Re: Malpractice?


Pete wrote:
Robert CLS, MT(ASCP) wrote:
cejo wrote:
Good afternoon,

I'm new on this board and I have a question. my brother in law was
taking Fluoxetine 20mg and norflouxetine 20mg. One night he took a
large quantity of the medication in an attempt to take his life. Upon
reaching the emergency room the doctors "cleaned" his stomach. They
told us his condition was stable and allowed us to go into the room
with him. There were still large chunks of pills going through the
tube, which according to the way it should be done by the book, it
should be completely clear. According to the FDA they were also
supposed to immediatly start him on activated charcoal, which was not
done until almost 24 hours later. He still had 410mg of fluoxetine
and 130mg of norflouxetine at the time of autopsy. He lasted three
days in the hospital.

malpractice? I think that maybe if they would have cleaned him better
and started him of on active charcoal immediately, he would've had a
better chance to be here today. What do you think?


Posted via medical forums at http://medical.gr77.com

I am sorry to hear about the outcome.

Most things have been done based on a feeling that some things should
theoretically work. There are those who practice experienced based
medicine and then those who practice evidence based medicine.

Clinical studies involving the use of gastric lavage GL and acitivated
charcoal AC are sketchy. This is not the same thing as nasogastric
aspiration which is ok for liguid poison but not ok for pills.

With Gl, the effect is clearly time dependent, and little effect is
expected when treatment is delayed beyond 60 minutes. One study using
radiographic markers suggested that GL may actually propel contents
past the pylorus, moving the poison into the small intestine where
most of the drug will be absorbed.
Although some studies have shown that GL may decrease drug absorption,
three clinical trials have failed to show improved outcomes when GL is
added to AC for management of undefferentiated symptomatic poisoning
patients.

AC studies have also been done and they compared AC versus supportive
care alone in an asymptomatic individual and they found no benefit in
AC use.


There was one large clinical trial involving 1479 patients in which AC
was used vs supportive care only in symptomatic and asymptomatic
overdose patients. There were no differences in the proportion of
patients deteriorating or requiring admission to either hospital or
ICU. There is some bias in studies like this.

One study that is in abstract form right now found no benefit over
supportive care alone. Preliminary results suggest that the patients
who were given AC had a trend toward longer ED stay and no change in
mortality.

There can be complications to AC treatment such as aspiration
pneumonia and acute lung injury resulting in death. There is a 25%
increase incidence in vomiting on AC vs only about a 10% increase
without it.

Again many things are done in medicine because that's the way things
have been done. Randomized clinincal trials have at times shown that
they may be of no use or even harmful. I can't really speak to the
circumstances in this case. AC should be used as soon as possible in
order for it to work and the 60 minutes also applies although 2 hours
after depending on drug such as long acting drugs, can possibly help.

Robert...You know I am one of your fans, but that was a lot of stuff you
wrote, and I have a couple simple statements about this.

Here is a quote I found (in one of my many hundreds of medical bookmarks),
regarding activated charcoal (AC).

"Activated charcoal exerts its effects by adsorption of a wide variety of
drugs and chemicals. Adsorption is a process in which atoms and molecules
move from a bulk phase (such as a solid, liquid, or gas) onto a solid or
liquid surface. In other words, the toxic substance attaches to the surface
of the charcoal. Because charcoal is not "digested," it stays inside the GI
tract and eliminates the toxin when the person has a bowel movement."

I am not an ER doc and neither are you, but I am pretty sure it is the
policy of the county "redneck" hospital where I live, to administer charcoal
immediately, for various kinds of drug overdoses. I believe it is given
most often immediately after gastric lavage, but I certainly am no expert on
that. So lets say we have one "immediately" followed by another
"immediately" (so to speak), but the important thing is the sooner the
better, unless I am totally all wet here.

Now having said that, here is my basic question to you (and you know a hell
of a lot more than me on this). Is it the basic policy of hospital ER's (in
general) to administer AC immediately, or not (for various overdoses of
drugs). I believe it can eliminate up to 60% of the absorption (you notice
I said "absorption" this time) into the small intestine (depending on the
drug of course).

I hope you will do better than responding with "it depends on each hospital,
and each ER doctor, and each specific case", da da da da.

I am looking for a general rule of thumb here - ie, is it general policy in
most cases to administer the AC or not. I believe it is. And the author
(cejo) mentioned something about the FDA referencing that policy also - but
I would have to check into that.

I would almost bet that our good friend Howard is going to stay out of this
one, but I certainly welcome his comments :-) .

Thanks...Pete

I don't work in the ER and so the direct answer is I don't know what
the poison protocol is. The above info was from a Clinical Toxicology
book overview I just read. AC has not been shown to improve the
outcomes of nonselected poisoning patients was the bottom line.
Your statements about how it works is correct in that it is eliminated
in the stool. Again , one thing is drawing it up on the blackboard and
saying it should work but when RCT's are done there is no difference in
outcome. There is also theoretical concerns of intestinal obstruction
with the charcoal.

Activated charcoal, if it is going to be used needs to be used within
60 minutes and with select drugs within 2 hours of ingestion. The
question is when did the patient present to the ER and was it within an
hour or two.

The FDA does not tell doctors how to practice medicine. Everybody can
make recommendations including the FDA and regulate somewhat.

.

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