these, about two thirds can be attributed to organiphosphorous pesticides, about 200,000 per year.

Usually, to treat self-poisoning, doctors administer resuscitation, antidotes, gastric decontamination, and supportive care. No evidence has been shown that gastric decontamination is effective, but the use of activated charcoal is a commonly applied treatment method.

In developed countries, very few victims of self-poisoning die in the hospital, so decontamination is not often applied. Usually treatment in these countries involves pharmaceuticals. In developing countries, new challenges are encountered. To investigate this, Dr Michael Eddleston, Scottish Poisons Information Bureau, New Royal Infirmary, Edinburgh, UK, and Professor David Warrell, University of Oxford and John Radcliffe Hospital, Oxford, UK, and colleagues performed a randomized controlled trial of 4,632 self-poisoned patients in Sri Lanka to establish the relative mortality in patients treated with charcoal at various time intervals.

The population was divided approximately into thirds. One group, of patients was administered six doses of 50 grams of activated charcoal at regular four hour intervals; a second, was administered 50 grams of activated charcoal once; the third were not treated with charcoal. Half of the patients had digested pesticides, while about one third had ingested seeds from yellow oleander (Thevetia peruviana)

Mortality did not differ between the three groups. The group given multiple doses had 6.3% of the cases result in death, compared with 6.8% in the group given no charcoal. There was no discrepancy for patients who took specific poisonous agents, were critically ill on admission, or who presented earlier.

The authors conclude with a summary of the results: "This randomised, controlled trial showed no benefit from routine administration of multiple-dose activated charcoal in Sri Lankan district hospitals. Most patients had ingested yellow oleander seeds or pesticides. Both poisons have major effects that are delayed for several hours...absence of benefit was seen irrespective of the poison ingested or time to presentation."

Dr Peter Eyer, Walther Straub Institute of Pharmacology and Toxicology, University of Munich, Germany and Dr Florian Eyer, Technical University, Munich, Germany, contributed to an accompanying comment in the same issue: "The results of Eddleston and colleagues study are relevant for the setting of a developing country, where most of these specific poisonings occur...There is an obvious need for robust toxicokinetic studies to select those poisons that are potentially amenable to multidose activated charcoal. Clinical science should meet basic science and vice-versa."

Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial
Michael Eddleston, Edmund Juszczak, Nick A Buckley,Lalith Senarathna,Fahim Mohamed,Wasantha Dissanayake, Ariyasena Hittarage, Shifa Azher, K Jeganathan, Shaluka Jayamanne, M H Rezvi Sheriff, David A Warrell for the Ox-Col Poisoning Study collaborators
The Lancet, Vol 371, February 16, 2008
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Anna Sophia McKenney