Activated charcoal: พระเอกมาแล้ว
พระเอกขี่ม้าขาวมาช่วยแล้ว !! (ตรงตามสเป๊กใครหลายคน ที่ชอบ ดำ เข้ม) เพราะในการดูแลผู้ที่ได้รับสารพิษ การให้ Activated charcoal เพื่อล้างพิษผ่านทางเดินอาหารหรือทำ Gastrointestinal decontamination มีข้อสังเกต ดังนี้ 1. เรียกใช้พระเอกของเราตั้งแต่ต้น โดยได้ประโยชน์ถ้าให้ในช่วงก่อน 1-4 ชั่วโมงหลังได้รับสารพิษ (ภายใต้ข้อสันนิษฐานเบื้องต้น จากการศึกษาพิษของยา paracetamol ว่ากระเพาะอาหารดูดซึมได้สมบูรณ์ที่ 4 ชั่วโมง) การให้ได้เร็วภายใน 1 ชั่วโมงจะยิ่งส่งผลดี แต่ก็มีบางรายงาน กล่าวว่า สารพิษที่ทำให้เวลาในการเคลื่อนที่ของกระเพาะ ลำไส้ ยาวนานขึ้นหรือเพิ่ม Gastric emptying time การให้ Activated charcoal หลัง 4 ชั่วโมงไปแล้วยังได้ประโยชน์อยู่
2. การทำ GI decontamination ให้แค่ครั้งเดียวเท่านั้น ใช้ dose ปริมาณ 10 เท่าของปริมาณสารพิษที่ได้รับ (หากทราบ ปริมาณที่แน่ชัด) หรือ dose 1 gm/Kg ขึ้นกับว่า dose ใดจะมาก กว่าก็ให้ตามนั้น โดย Activated charcoal สามารถละลายน้ำให้ ผู้ป่วยดื่ม (แต่มักไม่ค่อยเป็นที่นิยม เพราะไม่มีรส ไม่ซ่าเหมือน Pepsi Max แม้จะสีดำและ 0 Calorie เหมือนกัน แต่อาจลอง ปลอบใจว่า ดีน่า ให้คุณค่าเหมือนได้กินงาดำ 2 เท่า) หรือจะใส่ ผ่านท่อ NG, OG tube feed ก็ได้ และด้วยความที่ให้ครั้งเดียว จึงควร off NG tube สายดำๆ ออกหลัง feed เสร็จ แต่หาก พิจารณาให้หลายครั้งจะเป็นการเร่งการกำจัดสารพิษ (Enhanced elimination) ก็ให้คาสายไว้ก่อนได้ บางรายงาน แนะนำให้ผสมยาระบายเพื่อเร่งให้ขับถ่ายเร็วขึ้น แต่ก็พบว่าทำให้ Activated charcoal ของเราได้ผลไม่เต็มที่ (ไม่มีเวลาได้ show action นั่นเอง)
3. พระเอกของเราชอบพื้นที่มาก ๆ ในการกำจัดเหล่าร้าย การเลือกถ่านอัดเม็ดอย่าง Ultracarbon ที่พื้นที่ผิวในการดูดซึม เสียไปมากมาย ประสิทธิภาพลดลง จึงไม่ควรนำมาให้ในผู้ป่วย ทางพิษวิทยา
4. พระเอกของเราก็ไม่ได้เก่งไปซะทุกเรื่องนะ อย่างที่ทราบ กันว่า Activated charcoal ไม่ได้ประโยชน์ในการดูดซึมสารพิษ หลายชนิด เช่น กรด ด่าง (Acid & Alkalis), Carbamate, DDT, Alcohol (Ethanol, Methanol, Ethylene glycol), ธาตุเหล็ก เช่น Ferrous fumarate, Lithium, ตะกั่ว (Lead), สารทำละลายอินทรีย์ (Organic solvents) เมื่อทราบดังนี้แล้ว Case ผู้ป่วยที่กินเป็ดฆ่าตัวตาย (หมายถึงน้ำยาล้างห้องน้ำที่มี ฤทธิ์เป็น Corrosive agents ไม่ได้หมายถึงเป็ดตุ๋นยาจีน,เป็ดล่อน หรือผัดเผ็ดเป็ดย่างแต่อย่างใด) ก็ควรงดใส่ NG tube เพื่อ lavage หรือให้ Activated charcoal เพราะนอกจากจะไม่เกิด ประโยชน์ใด ๆ แล้วยังเสี่ยงต่อหลอดอาหารทะลุ, สำลักเกิดเป็น Aspiration pneumonitis อีก
5. ห้ามให้ Activated charcoal ในรายที่สงสัยหรือคิดว่าเสี่ยง ต่อภาวะลำไส้อุดตัน เพราะทำให้แย่ลงได้ (เข้าได้, ออกไม่ได้) เปลี่ยนจากอุดตันบางส่วนเป็นอุดตันสนิทได้
6. ในภาวะคนไข้ระดับความรู้สึกตัวไม่ดี หรือหมดสติ พระเอกของเราอาจกลายเป็นผู้ร้ายได้ มีโอกาสสำลักขณะ ให้ยาได้ จึงควรเปิดทางเดินหายใจและปกป้องทางเดินหายใจ โดยการใส่ Definitive airway (อุปกรณ์ทางเดินหายใจที่มี cuff) ป้องกันไว้ก่อน
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