High-surface area Charcoal, Harchelroad 163

in our treatment of poisoned patients in general, and the role of activated charcoal in particular.

Dr. Harchelroad is at Allegheny University of the Health Sciences, Allegheny Campus, Pitts- burgh, PA, Department of Emergency Medi- cine, and Allegheny General Hospital, Pitts- burgh, PA, Medical Toxicology Treatment Center.

Received: October 25, 1996; accepted: No- vember 2, 1996.

Address for correspondence and reprints: Fred Harchelroad, MD, Medical Toxicology Treat- ment Center, c/o Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212. Fax: 4 12-359-4963.

Key words: toxicology; poisoning; acetamin- ophen; activated charcoal.

REFERENCES

1. Roberts JR, Gracely EJ, Schoffstall JM. Advantage of high-surface-area charcoal for gastrointestinal decontamination in a human acetaminophen ingestion model. Acad Emerg Med. 1997; 4:167-74. 2. Cooney DO. In vitro adsorption of pheno- barbital, chlorpheniramine maleate, and the- ophylline by four commercially available ac- tivated charcoal suspensions. J Toxicol Clin Toxicol. 1995; 33:213-7. 3. Dillon EC, Wilton JH, Barlow JC, Watson WA. Large surface area activated charcoal and the inhibition of aspirin absorption. Ann Emerg Med. 1989; 18:547-52. 4. Krenzelok EP. Heller MB. Effectiveness of commercially available aqueous activated charcoal products. Ann Emerg Med. 1987; 16:

5. Pachter HM. Paracelsus-magic into sci- ence. New York Collier Books, 1961.

1340 - 3.

Poison Prevention- Where Can We Make a Difference? Randall Berlin. MD

I The article by Huott and Storrow’ in this month’s Academic Emergency Medicine addresses the potential role primary prevention may have in de- creasing adolescent drug overdoses by highlighting adolescents’ lack of knowledge with respect to drug tox- icities. Prevention should play a large role in poisoning management. It is unclear, however, which level of pre- vention could have the greatest im- pact on poisoning outcomes and which level is best addressed by emergency physicians (EPs).

P r i m l y prevention is the reduc- tion or control of causative factors for a specific health problem. In poison- ing, primary prevention is aimed at preventing the poisoning from occur- ring. This has been the focus of prevention in poisoning for the past 70 years. Primary prevention efforts are epitomized by The Poison Pre- vention Packaging Act, which Con- gress passed in 1970.’ Studies of child and parent education as a pn- mary prevention strategy have dem-

onstrated good results in education, but there is little evidence for an ac- tual decrease in the incidence of childhood poisonings. In addition, primary prevention has been mini- mally studied in the intentional ado- lescent or adult overdose. Several au- thors have highlighted the lack of patients’ knowledge with respect to potential toxicity, but few have stud- ied the effect that education (primary prevention) would have on the actual incidence of poisonings.

Secondary prevention involves early detection and management of disease. In poisoning, secondary pre- vention is best described in 2 tiers. The first tier applies to the patient who has already ingested the poison but may or may not need care. Poison control centers have focused on this tier of secondary prevention, with approximately 73% of their calls be- ing managed on-site in a non-health care facility as reported in the 1995 Annual Report of the American As- sociation of Poison Control Centers

6. Holt LE, Holz PH. The black bottle-a consideration of the role of charcoal in the treatment of poisoning in children. J Pediatr. 1963; 63:306-14. 7. Anderson H. Experimental studies on the pharmacology of activated charcoal. I. Ad- sorption power of charcoal in aqueous solu- tions. Acta Pharmacol. 1946; 2:69-78. 8. Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med. 1985; 14562-7. 9. Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW. Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aust. 1995; 163:345- 9. 10. Van de Graaf W, Thompson WL, Sunshine I, Fretthold D, Leickly F, Dayton H. Adsorbent and cathartic inhibition of enteral drug adsorp- tion. J Pharmacol Exp Ther. 1982; 221:656- 63.

Toxic Exposure Surveillance System (AAPCC TESS).3 Several studies have touted the cost-effectiveness of poison control centers in this tier of secondary prevention.

The second tier of secondary pre- vention involves the patient who has ingested a poison and does require medical attention. This tier of second- ary prevention includes management areas such as cardiorespiratory sup- port, gastrointestinal decontamina- tion, enhanced elimination, and anti- dotal therapy. This area of prevention is generally initiated and often com- pleted by EPs with or without con- sultation with a poison center or a toxicologist. This is the area of poi- son prevention in which EPs could have the greatest impact. To date, the effectiveness of this tier of secondary prevention has received limited atten- tion.

Tertiary prevention is the reduc- tion of morbidity and the maximiza- tion of patient quality of life by pro- viding good supportive care and rehabilitative services. Supportive care is often needed for the poisoned patient, but the effectiveness of this area of poison prevention also has re-

~~

164 ACADEMIC EMERGENCY MEDICINE MAR 1997 VOL 4/NO 3

ceived limited objective evaluation. Regarding rehabilitation, most patients who recover from their poisoning suf- fer little long-term physical disability, and physical rehabilitation plays a small role in poisoning management. However, mental rehabilitation plays a large role in the intentional ingestion. This area of prevention has been pri- marily studied by our psychiatric col- leagues, who have identified many risk factors; however, the optimal long-term approach to preventing ad- ditional mental disabilities remains un- clear. EPs should play a role in this aspect of poison prevention by coor- dinating mental health consultations for the patient who has an intentional ingestion.

Analyzing the reason for the in- gestion is an essential first step in de- ciding where to target prevention stra- tegies. In 1995 a total of 2,023,089 human exposures were reported through the AAPCC TESS. Of these total ex- posures, 86% were unintentional in- gestions; 1 1 % were intentional; and the remaining 3% were either adverse reactions, unknown, or classified as “other.” The unintentional ingestion or exposure is well suited to primary prevention. Approximately 61 % of the reported unintentional exposures were in patients 4 years old, show- ing why past efforts have been con- centrated in this area and why pedi- atric primary prevention should continue to receive attention in the fu- ture. An intentional exposure, at the other extreme, is categorized into the following: suicide, misuse, abuse, or unknown. Because these intentional exposures are purposeful, whether or not a harmful effect is anticipated, they are difficult to manage with pri- mary prevention. Because primary prevention should be the ultimate goal of all prevention strategies, pri- mary prevention in the intentional overdose should not be ignored. However, EPs’ efforts are probably more realistically focused on second- ary and tertiary prevention.

Although unintentional ingestions

account for 86% of reported expo- sures, they result in either a minor ef- fect or no effect in 91% of cases and account for only 12% of fatalities. In 1995 there were 724 fatalities re- ported through AAPCC TESS; 80% were intentional exposures (70% sui- cides, 5% misuse, 19% abuse, and 6% unknown). With respect to cost, again, the small number of serious exposures overwhelms all others. The cost for a poisoned patient requiring hospitalization is 100 times the cost for a patient not requiring hospitali- zation, and poisoning ranks second only behind firearm incidents for cost per fatality due to i n j ~ r y . ~

As EPs, we can make a significant impact on the outcome of the severely poisoned patient from the early iden- tification and management to the final disposition. From the standpoint of morbidity, mortality, and cost, poten- tial improvement in this small group of severely poisoned patients greatly exceeds the benefits that would be reached by focusing on the larger un- intentional group of poisoned pa- tients. It is critical that we continually assess our current management strat- egies in an attempt to identify areas in toxicologic management that would benefit from further research or ex- panded educational efforts.

Viewing tertiary prevention of the poisoned patient primarily as mental health rehabilitation allows us an ex- cellent opportunity to identify pa- tients who are at risk for either a re- peat intentional ingestion or another self-harm activity. By identifying these patients, we would then be able to investigate various primary preven- tion strategies such as patient and family education, or different modes of psycho- or pharmacotherapy. It is important that EPs work together with those in the other disciplines of mental health in instituting future pri- mary and tertiary poisoning preven- tion strategies in the intentional over- dose.

In summary, poison control and toxicologic management are well

suited to be studied in the context of injuryJdisease prevention. All aspects of prevention, which include primary, secondary, and tertiary prevention, need to be targeted with the objective of decreasing morbidity and mortality in a more cost-effective manner. Even though the intentional ingestion ac- counts for a minority of total poison- ing exposures, this is the group with the most morbidity, mortality, and cost and thus deserves the most im- mediate attention. At this time, sec- ondary prevention seems to be the area in which EPs can have the most immediate impact and it is also the area best managed and studied by EPs.

Supported by an EMF Research Fellowship Grant.

Dr. Berlin is at the Oregon Health Sciences University, School of Medicine, Portland, OR, Department of Emergency Medicine, Oregon Poison Center.

Received: October 23, 1996; accepted: Octo- ber 26, 1996.

Address for correspondence and reprints: Randall Berlin, MD, Oregon Health Sciences University, Department of Emergency Medi- cine, 3181 SW Sam Jackson Park Road, UHN- 52, Portland, OR 97201-3098. Fax: 503-494- 4980; e-mail: berlinr@ohsu.edu

Key words: toxicology: poisoning; prevention; adolescent; suicide gesture.

REFERENCES

1. Huott MA, Storrow AB. A survey of ado- lescents’ knowledge regarding toxicity of over-the-counter medications. Acad Emerg Med. 1997; 4:214-8. 2. National Poison Prevention Week 25 An- niversary Observance. MMWR. 1986; 35: 149 - 52. 3. Litovitz TL, Felberg L, White S, et al. 1995 Annual Report of the American Association of Poison Control Centers Toxic Exposure Sur- veillance System. Am J Emerg Med. 1996; 14: 487-537. 4. Rice DP, MacKenzie El, et al. Cost of In- jury in the United States: A Report to Con- gress. San Francisco, CA: Institute for Health and Aging, University of California and Injury Prevention Center, The John Hopkins Univer- sity, 1989.