Multiple-Dose activated Charcoal for treatment of Yellow Oleander Poisoning: A Single-blind, Randomised, Placebo - Controlled Trial

INTRODUCTION: Yellow oleander poisoning is the most common plant poisoning in South India. It being a cardiac glycoside has significant cardiac toxicity and a mortality rate of about 10%1. In Madras Medical College, Chennai, Poison Centre alone, there were 210 persons admitted with oleander poisoning during the period September 1, 2001 to May 31, 2004 with a mortality rate of 11.43%2. Specialized treatment with antidigoxin fab fragments and cardiac pacing is expensive and not widely available. Multiple dose activated charcoal binds cardiac glycosides in the gut lumen and promotes their elimination. Aim of the study was to assess the efficacy of multiple dose activated charcoal in the treatment of patients with yellow oleander poisoning. During the period June 1, 2004 to May 31, 2005 there were 63 cases of yellow oleander poisoning at the IMCU / Poison Centre of Madras Medical College, Chennai and the study included 47 patients who met the inclusion criteria. OBJECTIVES: Aim of the study was to assess between the two arms of the trial whether: a) Any significant reduction in mortality. b) Any reduction in occurrence of major or life threatening cardiac arrhythmias. c) Any reduction in the doses of other drugs-atropine- needed. d) Any significant reduction in the number of days of stay in the hospital. MATERIALS AND METHODS: Patients admitted during the period, June 1, 2004 to May 31, 2005 to the poison centre of Madras Medical College, Chennai, were included for the trial. Patients aged 12 – 70 years who were admitted within 24 hours of ingestion of yellow oleander seeds were eligible for inclusion. Patients who had taken another drug such as alcohol, organophosphates, paracetamol or sedatives, had other debilitating diseases like diabetes mellitus, hepatic or renal disease, heart failure or malignant disease, had abdominal surgery within the past 1 year were excluded from the trial. Patients with known hypersensitivity to activated charcoal, those with severe infections and pregnant and lactating women also excluded. Patients who received corticosteroids as part of treatment, as suggested by cardiologist, were also excluded from the study, to avoid confounding. Patients were informed about the nature, objectives, importance, expected benefits and possible adverse effects of the treatment. If the patient did not give the consent, permission from a parent, spouse or guardian was sought. Patients were told they were free to withdraw from the trial at any time if they wished to do so, without any prejudice to subsequent management. STATISTICAL ANALYSIS: Statistical analysis was carried out for 47 subjects- 23 persons in the single dose activated charcoal and placebo group and 24 persons in the multiple dose charcoal group-after categorizing each variable. Patient’s age, sex, weight, no of seeds, seeds crushed or not, time taken after ingestion was matched. Other base line parameters like pulse rate, blood pressure, serum potassium level, serum sodium level, B. Urea, & S. Creatinine were analysed. Occurrence of cardiac arrhythmias at presentation and at 24 hours after presentation, dose of atropine required, no of days for normalisation of ECG and duration of stay in hospital were evaluated& compared. Microsoft excel and SPSS (Statistical package for social sciences) were used for analysis and Z tests were done to assess differences between percentages and difference between means. Analysis was by intention to treat. Statistical significance was taken when P