Three weeks ago the toxicity of antoconvulsants was presented. The clinical picture of a patient taking phenytoin and developing toxicity was laid out, and it was not pretty. Initially ataxia, nystagmus and lethargy that can progress to seizures and coma. The difference between a therapeutic serum phenytoin level and a toxic one is small. There is some evidence that in the symptomatic patient who took an acute overdose multidose charcoal may be beneficial. Today in my mailbox is the latest issue of Clinical Toxicology. In it is a paper that attempts to quantify the effect multidose charcoal has on patients with a supratherapeutic serum level of phenytoin. Clinical Toxicology Paper (Abstract).
A few items of interest. This is a randomized controlled study lasting 18 months involving two large teaching hospitals. Pretty great for a tox study. But they could only enroll 17 patients. Pretty typical. They showed that there was a difference in time to a sub-toxic serum concentration between the study and control groups. Great! With a larger number of patients they may have been able to show a significant difference. Even better.
What to take away from this study? Clearly more study with more patients is required. Studies that looked at clinical parameters in addition to time to sub-toxic levels would be a plus. Based on this paper alone is it hard to change clinical practice. What this does do is make it easier to recommend multidose charcoal is the appropriate patient. It is one more piece in a larger clinical puzzle.
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