Activated charcoal is a highly porous form of carbon that's been processed to have small, low-volume pores that increase the surface area available for adsorption or chemical reactions. It's created by heating carbon-rich materials, such as wood, coconut shells, peat, or coal, to very high temperatures in the presence of gases that are unable to combine with the carbon atoms

When utilised as soon as possible after ingesting a chemical substance, ideally within an hour, activated charcoal works by adsorbing the ingested toxin or poison. Although the dose for various poisons may vary, they are essentially the same. Sustained-release formulations, salicylates, and drugs with delayed absorption can all be utilised after an hour has passed since intake. It may be suggested that patients take repeated doses of activated charcoal if they take high or potentially fatal dosages of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. Other oral anticoagulants, including vitamin K antagonists like warfarin, are also used off-label to treat cerebral bleeding.

Toxins and drugs where activated charcoal may be used:

• Calcium channel blockers, especially verapamil, and diltiazem
• Beta Blockers
• Amisulpride
• Chloroquine, hydroxychloroquine or quinine
• Flecainide
• Methotrexate
• Carbamazepine
• Colchicine
• Paraquat/diquat

Toxins and drug overdose where Charcoal may not be helpful and/ or contraindicated:

• • Ingestion of corrosives like Acids and Alkalis.
  • Cyanide ingestion.
  • Ethanol or methanol
  • Eucalyptus and Essential Oils
  • Fluoride
  • Hydrocarbons
  • Metals including Lithium, Iron compounds, potassium, and lead
  • Mineral acids like Boric acid

Activated charcoal dose in adult

Activated charcoal dosage in the treatment of Acute poisoning:

• For a single dose: Give them 25 to 100 grams.
• For multiple doses: Start with 50 to 100 grams, then give them 25 to 50 grams every 4 hours.

But be careful: Some activated charcoal products contain sorbitol, which can cause severe dehydration. It's best not to give charcoal mixed with sorbitol.

It's tricky because sometimes we don't know exactly how much poison they've swallowed, so giving the right amount can be tough. Some experts still suggest a 10:1 ratio of charcoal to poison, but this isn't always practical and could mean giving too much charcoal.

Activated charcoal off-label use in the treatment o Intracranial haemorrhage secondary to oral anticoagulants other than vitamin K antagonist:  

If someone on certain blood thinners like dabigatran or apixaban has bleeding in the brain, activated charcoal can be given to help reduce the effects of the medicine. Here's how much to give:

• Give 50 grams of activated charcoal within 2 hours of taking dabigatran or drugs like apixaban, edoxaban, or rivaroxaban.

It's also recommended to use other treatments alongside activated charcoal in certain cases, like giving prothrombin complex concentrate or activated PCC for reversing factor Xa inhibitors, or using idarucizumab for reversing dabigatran.

Activated charcoal Dose in Children

Activated charcoal dosage in Acute poisoning: 

Single Dose - Charcoal in Water:

• Infants <1 year:
  • Manufacturer's Labeling (Actidose-Aqua): 1 g/kg
  • AACT Recommendation: 10 to 25 g
• Children 1 to 12 years:
  • Manufacturer's Labeling:
    • Actidose-Aqua: 25 to 50 g
    • Kerr Insta-Char (Aqueous): Weight ≥16 kg: 1 to 2 g/kg or 15 to 30 g
  • AACT Recommendation: 25 to 50 g
• Adolescents:
  • Manufacturer's Labeling:
    • Actidose-Aqua: 50 to 100 g
    • Kerr Insta-Char (Aqueous): Weight ≥ 32 kg: 1 to 2 g/kg or 50 to 100 g
  • AACT Recommendation: 25 to 100 g

Single Dose - Charcoal with Sorbitol:

• Children 1 to 12 years (Actidose with Sorbitol):
  • Weight 16 to <32 kg: 25 g
  • Weight ≥ 32 kg: 25 to 50 g
• Adolescents (Actidose with Sorbitol):
  • 50 g
• Adolescents (Kerr Insta-Char in Sorbitol):
  • Weight ≥32 kg: 1 to 2 g/kg or 50 to 100 g

Multiple Dose - Charcoal in Water:

• Manufacturer's Labeling (Actidose-Aqua):
  • Infants <1 year: 1 g/kg every 4 to 6 hours
  • Children 1 to 12 years: 25 to 50 g every 4 to 6 hours
  • Adolescents: 50 to 100 g every 4 to 6 hours

These doses are typically repeated until clinical observations of toxicity lessen or until serum drug concentrations return to safe levels. However, multiple doses are usually reserved for severe cases involving certain drugs like carbamazepine, dapsone, phenobarbital, quinine, or theophylline.

Pregnancy Risk Factor B

• Activated charcoal given by mouth doesn't get absorbed into the body, so it's not likely to affect the baby during pregnancy.
• When it comes to using medicines to counteract poisons or toxins, doctors should weigh the benefits for the mother's health against any potential risks to the baby.
• Pregnant women should receive antidotes if they're needed, based on their health needs, without holding back because of concerns about harming the baby.

Use activated charcoal during breastfeeding

• Activated charcoal, when taken by mouth, doesn't get absorbed into the body.
• So, if a nursing mother takes activated charcoal, it's unlikely to have a significant effect on her breastfed child.

Activated charcoal Dose in Renal Disease:

• In individuals with renal illness, there has been no advised dosage modification.

Activated charcoal Dose in Liver Disease:

• In individuals with renal illness, there has been no advised dosage modification.

Common Side Effects of Activated charcoal Include: 

• Ophthalmic:
  • Corneal abrasion
• Gastrointestinal:
  • Mouth discoloration
  • Vomiting
  • Constipation
  • Dental discoloration
  • Abdominal distention
  • Appendicitis
  • Fecal discoloration
  • Intestinal obstruction
• Respiratory:
  • Respiratory failure
  • Aspiration

Contraindications to Activated charcoal include:

• The manufacturer's instructions don't have any absolute reasons to avoid using activated charcoal.
• However, according to expert guidelines from the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists, there are certain situations where using charcoal might not be safe.
• These include if someone has intestinal blockage, a damaged gastrointestinal tract, a high risk of gastrointestinal bleeding or perforation, or if they can't protect their airway (for example, if they're heavily sedated without a breathing tube), or if using charcoal might increase the risk of inhaling it into the lungs.

Warnings and Precautions

Vomiting:

• Activated charcoal can sometimes make people vomit, especially if it's given with sorbitol.
• It's not clear how much other factors like the speed of giving charcoal, the amount taken, or other medical conditions affect this risk.
• In some cases, doctors might need to use anti-nausea medications through a vein to help prevent or manage vomiting and make it easier to give charcoal.

Decreased peristalsis:

• Activated charcoal should be used carefully in patients with decreased peristalsis, which is the wave-like muscle contractions that move food through the digestive tract.
• This caution is because decreased peristalsis can affect how quickly the charcoal moves through the digestive system and how effective it is in adsorbing toxins.

Activated charcoal: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Monitoring Parameters:

• Monitor bowel sounds and consciousness level prior to administering it.

How to administer Activated charcoal?

Enhancing Palatability:

• Flavored beverages like cola, chocolate milk, or concentrated fruit juice can make activated charcoal easier to swallow.
• Some flavoring agents like chocolate syrup, milk, ice cream, sherbet, or marmalade, however, can reduce the effectiveness of activated charcoal by reducing its ability to absorb toxins.
• Whenever possible, opt for activated charcoal water slurries instead of these flavoring agents.
• Despite their impact on efficacy, these flavoring agents might be necessary in certain cases to improve compliance with taking activated charcoal.

Preparation and Administration:

• Before giving activated charcoal, check for the presence of bowel sounds.
• To minimize the risk of vomiting, IV antiemetics may be necessary.
• Thoroughly agitate the activated charcoal container before administration.
• Rinse the container with a small amount of water to ensure that the patient receives all of the activated charcoal.

Avoid Capsules and Tablets:

• Do not use capsules or tablets for treating poisoning.

Mechanism of action of Activated charcoal:

• Activated charcoal works by adsorbing (essentially sticking to) toxic substances in the gastrointestinal (GI) tract, which prevents or limits their absorption into the body.
• Giving multiple doses of charcoal can interrupt the circulation of certain drugs within the intestines, liver, and stomach.
• It can also bind to any drugs that haven't been absorbed yet, effectively trapping them in the GI tract.

In studies with adult human volunteers, it was found that giving a single dose of activated charcoal of 50 grams or more within certain time frames after ingestion of a substance led to reductions in the absorption of the substance. Here are the reductions observed:

• Given within 30 minutes after ingestion: 47.3% reduction
• Given at 60 minutes after ingestion: 40.07% reduction
• Given at 120 minutes after ingestion: 16.5% reduction
• Given at 180 minutes after ingestion: 21.13% reduction
• Given at 240 minutes after ingestion: 32.5% reduction

Activated charcoal is not absorbed from the gastrointestinal tract and is excreted primarily in feces in the form of charcoal.

Activated charcoal international brands:

• Kerr Insta-
• Char in Sorbitol
• Kerr Insta-Char
• Acticarb
• Allocholum
• Antipois
• Bekarbon
• Actidose-Aqua
• Actidose/Sorbitol
• Biocarbon
• Ca-R-Bon
• Carbobel Mono
• Carbomint
• Carbomix
• Carbosorb
• Char-Flo with Sorbitol
• EZ Char
• Carbosorb X
• Carbosorb XS
• Carbotox
• Carbotural
• Charbogir
• Charcodote
• Charcotrace
• Deltacarbon
• JL Bragg's Medicinal Charcoal
• Karbosorb
• Koal
• Kremezin
• Mamograf
• Norit
• RCOL
• Sorbex
• Ultra Carbon
• Ultracarbon
• Yo'Come Penney

Activated charcoal Brands in Pakistan:

Available as activated charcoal powder