Activated Charcoal and Beta Blocker Overdose: Clinical Decision Making and the Risks of Dichotomization

This very nice case report in the current issue of the Annals of the ATS is an opportunity to discuss rational clinical decision making.  The authors did almost everything that I would have done in this case and it is a lovely discussion of this toxidrome and its treatment.  There is just one simple and apparently inconsequential decision that I disagree with and I intend to use it as a springboard to discuss rational clinical decision making.

The young woman had a multidrug overdose including metoprolol succinate, extended release.  She presented in shock.  The authors state "Gastrointestinal decontamination was not performed because her ingestion was suspected to have occurred several hours before admission" [emphasis mine].  I have already in an early post on this blog, discussed the inadequacy of the existing data and experimental models on the timing of charcoal administration, which interested readers can read about here.

Studies of the timing of Activated Charcoal (AC) administration use normal volunteers taking therapeutic doses of drugs (for ethical reasons).  We have inadequate data on the speed of absorption of drugs in people who are shocked or who take very large doses of drugs, or extended release drugs.  To dichotomize the efficacy of AC by a bright line of 30 or 60 or even 120 minutes is a gross oversimplification of reality that belies overconfidence in the existing data and experimental models.  This patient took a large dose of a sustained release medication and at some point became shocked presumably causing splanchnic vasoconstriction.  She also took Tramadol and other medications which may slow gut motility via anticholinergic or other effects.  And there may be other unknowns - other medications she took that slowed absorption of the sustained release metoprolol that we don't even know about.

Accidental Survival from Beneficent Neglect: When "There's Nothing More We Can Do" Becomes Your Salvation

"There's nothing more we can do", according to this NYT article, is a terrible thing for a physician to say to a patient or his family member, even if the intention is much needed candor.

Yet sometimes, a physician's resignation or a patient's refusal becomes the patient's salvation.  There is something to be learned about the futility of many of our treatments and our arrogant ignorance of our impotence in many situations.  Several examples, I hope, will cause physicians to reflect on many of our practices.

A study showing that cancer patients choosing palliative care outlived those choosing aggressive care should have caused a lot of introspection about the possibility that many things we do harm rather than help patients.  How are we to know?  In the ICU, we have several unique opportunities to observe the futility or downright harm of many things we do.

A young woman came to the ICU with mental status changes, an EEG was ordered, and a diagnosis of "non-convulsive status epilepticus" (NCSE) was made.  She was intubated and heavily sedated and treated with every manner of anticonvulsant and CNS depressants and coma-inducing agents.  The EEG continued to show, according to the report, NCSE two weeks later.  The family was told that "there's nothing more we can do" and a decision was made to stop all therapy and withdraw care and prepare to send her to hospice.  This was done, but over the next 24 hours, she awakened and was alert and oriented. She walked out of the hospital later that week.