Activated Charcoal

Activated charcoal is the most commonly used treatment in patients with poisoning (Lai et al., 2006). It may be used for a variety of poisonings, except with corrosives, iron, lithium, arsenic, and alcohols, for which AC is unable to bind (Olson 2010).

Activated charcoal (AC) is a porous carbon product, with a large surface area for binding with drugs, chemicals, and organic compounds. This binding or "adsorption" is useful in the clinical context because when ingested it bind with toxins preventing gastric absorption. The AC bound chemicals are then excreted in feces.

There is debate about the efficacy of AC in toxicities. To date there hasn't been any high quality evidence linking morbidity or mortality improvements with the use of AC (Chyka et al., 2004). The evidence that is available comes from: small non-blinded trials, case reports, animal studies and trials performed on volunteers (some of which are RCT's) that examined serum toxicity levels as corrolary for clinical measures (Olson, 2010). Regardless of the lack of clear clinical benefit AC is widely used  as a first line treatment of toxic ingestion because it is relatively safe, has a has been shown to lower serum drug levels, and is widely endorsed as by professional groups and organizations.

Most current recommendations are that AC may reduce toxin absorption if administered within 1 hour of poison ingestion (although it can be administered later), that AC should not be used in patients who cannot maintain their own airway, because of the risk for AC aspiration and resultant pneumonitis (Chyka et al., 2004), and that AC should also not be given to patients with, or at risk for, GI perforation as it will obscure endoscopic investigation of the stomach (Chyka et al., 2004). Indeed in many patients it may be safer, and more effective to use specific antidotes ex: mucomyst (Olson 2010). Regional practice may also be guided by specific institutional policies which may vary from these guidelines.



Activated charcoal dosing is usually 0.5-1g/kg in pediatric populations. For adults there is typically an initial dose of 50-100g, which may be followed with 50g every 4 hours (which may be divided) (Chyka et al., 2004). If activated charcoal is administered by nasogastric (NG) tube it is essential to ensure correct tube placement, for the same reason that AC should not be given to patients unable to maintain their own airways, because it can cause severe chemical pneumonitis (Bond 2002). Because NG insertion can also be traumatic, painful, and poorly tolerated, most patients will be given AC orally. Most patients will tolerate AC orally; however palatability can be a major barrier, especially in the pediatric populations.

A number of studies have sought ways to improve and measure the palatability of AC, the majority have used readily accessible mixes such as juice, milk or cola. Most of these studies have examined pediatric populations and the effects of mixes have on flavor and ease swallowing the AC mixture: Cola  has consistently been selected as the preferred mix for AC in pediatric populations in terms of flavor, ease of swallowing, and overall preference (Dagnone et al, 2002., Skokan et al, 2001). Unfortunately there hasn't been much in the way of similar research among adult patients.

Anecdotally I have seen a huge difference in compliance of AC administration when mixed with cola in both the pediatric and adult populations. For children there is an improvement in flavor, the fizz is fun, and the color of the cola doesn't change with the addition of AC, for adults there is less of a chance that allergies or aversions to dairy will present a barrier of using it as a mixture. From a pragmatism perspective cola is a clear winner as it's shelf stable, and readily available wherever there is a vending machine.




Bond, G. R. (2002). The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review. Annals of emergency medicine, 39(3), 273-286.

Chyka, P. A., Seger, D., Krenzelok, E. P., & Vale, J. A. (2004). Position paper: Single-dose activated charcoal. Clinical toxicology (Philadelphia, Pa.), 43(2), 61-87.

Dagnone, D., Matsui, D., & Rieder, M. J. (2002). Assessment of the palatability of vehicles for activated charcoal in pediatric volunteers. Pediatric emergency care, 18(1), 19-21.

Lai, M. W., Klein-Schwartz, W., Rodgers, G. C., Abrams, J. Y., Haber, D. A., Bronstein, A. C., & Wruk, K. M. (2006). annual report of the American Association of Poison Control Centers toxic exposure surveillance system.Clinical Toxicology, 44(6-7), 803-932.

Olson, K. R. (2010). Activated charcoal for acute poisoning: One toxicologist’s journey. Journal of medical toxicology, 6(2), 190-198.

Skokan, E. G., Junkins, E. P., Corneli, H. M., & Schunk, J. E. (2001). Taste test: children rate flavoring agents used with activated charcoal. Archives of pediatrics & adolescent medicine, 155(6), 683-686.