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 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