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Activated charcoal was rediscovered by the toxicology community during the
1980s, with several studies demonstrating superiority to gastric emptying alone
and, at least, equivalence to the combination of gastric emptying plus charcoal
administration. The use of charcoal alone is less invasive and less likely to be
associated with complications than gastric emptying. Aspiration of charcoal can
be a serious concern among patients with poor airway protective reflexes, and
vomiting remains the most common difficulty associated with its use. The use of
an NG tube, which renders the esophagogastric sphincter patent, may also
increase aspiration risk. Charcoal is contraindicated in patients with an
unprotected airway or a disrupted GI tract (e.g., after severe caustic ingestion) or
in patients in whom charcoal therapy may increase the risk and severity of
aspiration (e.g., hydrocarbons). The use of multiple doses of activated charcoal to
achieve enhanced drug elimination is addressed later in this chapter.
Catharsis. Little evidence supports the use of cathartics (sorbitol, magnesium
citrate, magnesium sulfate) to reduce drug absorption by speeding intestinal
transit. It is also not established whether coadministration with activated charcoal
minimizes the risk of constipation, and there does appear to be an increased risk
of vomiting, cramping abdominal pain, and hypernatremic dehydration in young
infants with repeated use. As such, a single dose of premixed charcoal/sorbitol is
safe for most pediatric ingestions, but should not be used in young infants. Oilbased cathartics (mineral oil, castor oil) are discouraged because they may be
aspirated, may increase absorption of some poisons, or may unnecessarily extend
the cathartic effect.
Whole Bowel Irrigation (WBI). An additional technique of cathartic GI
decontamination is that of intestinal irrigation with large volumes and flow rates
of a high–molecular-weight polyethylene glycol-balanced electrolyte solution
such as GoLYTELY or Colyte. Typically, these solutions are not significantly
absorbed nor do they exert an osmotic effect, so the patient’s net fluid/electrolyte
status is unchanged. They have a long safety track record, including in infants.
WBI is particularly useful in pediatric iron overdoses, in which gastric lavage
may be limited by tube size and charcoal is ineffective. It has been used for other
metal ingestions (e.g., lead), overdoses of sustained-release medications (e.g.,

lithium, theophylline, bupropion, verapamil), ingested pharmaceutical patches,
and ingestions of vials or packages of illicit drugs. It might also be useful in
particularly massive, dangerous, and/or late-presenting overdoses for which
severe toxicity refractory to standard therapies may result and for which the
efficacy of gastric emptying and/or charcoal is suboptimal. The technique may be