Overdose, using charcoal on a combative pt?

[vampireslayer]

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

[andhow5, BSN, RN]

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!

[janejoeben]

hi all, i am an emergency nurse in the uk, moving to the us in july. some of the comments on this thread worry me slightly! can you legally restrain and 'force' someone to take charcoal? also, we only use it if they present within 1 hour of ingestion, which in reality is pretty rare. would intubating them and putting charcoal down a ng take longer than an hour? they would have to ingest the tablets whilst sitting in the waiting room. all seems a bit extreme to me.... encourage them to drink it, if not its their choice surely, they have to have some responsibility for their care. :uhoh21:

[Larry77, RN]

would intubating them and putting charcoal down a ng take longer than an hour?

boy i hope not! intubation and ngt placement would probably take about 10-15 minutes in my opinion, but that would be if we were in a hurry...with these types of patients we are usually not in a hurry unless their vitals are elevated so far that we would have to intubate to manage them...in that case we would probably not use charcoal.

[Altra, BSN, RN]

Boy I hope not! Intubation and NGT placement would probably take about 10-15 minutes in my opinion, but that would be if we were in a hurry...with these types of patients we are usually not in a hurry unless their vitals are elevated so far that we would have to intubate to manage them...in that case we would probably not use charcoal.

Agree. In a year & a half in the ER, and more overdoses than I can count, I've given charcoal only once and that was to an alert, oriented, cooperative pt. who drank it. Never given it via NGT.

Intubation generally takes 6-8 minutes from the time the decision is made. In intubated pts. we usually make it an OG, not an NG ... if someone's getting that ready while the pt. is being tubed it takes another 45 seconds after the ETT is in. Shoot the CXR to check placement of both and you're good to go.

[moomoo111]

With my experience as a Paramedic for 15 years and the many trauma centers I've transported mypatients to, I've seen gastric lavage used the most and with the final administration of charcoal using the dual piston mechanism procedure with restraints. I've only seen one patient that refused and was so combative and they even attempted to chemically restrain the patient and she still fought tooth and nails and the er doctor finally gave up and just sent her to ICU to be monitored. I don't remember what she took but I remember her taking several different things and she had overdosed so many times, she was a "frequent flyer" to EMS and the ER. They had attempted several times to get the NG tube down her throat but she was so forceful and she was a very tiny malnourished patient but she still managed to fight us all off. Sometimes EMS would stay to help if we were not backed up on calls and all my clinical hours were done in big trauma centers so I've had quite a few ER experiences with lots of patients. But getting different opinions on this web site is what helps us learn which is why I love it here. I have not gotten into clinicals yet and am working as a CNA in a nursing home so I don't see much right now but I do know that EMS and some ERs took away the charcoal if it had been so many hours after the drugs were ingested. Something else I can research later when I have the time. Good topic for us all here.

[Noryn]

They actually get people to volunteer to be lavaged and charcoal, why anyone would volunteer for this I will never know. Anyway when charcoal is given there is a 47% absorption reduction (of the medication)when given within 30 minutes, 40% at an hour then at 2 hours it goes down to I think around 16 percent.

That looks great on paper however the problem is, it really hasnt been shown to improve patient outcomes. If the pt is alert, there is minimal risk of complications such as aspiration and it is within the first hour it is reasonable to give it. Usually though after about an hour, the amount of medication it will absorb (and without evidence it will improve the pt's outcome) isnt worth the potential risks. A pt with cns depression or seizures from an overdose isnt one you want with a full stomach of charcoal.

[rgroyer1RNBSN, BSN, RN]

Why are you all sedating for an NG. First the doc tries to gastric lavage the pt then if the pt struggles and we have to stop the gastric lavage then the nurses restrain and another nurse drops an ng. nO SEDATIVES TO IT UNLESS WERE WORRIED ABOUT AN AIRWAY THEN WE INTUBATE THEM.

[vampiregirl, BSN, RN]

I have not gotten into clinicals yet and am working as a CNA in a nursing home so I don't see much right now but I do know that EMS and some ERs took away the charcoal if it had been so many hours after the drugs were ingested. Something else I can research later when I have the time. Good topic for us all here.

Our county EMS system removed charcoal from the protocols and the ambulances, about a year ago I think.