Overdose, using charcoal on a combative pt?

  1. What do you do with an overdose psych patient that refuses to drink the charcoal? Do you skip it? Sedate then NG? Intubate then NG? He was awake, agitated and becoming combative (and very very big & strong!).

    The pt. I have in mind took a cocktail of tricyclics, benzos, naroctics and beta blockers...well, as far as we know, that's what he had in his bag o' meds, and he just said he took "all of those".

    We skipped the charcoal altogether and gave bicarb & ativan. But the admitting doc really had a problem with the ER doc's choice to forgo the charcoal.

    I haven't seen that many overdoses yet...it seems to me that it would be the rule rather than the exception that the pt would refuse to drink the charcoal...so what do you do? (I HAVE seen the charcoal spit out all over the room and everyone in it though...luckily I saw that from a distance!)

    VS
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  2. 19 Comments

  3. by   traumaRUs
    Depends...because tricyclics are quickly absorbed, it might be sometimes prudent to sedate, paralyze, intubate and THEN place an NG under optimal conditions and also this would help with control of the pt.

    Many psych patients that overdose do refuse to drink charcoal...can sometimes cajole or convince them that drinking is preferable to an NGT>
  4. by   Rio
    What time ddid he allegedly ingest all these medications that would have caused sedation, respiratory depression, bradycardia, hypotension, arrythmias, etc... ?
  5. by   vampireslayer
    It had been 1-2 hours (according to the staff at his group home). He had several bottles (maybe 15-20), & several of them were duplicates, and some of them had recently been filled, but were nearly empty. But some of them were older prescriptions and half full still...so he obviously wasn't taking his meds as prescribed.

    Actually, he was tachycardic, not bradycardic...his heart rate was in the 140's. And he wasn't sedated at all. And I don't recall being concerned about his BP, but I can't remember what it was...it's been a couple months since I had this patient.

    Normally I would have counted the remaining pills and done the math on how many he may have taken, but then...I never quite got that chance. You know, what with calling the hospital security, trying to keep him from pulling his IVs out, trying to keep him in his bed, and back in his bed, and then back in his bed again...pushing bicarb, then ativan, then bicarb, then ativan, then all the repeat EKGs. Then pushing his bed back into his room after he "bounced" it out using just his body weight on the side rails.

    VS
  6. by   Rio
    The last I worked in the ER charcoal was not usually advised by poison control. I'm sure this is subject to change as most research in the past were animal studies.
    Reading the scenario I have a high degree of suspician whether he took all the drugs listed... after all you were pushing Ativan yet he allegedly took benzo's. So what was the toxicology report ?
  7. by   Rio
    vampireslayer,
    I'm on the chat , if you want to discuss your case.
    Rio
  8. by   Larry77
    Most of the time when we consult poison control they tell us that charcoal is either not advised or has not been shown to help (depending on the chemical ingested of course).

    In the case you describe we would have treated the symptoms rather then worry about trying to force the charcoal, if the vitals got out of control we would sedate and intubate to manage them.
  9. by   EDValerieRN
    If they refuse, show them the NG. If they still refuse, restrain them and put the NG down. Wear a mask (and gown and hair cover) because they'll spit at you. If it goes into the lungs, give them the choice to drink and if they still say no, attempt again.

    I would only do it this way if they had just taken the meds and poison control says it was a definite good idea.

    Those are my favorite patients in the world.

    Or not.
  10. by   RoxanRN
    If an OD patient comes into our ER, amoung things taken into consideration is the time of ingestion as well as what was ingested.. Basically, is gastric lavage warranted? If it is deemed necessary, we us this wonderful device. I think it is called a Code Blue Gastric Lavage kit (I can't find a sample of it on the web). If it takes 8 people holding the patient down, so be it. The head can easily be controlled by one person (yes, a finger under the nose works quite well), thus preventing the patient from sitting up.

    To use the device, the patient is placed on their side (as best as possible - suction at the ready) or sitting up, an oral bite block is placed and a plastic tube as bigger around than your thumb is introduced through the esophagus into the stomach. The irrigating solution is poured into a bag and a dual piston mechanism is used to pump the solution in and then out of the stomach into another bag. If charcoal is to be instilled, after the irrigation is completed, it is placed in this bag and pistoned in and the tube comes out. No fuss, no muss.

    Sometimes, all it takes is showing them the tube and they will gladly do as asked. But most of the time, they are impaired enough from what they took to be combative and the choice isn't offered.
  11. by   nuangel1
    depending on time of ingestion if the dr felt it was recent and charcoal is ordered we restrain sedate ngt and do the charcoal .it can still be messy depending how well sedated pt is .of course monitoring vss ekgs etc as well.
  12. by   vampireslayer
    If you restrain, sedate then NGT...what do you sedate with? Versed? Ativan? At what point does it become "conscious sedation" along with the required documentation? And isn't there an airway danger, if the pt truly has ingested whatever it was they say they did, aren't they likely to vomit? So shouldn't we intubate rather than just sedate? I've seen it done both ways, and of course seen it skipped altogether and the pt just monitored.

    And what do we have the "right" to do? If the pt. refuses the charcoal, can we assume they're not "competent" because of the suicide attempt, and force whatever measure we choose on them?

    VS
  13. by   Noryn
    My short and sweet version goes like this: it sounds like your management of the pt was appropriate. I would always recommend that you call your local poison control for tips on management of overdoses as they can really help. If they wouldnt drink the charcoal for me? I would skip it, and most definitely would never sedate or intubate them just so I could give them charcoal. His tachycardia could have been coming from the tricyclic or it could have just been from his agitation. Sedation with a benzo again is appropriate. Was he acidotic? or was his qrs prolonged as to why you were giving so much bicarb? Now for my long part

    I will be the first to admit that taking care of drug overdoses can be difficult and tricky. It would seem that gastric lavage would be an obvious intervention just like using ipecac to make a kid throw up. However despite research gastric lavage hasnt really been shown to be effective. Then you have to look at the fact that gastric lavage can be harmful so why have an intervention that is not effective and may actually cause harm?

    I will post an abstract from the Clinical toxicologist website on a position statement:
    "Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. The results of clinical outcome studies in overdose patients are weighed heavily on the side of showing a lack of beneficial effect. Serious risks of the procedure include hypoxia, dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and electrolyte abnormalities,
    and aspiration pneumonitis. Contraindications include loss of protective
    airway reflexes (unless the patient is first intubated tracheally), ingestion of a strong acid or alkali, ingestion of a hydrocarbon with a high aspiration potential, or risk of GI hemorrhage due to an underlying medical or surgical condition. A review of the 1997 Gastric Lavage Position Statement revealed no new evidence that would require a revision of the conclusions of the Statement."

    Similarly activated charcoal has not really been shown to improve pt outcomes but again carries risk of aspiration especially in an obtunded pt. The current thinking is pretty much this, activated charcoal may provide some benefit if given within an hour of ingestion however again you need to think of the risks. If a person is alert and willing to drink it, (and it is something charcoal will adsorb) then it is probably not going to hurt to give it. If the patient is lethargic, or you have to use a NG tube to give it, I would hesitate and directly consult with your poison control.

    I think a lot of people get hung up on "antidotes" when really with a drug overdose, you pretty much just have to treat what you see ie hypotension, arrythmias, etc.
  14. by   andhow5
    I'd have to say, "It depends." A lot a variables come in to play; time ingested, amount, medication, symptoms, intent (accidental or intentional), et cetera.

    A lot of times, I've forgone the charcoal and treated the symptoms after consulting with poison control. Sometimes it's been necessary to "throw down" and basically have a free for all trying to get it down. Other times I've had to resort to intubation and NG tube.

    Whatever the admitting doctor is having a cow about, he can take before the review board. The fact of the matter is, he wasn't in the same position the EDMD was in, and really can't do much about it.

    As long as the EDMD ordered what was appropriate, and you carried out (in your best nursing judgement) what was appropriate, the admitting MD can go jump in a lake.

    There will always be an admitting or consult MD, or receiving nurse that will second guess your situation and try to make themselves look "smarter". You can't make them all happy.

    You can only do what you can do sometimes. As long as you deliver the patient still breathing, in my opinion, it's all good!

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