Re: Malpractice?

Robert CLS, MT(ASCP) wrote:
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.

To all...I think you all are missing the OP's main point. They didn't give
him the damn activated charcoal until 24 hours after his arrival to the ER
(regardless of how soon he got to the ER after he took the overdose). IMO
this is incompetence, ie either give it to the patient within the 60min/2
hour window, or why bother. This is what the OP was really asking I
believe, at the end of his post.

I was merely asking what the general protocol was for hospital ER's
regarding AC. Regardless of that, the damn ER gave the patient the AC 24
hours too late, which sounds like incompetence to me, yes or no. No more
hemming or hawing please.

Pete


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


.

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