Blackwell’s Five-Minute Veterinary Consult Clinical...

55
Blackwell’s Five-Minute Veterinary Consult Clinical Companion About the Series Case Study and Answers Table of Contents Chapter 1 Appendix Index SAMPLER

Transcript of Blackwell’s Five-Minute Veterinary Consult Clinical...

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Blackwell’s Five-MinuteVeterinary ConsultClinical Companion

About the SeriesCase Study and Answers

Table of ContentsChapter 1Appendix

Index

SAMPLER

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• Features the familiar Five-Minute Veterinary Consult framework

• Builds on sections of the species- specificconsults,withmoredetail on each topic and additional topics included

• Carefully organized with bulleted information for quick search and easy reference

• Full-color photographs

• Written by subject experts

• Companion website (or CD) with client handouts and/or case studies (select titles)

• Authoritative coverage of: o Canine and Feline Behavior o Canine and Feline Infectious Diseases and Parasitology o Small Animal Emergency and Critical Care o Small Animal Dermatology o Small Animal Toxicology o Small Animal Dentistry o Small Animal Endocrinology and Reproduction o Equine Theriogenology

About the Series

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Terrible turn in toxicology You are excited that your first senior rotation is two weeks at a regional animal poison control center. The center provides public services as well as veterinarians professional guidance. You get to answer the phones with a supervising veterinary toxicologist. At 2 am during your first shift a small animal practice veterinarian calls about a 1-year-old rat terrier that she thinks has ingested some sort of toxin. She is driving into town as she calls so the information she relates is from her technician who has reached the clinic and has initiated lab work already. Apparently, two days ago the dog was accidentally trapped in the neighbor’s garage overnight and most of the next day. The owners had been searching for him and when they finally located him in the garage he was vomiting profusely and had diarrhea. They thought he must have gotten into something as he was perfectly fine before that and the neighbor’s garage had every possible piece of junk, food, yard equipment and an assortment of chemicals for his vehicles, lawn, home, etc. The referring vet stated the dog’s initial lab showed a markedly elevated Ca++ and moderately elevated PO4. The technician was horrified that his Ca++/PO4 ratio was exceptionally high! The dog reportedly looked dehydrated but had isosthenuric urine. His BUN and creatinine were elevated and a CBC indicated hemoconcentration and a mild stress leukogram. He was depressed and still vomiting when the technician called you. You had just finished Toxicology 426 so you knew the three top differentials, the tests you would do to confirm your diagnosis and how you would start treatment.

1. Of the following, which would best characterize the toxicosis described and the top 3 differential diagnoses for the “Terrible Turn in Toxicology”? Student Response Value Correct Answer Feedback

1. Nephrotoxin = ethylene glycol, aflatoxin, raisins

2. Hepatotoxin = cholecalciferol, ethylene glycol, aflatoxin

3. Nephrotoxin = cholecalciferol, ethylene glycol, raisins

4. Nephrotoxin = raisins, bromethalin, lilies

5. Nephrotoxin = arsenic, bromethalin, grapes

Clinical Case Study (available on the companion website)

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2. For the differential list you selected (Terrible Turn in Toxicology), which combination of tests would most clearly support the correct diagnosis? Student Response Value Correct Answer Feedback

1. azotemia, isosthenuria, leukocytosis

2. azotemia, hypocalcemia, isosthenuria

3. acidosis, hypocalcemia, hyperosmolality

4. acidosis, hypercalcemia, hyposthenuria

5. azotemia, hypercalcemia, isosthenuria

6. azotemia, cholestasis, hyperbilirubinemia

7. azotemia, hyperglycemia, isosthenuria

3. Given the circumstances for our dog in this “Terrible Turn”, select a potential treatment regimen you would recommend for a client with limited financial resources. You may choose 2 options.

Student Response Value Correct

Answer Feedback

1. Activated charcoal initially and again at 12 hours; start IV saline, furosemide and corticosteroid; monitor serum calcium, BUN and UA specific gravity

This is a good start because it monitors important parameters, but it doesn’t have a contingency for using a more powerful drug to reduce calcium. Early therapy may forestall the need for D3 drug antidote.

2. Emesis, cathartic, activated charcoal, IV fluids and start on salmon calcitonin q6h for 4 days; monitor BUN and UA specific gravity

Patient has already been vomiting, and adequate laboratory evaluation has not been done.

3. Activated charcoal initially and again at 12 hours; start IV saline, furosemide and corticosteroid; monitor serum calcium, BUN and UA specific gravity; start salmon calcitonin if serum Ca > 14 mg/dL

This choice provides excellent upfront detoxification (charcoal twice) and monitoring with a decision point that is specific (Ca @ 14 mg/dL); still allows client input if the decision point comes.

4. Activated charcoal initially and again at 12 hours; start

This choice provides excellent upfront detoxification (charcoal twice) and monitoring with a decision point

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IV saline, furosemide and corticosteroid; monitor serum calcium, BUN and UA specific gravity; start pamidronate if serum Ca > 14 mg/dL

that is specific (Ca @ 14 mg/dL); still allows client to decide about pamidronate therapy if conditions worsen. Remember, the reduced number of doses may keep down total drug use as well as reduce hospital care costs.

5. Start pamidronate and IV fluids, continue until UA is normal

Overkill without proper evaluation of patient status.

4. If this case had terminated as a fatality without being submitted for antemortem veterinary care, which of the following could you use to confirm toxicosis in a cost-effective manner? SELECT 3.

Student Response Value Correct Answer Feedback

1. Radiography of the renal area for increased radiodensity of the kidneys related to calcium content

Option if necropsy is not desired

2. Targeted necropsy of heart, GI tract and kidneys with submission for histopathology exam

Allows for confirmation of diagnosis by traditional histopathology

3. Chemical analysis of kidney for the toxic metabolite

Many labs don’t have the capability to find metabolites

4. Chemical analysis of kidney for calcium content

Inexpensive and readily available assay

5. Chemical assay for primary toxicant in liver and metabolites in liver and kidney

Expensive and many labs don’t offer both primary toxicant and secondary metabolites

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1

Terrible turn in toxicology You are excited that your first senior rotation is two weeks at a regional animal poison control center. The center provides public services as well as veterinarians professional guidance. You get to answer the phones with a supervising veterinary toxicologist. At 2 am during your first shift a small animal practice veterinarian calls about a 1-year-old rat terrier that she thinks has ingested some sort of toxin. She is driving into town as she calls so the information she relates is from her technician who has reached the clinic and has initiated lab work already. Apparently, two days ago the dog was accidentally trapped in the neighbor’s garage overnight and most of the next day. The owners had been searching for him and when they finally located him in the garage he was vomiting profusely and had diarrhea. They thought he must have gotten into something as he was perfectly fine before that and the neighbor’s garage had every possible piece of junk, food, yard equipment and an assortment of chemicals for his vehicles, lawn, home, etc. The referring vet stated the dog’s initial lab showed a markedly elevated Ca++ and moderately elevated PO4. The technician was horrified that his Ca++/PO4 ratio was exceptionally high! The dog reportedly looked dehydrated but had isosthenuric urine. His BUN and creatinine were elevated and a CBC indicated hemoconcentration and a mild stress leukogram. He was depressed and still vomiting when the technician called you. You had just finished Toxicology 426 so you knew the three top differentials, the tests you would do to confirm your diagnosis and how you would start treatment.

1. Of the following, which would best characterize the toxicosis described and the top 3 differential diagnoses for the “Terrible Turn in Toxicology”? Student Response Value Correct Answer Feedback

1. Nephrotoxin = ethylene glycol, aflatoxin, raisins

2. Hepatotoxin = cholecalciferol, ethylene glycol, aflatoxin

3. Nephrotoxin = cholecalciferol, ethylene glycol, raisins

100%

4. Nephrotoxin = raisins, bromethalin, lilies

5. Nephrotoxin = arsenic, bromethalin, grapes

Clinical Case Study Answers (available on the companion website)

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2. For the differential list you selected (Terrible Turn in Toxicology), which combination of tests would most clearly support the correct diagnosis? Student Response Value Correct Answer Feedback

1. azotemia, isosthenuria, leukocytosis

2. azotemia, hypocalcemia, isosthenuria

3. acidosis, hypocalcemia, hyperosmolality

4. acidosis, hypercalcemia, hyposthenuria

5. azotemia, hypercalcemia, isosthenuria 100%

6. azotemia, cholestasis, hyperbilirubinemia

7. azotemia, hyperglycemia, isosthenuria

3. Given the circumstances for our dog in this “Terrible Turn”, select a potential treatment regimen you would recommend for a client with limited financial resources. You may choose 2 options. Student Response Value Correct

Answer Feedback

1. Activated charcoal initially and again at 12 hours; start IV saline, furosemide and corticosteroid; monitor serum calcium, BUN and UA specific gravity

50%

This is a good start because it monitors important parameters, but it doesn't have a contingency for using a more powerful drug to reduce calcium. Early therapy may forestall the need for D3 drug antidote.

2. Emesis, cathartic, activated charcoal, IV fluids and start on salmon calcitonin q6h for 4 days; monitor BUN and UA sp. gr.

Patient has already been vomiting, and adequate laboratory evaluation has not been done.

3. Activated charcoal initially and again at 12 hours; start IV saline, furosemide and corticosteroid; monitor serum calcium, BUN and UA specific gravity; start salmon calcitonin if serum Ca > 14 mg/dL

50%

This choice provides excellent upfront detoxification (charcoal twice) and monitoring with a decision point that is specific (Ca @ 14 mg/dL); still allows client input if the decision point comes.

4. Activated charcoal initially and again at 12 hours; start

50%

This choice provides excellent upfront detoxification (charcoal twice) and monitoring with a decision point

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IV saline, furosemide and corticosteroid; monitor serum calcium, BUN and UA specific gravity; start pamidronate if serum Ca > 14 mg/dL

that is specific (Ca @ 14 mg/dL); still allows client to decide about pamidronate therapy if conditions worsen. Remember, the reduced number of doses may keep down total drug use as well as reduce hospital care costs.

5. Start pamidronate and IV fluids, continue until UA is normal

Overkill without proper evaluation of patient status.

4. If this case had terminated as a fatality without being submitted for antemortem veterinary care, which of the following could you use to confirm toxicosis in a cost-effective manner? SELECT 3.

Student Response Value Correct Answer Feedback

1. Radiography of the renal area for increased radiodensity of the kidneys related to calcium content

33.333%

Option if necropsy is not desired

2. Targeted necropsy of heart, GI tract and kidneys with submission for histopathology exam

33.333%

Allows for confirmation of diagnosis by traditional histopathology

3. Chemical analysis of kidney for the toxic metabolite

Many labs don’t have the capability to find metabolites

4. Chemical analysis of kidney for calcium content

33.333%

Inexpensive and readily available assay

5. Chemical assay for primary toxicant in liver and metabolites in liver and kidney

Expensive and many labs don’t offer both primary toxicant and secondary metabolites

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ftoc vii 12 February 2016 8:13 PM

Contents

Contributor List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix About the Companion Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi

section 1 Clinical Toxicology

chapter 1 Decontamination and Detoxification of the Poisoned Patient . . . . . . . . . . . . . 3

chapter 2 Emergency Management of the Poisoned Patient . . . . . . . . . . . . . . . . . . . . . 19

chapter 3 Antidotes and Other Useful Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

chapter 4 Identification and Management of the Unknown Toxicant . . . . . . . . . . . . . . 49

chapter 5 Laboratory Diagnostics for Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

section 2 Specific Toxins & Toxicants

Alcohols and Glycol Ethers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

chapter 6 Alcohols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

chapter 7 Ethylene Glycol and Diethylene Glycol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

chapter 8 Propylene Glycol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Construction and Industrial Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

chapter 9 Glues and Adhesives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

chapter 10 Hydrocarbons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

chapter 11 Hydrofluoric Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Drugs: Human Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

chapter 12 5-Fluorouracil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

chapter 13 Amphetamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

chapter 14 Angiotensin-Converting Enzyme (ACE) Inhibitors . . . . . . . . . . . . . . . . . . . . 132

chapter 15 Atypical Antipsychotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

chapter 16 Baclofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

chapter 17 Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

chapter 18 Beta2 Receptor Agonists (Albuterol and Others) . . . . . . . . . . . . . . . . . . . . . 155

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chapter 19 Beta Receptor Antagonists (Beta-Blockers) . . . . . . . . . . . . . . . . . . . . . . . . . 162

chapter 20 Calcipotriene/Calcipotriol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

chapter 21 Calcium Channel Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

chapter 22 Colchicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

chapter 23 Cyclosporine A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

chapter 24 Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

chapter 25 Minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204

chapter 26 nonbenzodiazepine sleep Aids  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

chapter 27 Opiates and Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

chapter 28 ssRI and snRI Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

chapter 29 Tacrolimus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

chapter 30 Thyroid Hormones (T3 and T4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

Drugs: Illicit and Recreational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

chapter 31 Club Drugs (MDMA, GHB, Flunitrazepam, and Bath salts) . . . . . . . . . . . . . 245

chapter 32 Cocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

chapter 33 LsD (Lysergic Acid Diethylamide) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

chapter 34 Marijuana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

chapter 35 Methamphetamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

chapter 36 Miscellaneous Hallucinogens and Dissociative Agents . . . . . . . . . . . . . . . . . 278

chapter 37 Opiates and Opioids (Illicit) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

chapter 38 PCP (Phencyclidine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

chapter 39 synthetic Cannabinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Drugs: Over the Counter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

chapter 40 Acetaminophen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

chapter 41 Antitussives and Expectorants (Dextromethorphan) . . . . . . . . . . . . . . . . . . 313

chapter 42 Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320

chapter 43 Decongestants (Pseudoephedrine, Phenylephrine) . . . . . . . . . . . . . . . . . . . 327

chapter 44 Decongestants (Imidazolines) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

chapter 45 Human nsAIDs (Ibuprofen, naproxen) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

chapter 46 nicotine and Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

chapter 47 Vitamins and Minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354

Drugs: Veterinary Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

chapter 48 Alpha2-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

chapter 49 Ivermectin/Milbemycin /Moxidectin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374

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COnTEnTs ix

chapter 50 Phenylpropanolamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385

chapter 51 Pimobendan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391

chapter 52 Veterinary nsAIDs (Carprofen, Deracoxib, Firocoxib, Ketoprofen, Meloxicam, Robenacoxib, Tepoxalin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396

Envenomations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

chapter 53 Black Widow spiders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407

chapter 54 Brown Recluse spiders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

chapter 55 Bufo Toads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418

chapter 56 Crotalids (Pit Vipers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424

chapter 57 Elapids (Coral snakes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436

chapter 58 scorpions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444

chapter 59 Venomous Lizards (Heloderma) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450

chapter 60 Wasps, Hornets, and Bees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457

Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

chapter 61 Bread Dough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

chapter 62 Calcium supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

chapter 63 Chocolate and Caffeine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479

chapter 64 Grapes and Raisins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485

chapter 65 Hops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491

chapter 66 Macadamia nuts  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497

chapter 67 Mycotoxins – Aflatoxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502

chapter 68 Mycotoxins – Tremorgenic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508

chapter 69 Onions and Garlic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515

chapter 70 salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521

chapter 71 Xylitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Foreign Objects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535

chapter 72 Foreign Objects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537

Garden, Yard, and Farm Chemicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545

chapter 73 Bone and Blood Meal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547

chapter 74 Diquat and Paraquat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552

chapter 75 Fertilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560

chapter 76 Herbicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565

chapter 77 Methionine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571

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Herbals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577

chapter 78 Ephedra/Ma Huang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579

chapter 79 Essential Oils/Liquid Potpourri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

chapter 80 Tea Tree Oil/Melaleuca Oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592

Home Care and Recreational Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599

chapter 81 Acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601

chapter 82 Alkalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609

chapter 83 Batteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617

chapter 84 Matches and Fireworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624

chapter 85 Mothballs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630

chapter 86 Paintballs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637

chapter 87 Phenols and Pine Oils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646

chapter 88 soaps, Detergents, Fabric softeners, Enzymatic Cleaners, and Deodorizers . 655

Insecticides and Molluscicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

chapter 89 Amitraz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665

chapter 90 Metaldehyde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672

chapter 91 Imidacloprid and Other neonicotinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678

chapter 92 Miscellaneous Insecticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683

chapter 93 Organophosphorus and Carbamate Insecticides . . . . . . . . . . . . . . . . . . . . . 689

chapter 94 Pyrethrins and Pyrethroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697

Metals and Metalloids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705

chapter 95 Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

chapter 96 Lead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716

chapter 97 Zinc  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723

Nondrug Consumer Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729

chapter 98 Glow Jewelry (Dibutyl Phthalate)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731

chapter 99 Fluoride  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736

Plants and Biotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743

chapter 100 Azaleas and Rhododendrons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745

chapter 101 Blue-green Algae (Cyanobacteria) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 751

chapter 102 Cardiac Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760

chapter 103 Lilies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770

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chapter 104 Mushrooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778

chapter 105 Oxalates – Insoluble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 787

chapter 106 Oxalates – soluble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 797

chapter 107 sago Palm (Cycads) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804

chapter 108 spring Bulbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812

chapter 109 Yesterday, Today, and Tomorrow Plant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821

chapter 110 Yew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827

Rodenticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833

chapter 111 Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835

chapter 112 Bromethalin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 844

chapter 113 Cholecalciferol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850

chapter 114 sodium Monofluoroacetate (Compound 1080) . . . . . . . . . . . . . . . . . . . . . 856

chapter 115 Phosphides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862

chapter 116 strychnine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871

Toxic Gases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879

chapter 117 Carbon Monoxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 881

chapter 118 smoke Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885

section 3 Reference Information

appendix 1 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899

appendix 2 Information Resources for Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905

appendix 3 Metallic Toxicants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913

appendix 4 Toxic Plants and Their Clinical signs: Antidotes and Treatment . . . . . . . . . . 919

appendix 5 Topical Toxins: Common Human OTC Dermatological Preparations . . . . . . . 927

Index by Toxins and Toxicants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933

Index by Clinical Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 951

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Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology, Second Edition. Lynn R. Hovda, Ahna G. Brutlag, Robert H. Poppenga, and Katherine L. Peterson. © 2016 John Wiley & Sons, Inc. Published 2016 by John Wiley & Sons, Inc. Companion website: www.fiveminutevet.com/toxicology

chapter 1Decontamination and Detoxification of the Poisoned Patient

DEFINITION/OVERVIEW

■ In veterinary medicine, the primary treatment for toxicant exposure should be decon-tamination and detoxification of the patient, along with symptomatic and supportive care.

■ The goal of decontamination is to inhibit or minimize further toxicant absorption and to promote excretion or elimination of the toxicant from the body.

■ When treating the poisoned patient, the clinician should have an understanding of the underlying mechanism of action of the toxicant, the pharmacokinetics (including absorp-tion, distribution, metabolism, and excretion), and the toxic dose (if available). This will help determine appropriate decontamination and therapy for the patient.

■ As decontamination can only be performed within a narrow window of time for most sub-stances, it is important to obtain a thorough history and time since exposure.

■ Emesis induction, which is the most common route of GI decontamination, is contraindi-cated in symptomatic patients.

■ While the GI route is the most common type of decontamination in veterinary medicine, other categories may include ocular, dermal, inhalation, injection, forced diuresis, or sur-gical removal of the toxicant.

Ocular Decontamination

■ If ocular exposure to a toxicant has occurred, thorough evaluation and appropriate medi-cal care of the eye may be necessary.

■ Ocular decontamination is often difficult for the pet owner, as it requires restraint of the animal.

■ If the product is corrosive or caustic, owners should flush the eye at home with physi-ological saline (e.g., contact lens solution without any cleaners, soaps, etc.) or tepid water for 15–20 minutes prior to transportation to a veterinarian. This will help maximize decontamination and reduce secondary injury to the cornea. Immediate veterinary care is imperative. Owners should be advised to prevent injury or rubbing of the eye until veteri-nary attention is sought. An Elizabethan collar should be used, if available.

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■ If the product is considered a noncorrosive irritant, owners should flush the eye at home with physiological saline (e.g., contact lens solution without any cleaners, soaps, etc.) or tepid water for 10–15 minutes, if possible. Ophthalmic ointments or medica-tions should not be used, and the pet should be monitored carefully for an extended period of time to prevent iatrogenic corneal abrasion or ulceration from rubbing the eyes. Owners should be advised to prevent injury or rubbing of the eye. An Eliza-bethan collar should be used, if available. Any change in condition (e.g., blepharo-spasm, pupil size change, pruritus, ocular discharge) should prompt immediate medi-cal attention.

Dermal Decontamination

■ The use of dermal decontamination is important to prevent transdermal absorption of the toxicant, but also to prevent oral reexposure secondary to grooming (particularly in cats).

■ Owners should be advised to prevent the pet from grooming, and cautioned to protect themselves from exposure to the toxicant while transporting the pet to the veterinary clinic.

■ When decontaminating a patient, it is important that pet owners and veterinary staff be protected from the toxic agent (e.g., pyrethrins, blue-green algae, organophosphates, cor-rosive or caustic chemicals, etc.). Appropriate protection should be used (e.g., rubber gloves, waterproof apron, face shield, etc.) as needed.

■ Oil-based toxicities (e.g., high concentration pyrethrins) should be bathed off with tepid water and a liquid dish degreasing soap (e.g., Dawn™, Joy™, etc.). Pet owners should be specifically told not to use dish detergent from an automatic dishwasher; rather, they should be instructed to use liquid dish soap designated to wash dishes in the sink. The patient should be bathed and rinsed multiple times as soon after exposure as possible. Pet or human shampoos are typically insufficient to remove the oil-based product, as a fol-licular flushing shampoo or degreasing soap is necessary.

■ Appropriate dermal decontamination is warranted to prevent continued absorption of the toxicant; this will also help minimize persistent clinical signs due to continued absorp-tion. Avoid the use of shampoos containing insecticides (e.g., flea or tick shampoos), coal tar, antibiotics, or antifungals.

■ The most common toxicant requiring dermal decontamination in veterinary medicine is high-concentration pyrethrins (e.g., used inappropriately in cats). In symptomatic cats exposed to pyrethrins, sedation with IV methocarbamol first may be beneficial prior to dermal decontamination (see chapter 94, Pyrethrins and Pyrethroids).

■ Gentle clipping of the hair may also help remove the toxin, particularly in long-haired pets or patients that cannot be bathed.

■ If caustic, acidic, or alkaline exposure has occurred to the skin, careful, gentle decontami-nation must occur. The skin should be thoroughly flushed with copious amounts of tepid water for 15–20 minutes, making sure not to traumatize the area with abrasive scrubbing or high-pressure water sprays.

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■ Avoid the use of “neutralizing” agents on the skin (e.g., an acid for an alkaline expo-sure), as this may cause a chemical or thermal reaction that results in more serious dermal injury.

■ After dermal decontamination, the patient’s temperature should be appropriately moni-tored. Due to cooling from the bathing process, patients may become hypothermic and may require appropriate heat support.

Inhalant Decontamination

■ With exposure of an inhaled toxicant (e.g., zinc phosphide rodenticides, carbon mon-oxide, etc.), the patient should be removed from the environment and evaluated. Often, simple removal is all that is necessary.

■ Further treatment may include administration of a humidified oxygen source, monitor-ing of oxygenation and ventilation (e.g., via arterial blood gas analysis, pulse oximetry, co-oximetry, etc.) and rarely, mechanical ventilation. Please see chapters 117 and 118 on toxic gases for more information.

■ The nares and upper airway help filter particulate matter, helping prevent lower airway exposure. The use of bronchoscopy is typically unnecessary.

■ The area where the inhalant exposure occurred should be adequately ventilated to prevent reexposure by persistent toxic fumes.

Injection Decontamination

■ Injection decontamination is typically necessary when an animal has been exposed to an insect stinger or venom sac. If embedded in the patient’s skin, gentle manipulation (e.g., tweezers) to remove the stinger or venom sac should be performed, after careful examina-tion of the affected area. Typically, this does not require sedation.

■ Snake bites should not be decontaminated via incision and “sucking” of the venom from the bite wound, nor should hot or cold compressions or tourniquet application be used. Please see chapters 53–60 for more information on envenomations.

Gastrointestinal Decontamination

■ “At-home” decontamination (e.g., emesis induction) can be performed by pet owners to prevent or treat toxicosis; however, the medical recommendation to decontaminate a pet at home must be thoroughly evaluated by the veterinarian, veterinary staff, or an Animal Poison Control Center first.

■ A complete history should be obtained from the pet owner prior to emesis induction (for home emesis or veterinary emesis induction).

■ It is important to understand the contraindications for emesis induction to prevent sec-ondary complications such as aspiration pneumonia, protracted emesis, hematemesis, or caustic or corrosive injury to the esophagus, oropharynx, and GIT.

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■ Prior to inducing emesis, several factors must be considered. • Time frame – A thorough history and time frame since ingestion must be

obtained prior to recommendations for emesis induction. If several hours have passed, toxic contents may have moved out of the stomach. Emesis induction is indicated for most toxins ingested within 1–2 hours, provided the patient is asymptomatic.

• Underlying medical problems – Dogs with brachycephalic syndrome (e.g., stenotic nares, everted saccules, hypoplastic trachea, and elongated soft palate) may be at higher risk for aspiration, and emesis induction at a veterinary facility may be safer. Dogs with a prior history of laryngeal paralysis, megaesophagus, aspiration pneumo-nia, upper airway disease, etc., should not have emesis induction performed due to the risk of aspiration pneumonia.

• Symptomatic patients – Patients that are already symptomatic should not undergo emesis induction. Symptomatic patients that are excessively sedate may have a decreased gag reflex or a lowered seizure threshold and may be unable to protect their airway, resulting in aspiration pneumonia.

• Corrosive or caustic agent – Emesis induction may cause additional injury to the esophagus, oropharynx, and GIT when these agents are expelled.

• Hydrocarbons – Low-viscosity liquids (e.g., gasoline, kerosene, motor oil, trans-mission fluid, etc.) can be easily aspirated into the respiratory system, result-ing in severe aspiration pneumonia. See chapter 10 on hydrocarbons for more information.

Effectiveness of Emesis Induction

■ The effectiveness of emesis induction is based on several factors, including: • emetic agent used • time elapsed since ingestion • physical characteristics of the toxicant ingested • toxicant’s effect on gastric emptying • presence of gastric contents.

■ The more rapidly emesis is induced post ingestion, the greater yield of recovery of gastric contents. Studies have shown that gastric recovery within 1 hour after toxin ingestion was approximately 17–62%. When emesis was induced within an even shorter time span (within 30 minutes), mean recovery of gastric contents was approximately 49% (range 9–75%).

■ While delayed emesis after 1–2 hours may still be successful, the amount of gastric recov-ery significantly decreases as time passes.

■ Emesis induction performed after 4 hours is likely of no benefit, with the exception of delayed gastric emptying or ingestions of large bezoars or concretions of toxic agents (if still present in the stomach). Examples include:

• large wads of xylitol gum • large amounts of chocolate • grapes and raisins

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• massive ingestions that can form a concretion or bezoar (e.g., fish oil capsules, pre-natal iron vitamins, etc.)

• ingestions that can form a bezoar or foreign body (e.g., blood or bone meal, fire starter logs, etc.)

• drugs that delay gastric emptying (e.g., opioids, anticholinergics, salicylates, TCA antidepressants).

Recommendations for Home Emesis

■ The decision to recommend emesis induction at home is based on the clinical judgment of the veterinary facility.

■ Numerous “antidotes” and “emetics” exist on the internet, and pet owners may find and use inappropriate information. Vegetable oil, milk, bread, and physical gagging with a finger have all been reportedly used by pet owners as antidotes or emetics.

■ In addition, pet owners may use an inappropriate dose based on an estimated weight of the patient, resulting in side effects (e.g., protracted vomiting, hematemesis). Appropriate counseling by the veterinary staff or an Animal Poison Control Center is imperative (on which emetic to use, how much to use, if home emesis induction is warranted, etc.).

■ As time is of the essence with emesis induction, it is often more effective to seek veteri-nary attention immediately rather than attempt emesis induction at home. This depends on the comfort and ability of the pet owner and availability of appropriate emetics (e.g., hydrogen peroxide) at home. Rather than send a pet owner to a local store to purchase hydrogen peroxide and wait 10 minutes for the effect of the emetic (which may or may not be productive), it may be more efficient to seek veterinary care for prompt emesis induction.

■ As certain human medications have a rapid onset of action (e.g., SSRI antidepressants, amphetamines, etc.) and clinical signs can be seen as early as 15–30 minutes, the use of emesis induction at home is generally not recommended with certain toxicants. In these situations, emesis induction is best done under the supervision of a veterinarian; the patient should be assessed to confirm that it is asymptomatic prior to emesis induction. Other examples of toxicants with a rapid onset of action include baclofen and benzodiaz-epine or nonbenzodiazepine agents (e.g., sleep aids).

■ There are no safe emetic agents for cats that pet owners can use at home.

Emetic Agents

■ Currently the only recommended at-home, oral emetic agent is 3% hydrogen peroxide. Other emetic agents that have been previously recommended include table salt (sodium chloride), liquid dishwashing detergent, or 7% syrup of ipecac.

■ Common veterinary emetics available at a veterinary clinic include apomorphine for dogs and alpha

2-adrenergic agonist agents (e.g. xylazine, dexmedetomidine) for cats. Hydrogen

peroxide is also commonly used by veterinarians as an emetic, and is equally effective to apomorphine.

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3% Hydrogen Peroxide ■ Hydrogen peroxide is thought to act as an emetic by direct gastric irritation. ■ Hydrogen peroxide is the current recommendation for at-home emesis induction in dogs.

Only the 3% concentration should be used, as higher concentrations can result in severe gastritis.

■ In cats, the use of hydrogen peroxide as an emetic is not recommended. It is not as effective in cats compared to dogs, and can result in significant adverse effects (e.g., hypersalivation, hemorrhagic gastritis, protracted hematemesis, etc.). Any toxic ingestion in a cat should be sent directly to the veterinarian for emesis induction under veterinary supervision.

■ When using hydrogen peroxide, make sure the product is first aid grade (e.g., 3%) and nonexpired (e.g., fresh, bubbly, not exposed to light) to be most effective. Dose: 1–2 mL/kg orally, not to exceed 50 mL in dogs.

■ It should be acknowledged that this dose has been exceeded by many veterinarians with-out ill effect; however, persistent emesis and hematemesis may result.

■ Emesis induction typically occurs within 5–10 minutes. If the first dose is ineffective as an emetic, a second dose can be repeated and potentially doubled.

■ Hydrogen peroxide is generally safe, but more than two doses should not be administered at home before seeking veterinary attention.

■ Pet owners should be informed that they must carefully syringe hydrogen peroxide (via tur-key baster, oral syringe, etc.), as most dogs will not electively drink this on their own, delaying emesis even further. Owners should be careful to prevent aspiration during administration.

■ Anecdotally, hydrogen peroxide works best if a small amount of food is present in the stomach. When advising pet owners on how to perform emesis induction at home, the pet owner should be informed to feed a few dog treats or small amount of kibble prior to emesis induction.

■ Another option is to soak a small amount of food or bread with the prescribed amount of hydrogen peroxide.

Table Salt (Sodium Chloride) ■ Salt acts as an emetic by direct gastric irritation. ■ The use of salt as an emetic is no longer recommended due to the risks of hypernatremia,

persistent emesis, and hematemesis. ■ Dose of salt in dogs and cats: 1–3 teaspoons orally, depending on the size of the patient. ■ Emesis induction typically occurs within 10–15 minutes. ■ In children treated with salt as an emetic, hypernatremia, secondary cerebral edema, and

neurological complications have been seen. Rarely, death has been reported (see chapter 70 on salt toxicity).

Liquid Dish Detergent (e.g., Dawn, Palmolive, Joy) ■ Liquid dish detergent acts as an emetic due to direct gastric irritation. ■ The use of liquid dish detergent is not typically recommended, although it may be consid-

ered more benign than table salt or syrup of ipecac.

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■ Detergents containing phosphate are most effective (thus excluding eco-friendly products). ■ Dose: 10 mL/kg of a mixture of 3 tablespoons of detergent to 8 ounces of water. ■ Emesis induction typically occurs within 20 minutes. ■ It is imperative that pet owners and veterinary staff ensure that the appropriate product is

used, rather than products designed for use in automatic dishwashers (which can be cor-rosive). These types of detergents should never be used due to their alkaline nature, which may cause severe injury to the GIT.

7% Syrup of Ipecac ■ Syrup of ipecac acts as an emetic due to direct gastric irritation and stimulation of the

CTZ. This is likely due to the active alkaloid compounds emetine and cephaeline. ■ Syrup of ipecac is derived from Cephaelis ipecacuanha, which is a dried root indigenous to

South America. ■ Syrup of ipecac is no longer recommended as an emetic in both human and veterinary

medicine. ■ Syrup of ipecac is not to be confused with ipecac fluid extract, which is estimated to be

14 times more potent. ■ Dose: dogs, 1–2 mL/kg PO; cats, 3.3 mL/kg; cumulative dose in either species is not to

exceed 15 mL; dose may be repeated once. ■ Emesis induction typically occurs within 10–30 minutes but may take up to 1 hour. ■ Potential complications from syrup of ipecac administration include:

• delayed effect • lack of effectiveness in approximately 50% of small animals • distaste (particularly to cats) • protracted emesis, severe hematemesis, lethargy, diarrhea, depression • potential cardiotoxic arrhythmogenic action.

VETERINARY EMETIC AGENTS

Apomorphine

■ Apomorphine acts directly on the CTZ. ■ Apomorphine is an effective emetic agent for dogs that is commonly used by veterinarians. ■ Dose: dogs, 0.02–0.04 mg/kg IV or IM; or direct application of the tablet form into the sub-

conjunctival sac. The injectable apomorphine can also be administered SQ; however, this is not currently the recommended route due to delayed onset of action and a prolonged dura-tion of effect. If subconjunctival apomorphine is used, thorough flushing of the subcon-junctival sac must be performed after emesis induction, or protracted vomition may occur.

■ Emesis occurs within 4–6 minutes. ■ If emesis does not occur, a second titrated dose can be used. If emesis does not occur after a

second dose, an additional oral dose of hydrogen peroxide may be beneficial. ■ Apomorphine is not recommended for cats, as it is an ineffective emetic and may result in

CNS stimulation.

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■ The use of apomorphine as an emetic should be carefully considered with opioid or seda-tive toxicosis, due to the potential for severe sedation.

■ If a patient exhibits excessive CNS sedation or respiratory depression after apomorphine administration, naloxone can be used as a reversal (dose: 0.01–0.04 mg/kg, IV, IM, or SQ). However, naloxone will not reverse the emetic effect of apomorphine due to different receptor effects.

■ Apomorphine tablets can be purchased through veterinary pharmaceutical companies. ■ The emetic effects of apomorphine are counteracted by potent antiemetic agents such as

maropitant, ondansetron, or dolasetron.

Xylazine

■ Xylazine is a centrally mediated alpha2-adrenergic agonist.

■ Xylazine is an emetic used by veterinarians for emesis induction in cats. Occasionally, it can effective in dogs, but is generally not recommended due to more effective emetic agents being available (e.g., hydrogen peroxide, apomorphine).

■ Dose: cats, 0.44 mg/kg, IM or SQ. ■ Emesis induction typically occurs within 10–20 minutes but is not always effective. ■ The use of xylazine often results in profound CNS and respiratory depression, and cats

should be carefully monitored for excessive side effects (e.g., sedation, hypotension, etc.). ■ Xylazine can be reversed with alpha

2-adrenergic antagonists.

• Yohimbine: 0.1 mg/kg IM, SQ, or IV slowly. • Atipamezole (Antisedan): 0.2 mg/kg IM, IV.

Gastric Lavage (Fig. 1.1)

■ The goal of gastric lavage is to remove gastric contents when emesis induction is unpro-ductive or contraindicated.

■ Human studies have shown that if gastric lavage was performed within 15–20 minutes after toxicant ingestion, gastric lavage recoveries were minimal (38% and 29%, respec-tively). If lavage was performed at 60 minutes post ingestion, only 8.6–13% was recovered.

■ As most poisoned patients present to the veterinary clinic after 1 hour, the clinical useful-ness of gastric lavage is debated.

■ Despite low gastric recovery and labor intensiveness, the use of gastric lavage is indicated in certain circumstances.

• A symptomatic patient that is already excessively sedate, unconscious, tremoring, or seizing that still needs controlled decontamination (e.g., metaldehyde, marijuana, organophosphates).

• Material that is large in size or has formed a bezoar or concretion (e.g., bone meal, iron tablets, large amounts of chocolate, etc.).

• Large toxic ingestions of capsules or tablets approaching the LD50

or toxicants with a narrow margin of safety (e.g., calcium channel blockers, beta-blockers, baclofen, ivermectin, organophosphate and carbamate insecticides).

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■ A newer modality is to administer AC via orogastric tube prior to lavage to prevent further absorption of the toxin, and then to lavage out the charcoal-toxin complex. Following copious lavage, AC is then readministered. There is lack of data evaluating this technique, and this modality still needs to be evaluated. Currently, the author does not recommend this technique without further evidence.

■ Complications of gastric lavage include: • risks of sedation • aspiration pneumonia • hypoxemia secondary to aspiration pneumonia or hypoventilation from sedation • mechanical injury to the mouth, oropharynx, esophagus, or stomach.

■ Contraindications for gastric lavage include: • a corrosive agent, where esophageal or gastric perforation can occur with orogastric

tube placement • a hydrocarbon agent, which may be easily aspirated due to its low viscosity • sharp objects ingested (e.g., sewing needles, etc.).

■ Many veterinarians may not feel comfortable performing gastric lavage, but it can be easily accomplished when organized with the appropriate supplies in a team-oriented approach.

• Begin by preparing all materials in an organized fashion. ◽ White tape ◽ Mouth gag ◽ Sterile lubrication ◽ Gauze ◽ Warm lavage fluid in a bucket

■ Fig. 1.1. Patient undergoing gastric lavage. Photo courtesy of Justine a. lee, DVM, DaCVECC, DaBT.

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◽ Bilge or stomach pump ◽ Funnel ◽ Step stool ◽ Sedatives predrawn and labeled ◽ Sterile ETT, ideally with a high-volume, low-pressure cuff ◽ Empty syringe to inflate the cuff ◽ Material to secure and tie in the ETT ◽ IV catheter supplies ◽ Activated charcoal predrawn in the appropriate dose in 60 mL syringes ready

for administration ◽ Sedation reversal agents if necessary

• Place an IV catheter. • Sedate and intubate with ETT; secure ETT in place and connect to oxygen ± inhal-

ant anesthesia source. Inflate cuff to prevent aspiration of gastric contents or lavage fluid. Place the patient in sternal recumbency.

• Premeasure an appropriately sized orogastric tube to the last rib and mark this line with white tape. This will be the maximum distance to pass the tube.

• Lubricate the orogastric tube, and pass the tube into the stomach using gentle, twist-ing motions. Blowing into the other end of the tube to inflate the esophagus with air may assist with passing of the tube into the stomach.

• Confirm orogastric tube placement by: ◽ palpation of the orogastric tube on abdominal palpation ◽ blowing into the orogastric tube and simultaneously ausculting for “bubbles”

in the stomach ◽ palpation of the neck for two tube-like structures (trachea, esophagus with

tube placement). • Infuse tepid or warm water by gravity flow via funnel, bilge, or stomach pump. The

volume of the stomach is estimated to be approximately 60 mL/kg; therefore, copi-ous amounts of fluid can be used to gavage. Fluid recovery (by gravity) should be emptied into an empty bucket.

• The stomach should be frequently palpated to monitor overdistension of the stom-ach and massaged/agitated to help break up contents within the stomach; this will hopefully allow small material to be removed via gastric lavage.

• Several lavage cycles (>5–20) should be performed to maximize decontamination of the stomach. All of the gavage fluid, if possible, should be removed prior to AC administration.

• The gastric lavage fluid should be examined for the presence of toxicants (e.g., plant material, mushrooms, rodenticides, medications, etc.), and can be saved for toxico-logical testing at a veterinary diagnostic laboratory if needed.

• Prior to removal of the orogastric tube, the appropriate amount of activated charcoal (with a cathartic for the first dose) should be instilled.

• The AC contents can then be flushed further into the orogastric tube with water or by blowing forcefully into the tube.

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• Prior to removal of the orogastric tube, it is imperative that the tube be kinked off to prevent lavage fluid from being aspirated. Once kinked, the tube should be removed quickly in one sweeping movement.

• The patient should continue to be intubated until gag reflex is present. Position-ing the patient in sternal recumbency with the head elevated may help prevent aspiration.

• Administration of a potent antiemetic (e.g., maropitant, dolasetron, ondansetron) should be considered.

• A video example of gastric lavage can be found here: http://vetgirlontherun.com/veterinary-continuing-education-how-perform-gastric-lavage-dog-vetgirl-video/

Whole Bowel Irrigation (WBI)

■ The goal of WBI is to clean the GIT by removing toxins and normal intraluminal GI contents.

■ This is done by enteral administration of large amounts of polyethylene glycol electrolyte solution (PEG-ES or PEG; e.g., Golytely™) until effluent (e.g., stool) is clear.

■ WBI is frequently done in human medicine, but is rarely necessary for treatment of the poisoned veterinary patient. Rather, WBI is more commonly used for bowel preparation (e.g., for endoscopy, colonoscopy, etc.).

■ WBI may be necessary in the poisoned patient if the toxicant is suspected to be present within the small intestinal tract. Examples of toxicants may include life-threatening inges-tions of prenatal iron tablets, large ingestions of sustained-release medicines, etc.

■ Due to the massive amount of PEG-ES that needs to be ingested, administration must typically occur via a temporary feeding tube (e.g., nasoesophageal, nasogastric, orogastric, etc.).

■ Dose of PEG-ES: 25–40 mL/kg, followed by continuous oral infusion of 0.5 mL/kg/hour. Alternatively, 30–40 mL/kg can be gavaged every 2 hours.

■ Stool typically appears within 2–4 hours, and WBI should be continued for approximately 8–12 hours until the effluent is clear.

■ The use of antiemetics may be necessary. Metoclopramide (0.2–0.5 mg/kg, SQ or 1–2 mg/kg/day, IV CRI) would be an appropriate choice due to its antiemetic, prokinetic, and gastric-emptying effects.

■ Complications of WBI include nausea, vomiting, bloating, abdominal discomfort, and aspiration pneumonia.

■ Contraindications for WBI include a foreign body obstruction, ileus, perforated bowel, shock, refractory emesis, and significant GI hemorrhage.

Activated Charcoal (AC)

■ The goal of AC is to act as an adsorbent and to prevent systemic absorption of the toxicant. ■ While less commonly used in human medicine, AC still remains the primary treatment of

choice for detoxification of the veterinary poisoned patient.

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■ AC is produced by heating wood pulp to extreme temperatures (900°C), washing it with inorganic acids, and drying it. This results in “activated” charcoal particles with a large surface area that promotes absorption. One gram of AC has approximately 1000 m2 of surface area.

■ AC contains carbon moieties that adsorb compounds with varying affinity. • Nonpolar compounds bind to AC well. • Heavy metals (e.g., zinc, iron, etc.) and alcohols (e.g., ethylene glycol, methanol,

isopropyl alcohol, ethanol) typically are not absorbed by AC. • Xylitol binds poorly to AC.

■ The interaction between the bound toxin and AC could potentially undergo desorption (where the toxicant unbinds from the AC over time); hence, the addition of a cathartic is often used to help promote fecal expulsion and increase GIT transit time.

■ Administration of AC with a cathartic as long as 6 hours out may still be beneficial with toxicosis, particularly if the product has delayed release (e.g., extended or sustained release) or undergoes enterohepatic recirculation.

• The use of AC with a magnesium-containing cathartic should be undertaken judi-ciously in cats.

■ Dose: 1–5 g of AC per kg of body weight orally; in general, the higher the dosage used, the more effective the adsorption.

■ Certain situations or toxicities warrant multidose administration of AC. Drugs under-going enterohepatic recirculation (e.g., ibuprofen, carprofen, etc.), with a long half-life (naproxen), or delayed-release products will require multidose administration of AC.

■ Dose: for multidose charcoal (1–2 g/kg, PO q 6 hours for 24 hours). • Additional doses of AC should ideally not contain a cathartic, due to increased risks

for dehydration via fluid losses from the GIT. If AC without a cathartic is not avail-able, then appropriate and aggressive hydration of the patient is imperative to pre-vent rare complications of hypernatremia.

■ There are several types of AC commercially available, and the labeled directions should be followed appropriately for each specific type. Note that not all brands are labeled correctly; when in doubt, the appropriate dose (1–5 g/kg) should be calculated and administered.

■ Many types of AC contain a cathartic already present (e.g., typically 70% sorbitol). ■ At-home AC tablets and capsules (typically used by humans for colonic cleansing pur-

poses) are not as effective as veterinary AC liquid slurries. ■ The use of AC granules can also be considered (e.g., Toxiban™ granules), and mixed with

a small amount of food to increase palatability for dogs. ■ Few animals will ingest AC voluntarily, and administration may need to occur via forced

but careful syringe feeding or orogastric tube administration. ■ Based on an in vitro study assessing the administration of AC with a palatable veterinary

prescription canned food (Hills™ a/d), the administration of AC with food can decrease the absorptive capacity of AC; however, this was thought to be clinically insignificant. That said, when administering AC with food, ideally the smallest amount of food should be used.

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■ Due to the thick viscosity of AC, it is often difficult to administer via NE or NG tube admin-istration. Oral tubing in an awake patient (e.g., with a mouth gag and careful restraint) has been successfully used to administer AC.

■ Rarely, reports of hypernatremia have been clinically seen with AC administration. This is likely due to the sorbitol effect (see “Cathartics”). The patient should be assessed for hydration status.

■ To prevent dehydration and hypernatremia, the patient should be appropriately hydrated with either IV or SQ fluids.

■ A potent antiemetic should be administered to prevent secondary vomition or aspiration pneumonia, and to allow for rapid return to oral water (to help maintain hydration of the patient).

• Maropitant 1 mg/kg, SQ q 24 hours; administration to cats or by intravenous admin-istration is considered extra-label but has been used by this author successfully.

• Ondansetron 0.1–0.3 mg/kg, SQ, IM, IV q 6–12 hours. • Dolasetron 0.6–1 mg/kg, SQ, IM, IV q 24 hours. • Metoclopramide 0.2–0.5 mg/kg, SQ, IM q 6–12 hours; or CRI at 1–2 mg/kg/day IV;

generally less effective as an antiemetic than maropitant or ondansetron, but pro-vides gastric emptying and a prokinetic effect.

■ Contraindications for AC include dehydration, hypernatremia, vomiting, late-stage pre-sentation with clinical signs already present, a compromised airway (risk for aspiration pneumonia), endoscopy, abdominal surgery of the GIT, gastric or intestinal obstruction, perforation of the GIT, lack of borborgymi, ileus, hypovolemic shock, caustic substance ingestion, and hydrocarbon toxicosis (due to increased risk for aspiration pneumonia).

Cholestyramine

■ Cholestyramine, a chloride salt of a basic anion exchange resin, is recommended by the ASPCA Animal Poison Control Center over the use of charcoal.

■ Cholestyramine binds with bile acids within the intestines, producing an insoluble com-plex and preventing bile acids from being reabsorbed (and instead, excreted through the feces).

■ Cholestyramine can be dosed at 0.3–1 g/kg every 6–8 hours with toxicants that undergo enterohepatic recirculation or biliary elimination.

■ Little is known about the success of cholestyramine in veterinary medicine; anecdotally, the ASPCA Animal Poison Control Center has had success with its use instead of AC for the poisoned patient.

■ Cholestyramine, like AC, has fallen out of favor in human medicine.

Cathartics

■ Cathartics are designed to increase the speed and transit time of the GIT, promoting fecal excretion of the toxicant; more importantly, cathartics decrease the time allowed for toxi-cant absorption through the GIT.

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■ Two of the most common types of cathartics used in the poisoned patient are: • saccharide cathartics (e.g., sorbitol) • saline cathartics (e.g., magnesium citrate, magnesium sulfate, sodium sulfate).

■ Dose: sorbitol (70% solution, 1–2 mL/kg, PO, given within 60 minutes of toxin ingestion). ■ Side effects of sorbitol administration: vomiting, dehydration, secondary hypernatremia,

abdominal cramping or pain, and possible hypotension. ■ Contraindications for cathartics are similar to those for AC listed above. ■ Mineral oil is no longer recommended as a cathartic due to the high risks of aspiration. ■ The use of cathartics alone is no longer recommended or beneficial. ■ Cathartics should not be used in a dehydrated patient, due to the risks of voluminous

fluid losses through the GIT and secondary hypernatremia. For patients receiving either multidoses of AC with or without cathartics, serum sodium levels and hydration status should be carefully monitored.

Fluid Therapy

■ Fluid therapy is one of the cornerstone therapies of emergency management of the poi-soned patient to:

• correct dehydration • maintain perfusion at a cellular level • vasodilate the renal vessels, flush the renal tubules, and diurese the patient. This

is particularly important with nephrotoxicants such as grapes, raisins, NSAIDs, ethylene glycol, lilies, etc.

• treat hypotension (particularly with drugs like beta-blockers, calcium channel blockers, ACE-inhibitors, etc.).

■ Fluid therapy can also be used to aid in detoxification of the patient by increasing renal excretion of toxicants by forced diuresis, provided the toxicants undergo renal excretion (e.g., amphetamines, etc.).

■ Dose: the dose of IV fluids to administer is dependent on the clinical state and physical examination findings of the patient.

• In a healthy patient, fluid rates of 4–10 mL/kg/hour can be used to force renal clear-ance of the toxicant.

• Neonates have a higher maintenance fluid rate (80–180 mL/kg/day), and fluid rates should be adjusted accordingly.

• Patients with cardiac disease or respiratory disease, or those who have ingested toxicants that may increase the patient’s risk of pulmonary edema (e.g., phosphide rodenticide) should have judicious fluid administration.

• Careful assessment of hydration should be made based on PCV/TS, weight gain, CVP, and physical examination findings.

■ The additional use of diuretics can be undertaken in hydrated patients to increase forced diuresis. This should be less commonly considered, as diuretics can result in dehydration or nephrotoxicity.

• Furosemide 1–4 mg/kg, IV, SQ, IM q 6–8 hours. • Mannitol 0.5–2 g/kg, IV slow over 20–30 minutes q 6–8 hours.

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■ Highly protein-bound toxins are not cleared efficiently by diuresis (e.g., NSAIDs). ■ Drugs that respond well to forced diuresis include:

• phenobarbital • amphetamines • salicylate • lithium • bromide.

Surgical Decontamination

■ Surgical removal of toxic agents may occasionally need to be performed, particularly if the toxicant is caustic or corrosive (e.g., batteries), results in a bezoar that cannot be removed by gastric lavage (e.g., iron tablets, bone meal), results in foreign body obstruction (e.g., Gorilla Glue), or continues to leach its toxic effect (e.g., Amitraz collars, zinc pennies, fentanyl or nicotine patches, etc.). Please see chapter 72, Foreign Objects, for more information.

■ Prior to surgery, patients should have radiographs done to verify presence of the agent and presence of an obstructive pattern. Keep in mind that not all foreign bodies are radi-opaque. Patients should be properly volume resuscitated with IV fluid therapy and anti-emetic therapy, and have their electrolyte, glucose, and acid–base imbalances corrected prior to anesthesia.

CONCLUSIONS

■ Aggressive decontamination and detoxification of the poisoned patient are imperative and still considered the mainstay therapy in veterinary medicine.

■ The clinician should feel well versed in appropriate decontamination methods to treat poisoned patients.

Abbreviations

See Appendix 1 for a complete list.

PEG-ES = polyethylene glycol electrolyte solutionWBI = whole bowel irrigation

Suggested Reading

Abdallah AH, Tye A. A comparison of the efficacy of emetic drugs and stomach lavage. Am J Dis Child 1967; 113:571–575.

American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxi-cologists. Position paper: Gastric lavage. J Toxicology 2004; 42(7):933–943.

American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxi-cologists. Position paper: Single-dose activated charcoal. Clin Toxicol 2005; 43:61–87.

Arnold FJ, Hodges JB Jr, Barta RA Jr. Evaluation of the efficacy of lavage and induced emesis in treatment of salicylate poisoning. Pediatrics 1959; 23:286–301.

Cope RB. A screening study of xylitol binding in vitro to activated charcoal. Vet Human Tox 2004; 46:336–337.

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Corby DG, Lisciandro RC, Lehman RW, et al. The efficacy of methods used to evacuate the stomach after acute ingestions. Pediatrics 1967; 40:871–874.

Khan SA, McLean MK, Slater M, et al. Effectiveness and adverse effects of the use of apomorphine and 3% hydrogen peroxide solution to induce emesis in dogs. J Am Vet Med Assoc 2012; 241(9):1179–1184.

Peterson ME. Toxicological decontamination. In: Peterson ME, Talcott PA, eds. Small Animal Toxicology, 3rd edn. St Louis, MO: Elsevier Saunders, 2013; pp. 73–85.

Plumb DC. Veterinary Drug Handbook, 7th edn. Ames, IA: Blackwell Publishing Professional, 2011.Teshima D, Suzuki A, Otsubo K, et al. Efficacy of emetic and United States Pharmacopoeia ipecac syrup in

prevention of drug absorption. Chem Pharm Bull 1990; 38:2242–2245.Türk EE, Schulz F, Koops E, et al. Fatal hypernatremia after using salt as an emetic – report of three autopsy

cases. Leg Med (Tokyo) 2005; 7(1):47–50.Wilson HE, Humm KR. In vitro study of the effect of dog food on the adsorptive capacity of activated char-

coal. J Vet Emerg Crit Care 2013; 23(3):263–267.

Author: Justine A. Lee, DVM, DACVECC, DABTConsulting Editor: Lynn R. Hovda, RPh, DVM, MS, DACVIM

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Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology, Second Edition. Lynn R. Hovda, Ahna G. Brutlag, Robert H. Poppenga, and Katherine L. Peterson. © 2016 John Wiley & Sons, Inc. Published 2016 by John Wiley & Sons, Inc. Companion website: www.fiveminutevet.com/toxicology

Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Air plant, Cathedral bells (Kalanchoe spp.)

Bright red‐orange to pink blooms; umbel flower pattern.

Plant contains cardiotoxins similar to azalea and rhododendrons, concentrated mainly in flowers.

Cardiac glycoside causes acute signs 1–3 hours after ingestion. Signs include depression, salivation, diarrhea, bradycardia, tachypnea, ataxia, tremors, and paralysis.

Emesis and/or activated charcoal early after ingestion. Treat as a cardiac glycoside. (see chapter 102).

Aloe, Octopus plant, Candelabra plant (Aloe spp.)

Succulent plant, used in folk and herbal medicine.

Toxic fraction is anthraquinone glycoside; disrupts water and electrolyte balance in large intestine.

Anorexia, depression, vomiting, colic, diarrhea, tremors (uncommon), and change in urine color.

Generally mild in nature.

Drugs for abdominal pain/diarrhea.

Protect airway, treat locally for pharyngitis associated with oxalate crystals (rare).

Autumn crocus (Colchicum autumnale)

Houseplant, garden plant.

Typically blooms in fall, different from most other bulbs. Dosages above 6 g/kg BW considered lethal.

Although the whole plant is toxic, the toxin (colchicine) is highest in bulbs.

Acute onset 2–12 hours post ingestion. Initial signs are nausea, salivation, vomiting, colic, diarrhea, incoordination, and weakness. Multiple organ systems (heart, lungs, and kidneys) also may be involved. Potential for coagulopathy and elevated serum enzymes.

Induce emesis if not vomiting. Activated charcoal if early. Evaluate CBC and serum chemistries, including prothrombin, LDH, CK.

IV fluids, analgesics, anticonvulsants as needed.

Baneberry, Doll’s eye, Cohosh (Actea spp.)

Toxic principle is protoanemonin glycoside, as well as irritant essential oils.

Clinical response ranges from dermatitis and blistering of skin to oral irritation, drooling, pawing at face or mouth, emesis, diarrhea, and hematuria.

Neurological and cardiovascular signs are occasionally reported.

Cleanse mouth thoroughly with water; apply appropriate local demulcents; control emesis and diarrhea as necessary; monitor for organ dysfunction, especially renal damage.

Toxic Plants and Their Clinical Signs: Antidotes and Treatment

4appendix

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Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Belladonna lily (Amaryllis spp.)

Potted plant, Bulbs are most toxic.

Contains both lycorine alkaloid (systemic effects) and insoluble oxalates (local pharyngitis).

Nausea, vomiting, diarrhea, hypotension, depression.

oxalate crystals can cause direct pharyngeal irritation.

Gastric lavage, activated charcoal, fluids, and supportive treatment.

Bittersweet (Celastrus spp.)

Weed, vine with red berries.

Immature fruits are toxic.

Toxins are sesquiterpene alkaloids (celapanine, celastrine, paniculatine).

Gastric irritation, vomiting, diarrhea.

fluids, supportive care as needed.

Bleeding heart (Dicentra spp.)

Garden, woods, potted plant.

Roots more toxic than leaves.

Toxins are isoquinoline alkaloids (apomorphine, cularine, protoberberine).

Vomiting, diarrhea, muscle tremors, convulsions or paralysis.

fluids and seizure control.

Castor bean (Ricinus communis)

Garden shrub or ornamental grows to 2 meters. Seeds are 1 cm, dark and light mottled, and highly toxic. Chewing the seed greatly increases toxicity.

Toxin is ricin.

Severe, dangerous if seeds chewed before swallowing.

Latent period 6–48 hours. Emesis, severe and hemorrhagic diarrhea, colic, muscle tremors, sudden collapse. Dehydration, hypotension, hemolysis and/or hemoglobinuria.

Emesis for recent exposure: sorbitol if diarrhea not present; charcoal, fluids, and electrolytes. Monitor electrolytes, liver, kidney, adrenal function up to 6 days; H2 blockers for GI signs; diazepam for seizures. Antibiotics, lactulose, SAMe for liver damage.

Chinaberry tree (Melia azedarach)

other common names are Persian lilac, white cedar, Texas umbrella tree.

ornamental tree in temperate to subtropical areas: southern coastal states, Mexican border.

Berry is most toxic.

Toxins are meliatoxins.

Salivation, anorexia, vomiting, diarrhea. May be followed by weakness, ataxia, excitement or seizures. fatalities have occurred, generally within 2 days post ingestion.

Early emesis, GI lavage and charcoal are considered beneficial. fluid and electrolyte replacement, anticonvulsants and supportive care.

Christmas rose (Helleborus niger)

House and garden plant. Entire plant is toxic, but fruits are most dangerous.

Small amounts considered dangerous.

Contains several toxins including ranunculin that is converted to protoanemonin when chewed, cardenolides, and bufadienolides.

Hypersalivation, vomiting, anorexia, diarrhea followed by cardiac arrhythmias, heart block with premature beats, premature beats, slow irregular pulse.

Potent cardenolide action is greatest risk.

Gastric lavage or emesis; activated charcoal or saline cathartics to decontaminate the GI tract.

Atropine may be helpful as for other cardenolide plants such as Digitalis spp.

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Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Daphne (Daphne mezereum)

Landscape shrub; evergreen or deciduous.

Entire plant is toxic. Bitter or acid taste discourages consumption, may reduce toxic effects.

Toxins are tricyclic daphnane and diterpenes.

Vesication and edema of the lips and oral cavity associated with ingestion. Signs progress to salivation, thirst, abdominal pain, emesis, hemorrhagic diarrhea.

Analgesics to control pain. General GI detoxification, medical treatment for vomiting and diarrhea. fluid and electrolyte replacement as needed. Monitor body fluids and electrolytes.

Delphinium/larkspur (Delphinium spp.) and/or pheasant’s eye, yellow oxeye (Adonis spp.)

outdoor perennial: gardens, mountains; tall with blue, purple, or pinkish flowers.

Seeds more toxic than leaves.

Toxin is a diterpenoid alkaloid.

Small animal poisoning unlikely unless by access to seeds.

Early signs are vomiting, colic, and diarrhea. May progress to trembling, ataxia, weakness, lateral recumbency.

GI detoxification; demulcents and antidiarrheal for GI signs; physostigmine to treat muscarinic signs.

English holly (Ilex spp.)

Landscape plant; glossy green leaves with marginal spicules. fruit (drupe) white, yellow, black, red, orange. occurs in forested areas of eastern N. America; elsewhere as an ornamental.

fruit is most likely portion consumed.

fruit and leaves contain potentially toxic saponins.

Nausea, vomiting, diarrhea most common from consumption of berries. Some animals may be depressed.

Clinical response most often mild/moderate and transient.

Relief of digestive distress; activated charcoal may be helpful. fluid and electrolyte replacement as needed.

English ivy (Hedera helix), also known as Atlantic ivy, Irish ivy, common ivy.

Houseplant, or in mild climates used as a ground cover.

occurs as a woody, climbing or creeping vine.

Commonly grown throughout North America.

Toxins are triterpenoid saponins.

Salivation, thirst, emesis, gastroenteritis, diarrhea, dermatitis. Relatively few reported cases, most are moderate GI irritation. often moderate or mild.

Symptomatic relief of GI distress; supportive care for vomiting and diarrhea.

Golden angel’s trumpet (Brugmansia spp.)

Nonnative ornamental, similar to jimsonweed. Large pendulous flowers, similar to angel’s trumpet.

Toxin similar to jimsonweed (tropane alkaloid scopolamine) causes anticholinergic effects.

Typical anticholinergic effects are restlessness, dilated pupils, tachycardia, dyspnea, dry mouth, GI atony, rarely seizures.

Rarely lethal.

Treat similar to Datura spp. (see Thornapple below).

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Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Horse chestnut or Ohio buckeye (Aesculus spp.)

Landscape or forest tree; palmate leaves. Native range is Midwest, east to Appalachian Mountains, south into Texas. Planted as ornamental/landscape tree as well.

Nuts and twigs most toxic; very early green foliage in spring.

Horse chestnut highly toxic; ohio buckeye very low toxicity.

Contain several toxins including saponins, anthraquinones, and a coumarin glycoside.

Gastroenteritis, diarrhea, dehydration, electrolyte imbalance.

Neurological signs possible, including incoordination, hypermetria, staggering. Usually transient, rarely fatal. Recovery usual within 24–48 hours.

fluid and electrolyte replacement, demulcents, and therapy for gastroenteritis.

Confine animals during neurological phase.

Iris or flag (Iris spp.)

Perennial garden flower – very commonly available.

Rootstock (rhizome) most toxic; most risk at transplantation. Close to soil surface, may be dug up by dogs.

Advise clients of potential risk.

Rootstock contains purgative toxin known as irisin.

Hypersalivation, vomiting, colic, diarrhea which may be hemorrhagic. occasionally irritation of the lips and muzzle.

GI decontamination early.

fluid and electrolyte therapy as needed.

Irish potato (Solanum tuberosum)

Vegetable garden plant.

Vines, green skin, and sprouts are toxic.

Toxins vary but are solanine and other glycoalkaloids.

Vomiting, diarrhea, depression, rapid heart rate, mydriasis, muscle tremors. Signs may vary from atropine‐like to cholinesterase inhibition. Use antidotes accordingly and with caution.

GI decontamination.

If atropine‐like signs predominate, use physostigmine. If salivation and diarrhea are present, use atropine cautiously.

Jerusalem cherry, winter cherry (Solanum pseudocapsicum)

Common ornamental houseplant.

Toxin is the glycoalkaloid solanine similar to other plants of the nightshade (Solanaceae) family.

Severe GI irritation characterized by drooling, vomiting, diarrhea, ulceration, depression, and sometimes seizures.

GI decontamination if exposure is recent.

If salivation and diarrhea are present and severe, use atropine cautiously.

Provide fluid therapy based on condition of patient and results of laboratory tests.

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APPENDIx 4 ToxIC PLANTS AND THEIR CLINICAL SIGNS: ANTIDoTES AND TREATMENT 923

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Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Lantana (Lantana camara)

occurs wild and in gardens in mild temperate to tropical areas. Naturalized in southeastern coastal states of the USA. Bright orange, yellow, red, purple, or pink flowers. foliage and immature berries are most toxic.

Toxins are pentacyclic triterpenoid lantadenes A,B, and C.

Weakness, lethargy, vomiting, diarrhea, mydriasis, dyspnea.

Continued ingestion can lead to chronic disease.

Advanced signs: cholestasis, hyperbilirubinemia. Liver changes predispose to photosensitization.

GI decontamination, activated charcoal for acute exposures. Provide fluids and respiratory support.

Protect from sunlight and treat for hepatic insufficiency.

Lily of the valley (Convallaria majalis)

ornamental garden plant. Prefers moist, shaded areas. Blossoms nodding/drooping on stem.

Toxic principle (cardenolides) persists in dried plants; highest concentration in roots.

Multiorgan failure. Tremors, thirst, vomiting, diarrhea, cardiac arrhythmia/bradycardia, weakness, shock.

Monitor for cardiac arrhythmias, shock and hyperkalemia.

Emesis or gastric lavage. Control dehydration, maintain electrolytes; control diarrhea; monitor ECG and serum potassium.

Lupine, bluebonnet (Lupinus spp.)

Common garden ornamental throughout USA; wild plants abundant in some regions, primarily western USA.

Seeds more toxic than leaves, but plant, seeds and pods are toxic.

Toxin is lupine.

Signs begin 1–24 hours post exposure. Salivation, ataxia, mydriasis, depression or seizures, disorientation, dyspnea.

Liver and kidney damage may develop from continued ingestion.

Lupines are teratogenic in ruminants. Risk in small animals is not well known.

GI decontamination with activated charcoal for acute exposure.

Anticonvulsants may be needed if neurological signs are severe.

Mexican breadfruit, Swiss cheese plant, hurricane plant (Monstera deliciosa)

Stems and leaves contain insoluble calcium oxalate spicules (raphides).

Chewing on the plant releases oxalate spicules into mouth, tongue and lips.

Response is immediate irritation, pain, salivation, and inflammation. Signs include pawing at face, drooling, and vomiting; potential interference with upper airway.

Cleanse mouth thoroughly with water.

Apply local and/or systemic antiinflammatory agents based on clinical condition of patient.

Mistletoe (Phoradendron spp.)

Access to pets in homes at holiday time. oval evergreen leaves with white berries.

Leaves, stems, and berries are moderately toxic – contain toxic amines and proteins.

Vomiting, GI pain, diarrhea; ataxia, hypotension, occasional seizures, cardiovascular failure.

Principal risk may be from use during holiday season.

fluid and electrolyte replacement; demulcents for gastroenteritis.

(Continued)

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Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Monkshood (Aconitum spp.)

Perennial garden ornamental.

Entire plant is toxic, contains diterpene alkaloids that are primarily neurotoxic.

Interferes with inactivation of Na+ channels in nerves.

Salivation, vomiting, diarrhea. Muscle tremors, weakness, cardiac arrhythmia and/or heart failure; respiratory depression.

GI decontamination, fluid and electrolyte replacement. Manage similar to digitalis glycoside overdose, with caution for potassium administration.

Morning glory (Ipomoea purpurea and Ipomoea tricolor)

Garden annual, potted plant.

Seeds most toxic. Increased risk when seeds are presoaked, consumed by dogs.

Indole alkaloid toxin similar to ergot alkaloids; abused as hallucinogen.

Nausea, mydriasis, ataxia, muscle tremors, hallucinations, decreased reflexes, diarrhea, hypotension.

Dark, quiet surroundings; tranquilization as needed.

GI decontamination is not routinely recommended.

Mountain laurel (Kalmia spp.)

Native of eastern and southeastern woods, mountains. Both leaves and flowers are toxic. Honey from nectar also toxic.

Toxins are diterpenoids, in particular grayanotoxins I and II.

oral irritation, salivation, projectile vomiting, diarrhea, weakness, impaired vision, bradycardia, hypotension, AV block.

Activated charcoal, fluid replacement, and respiratory support as needed.

Narcissus, daffodil, jonquil (Narcissus spp.)

Garden ornamental bulb. Bulb is most toxic.

Contains lycorine alkaloid.

Nausea, vomiting, salivation, hypotension, diarrhea.

Prolonged signs may cause dehydration.

Gastric lavage, activated charcoal, fluid replacement, supportive treatment for gastroenteritis.

Nettle (Urtica spp.)

Garden or waste area weed.

Hairs on leaves contain toxin that enters skin on contact.

Most common in hunting or outdoor free‐roaming dogs.

Toxins are biogenic amines (acetylcholine, histamine, etc.).

oral irritation and pain, hypersalivation, swelling and edema of nose and periocular areas or other areas of skin contact.

Antihistamines and analgesics. Local or systemic antiinflammatory supportive therapy to treat affected contact areas.

Persian violet, sowbread (Cyclamen persicum)

Popular florist’s plant; widely available.

Irritant saponins in all parts of the plant, especially tubers or roots.

Chewing plant parts causes oral irritation with drooling, vomiting and diarrhea. occasional hemoglobinuria may color urine red‐brown.

Large amounts may cause cardiac arrhythmias, seizures and rarely mortality.

Control vomiting and diarrhea if severe; administer fluids as needed.

Monitor urine for color and/or hemoglobin.

Control seizures and cardiac arrhythmias as needed.

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APPENDIx 4 ToxIC PLANTS AND THEIR CLINICAL SIGNS: ANTIDoTES AND TREATMENT 925

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Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Philodendron spp.

Very common indoor ornamental vine.

Toxic principle is insoluble oxalate.

Chewing on the plant releases oxalate spicules into mouth, tongue and lips. Response is immediate irritation, pain, salivation, and inflammation.

Signs include pawing at face, drooling, and vomiting; also potential interference with upper airway.

Cleanse mouth thoroughly with water.

Apply local and/or systemic antiinflammatory agents based on clinical condition of patient.

Poinsettia (Euphorbia pulcherrima)

Garden or potted plant, especially during the Holiday season.

Sap of stem and leaves mild irritant.

Contains a variety of diterpenoid euphorbol esters.

Irritation of mouth: may cause vomiting, diarrhea, and dermatitis.

Usually transient and not life‐threatening.

Demulcents for local lesions; fluids to prevent dehydration.

Rosary pea, precatory bean (Abrus precatorius)

Native of Caribbean islands.

Seeds (when broken or chewed) are highly toxic.

Seeds used in ornamental jewelry in some countries. Illegal to import into USA.

Toxin is abrin.

Signs may be delayed up to 2 days after ingestion. Early signs are nausea, vomiting, diarrhea (often hemorrhagic) followed by weakness, tachycardia, possible renal failure, coma, death.

Emesis or lavage followed by activated charcoal, demulcents, fluids, and electrolytes.

Early and thorough detoxication is important for survival.

Thorn apple, jimsonweed (Datura stramonium)

Annual weed, some species are ornamental (Datura metel).

Entire plant is toxic, but seeds are most toxic and available.

Toxins are tropane alkaloids (hyoscyamine and scopolamine) with effects similar to atropine.

Thirst, disturbances of vision, delirium, mydriasis, thirst, tachycardia, hyperthermia, GI atony/constipation.

Commonly described as “Hot as a pistol, blind as a bat, red as a beet, mad as a hatter.”

GI decontamination if early after ingestion.

Parasympathomimetic drug (e.g., physostigmine).

Tulips (Tulipa spp.) and hyacinths (Hyacinthus spp.)

Poisoning usually occurs when dogs consume available bulbs or dig up freshly planted bulbs.

Toxic principle includes allergenic lactones and similar alkaloids.

Signs reflect direct irritation and include drooling, nausea, vomiting, diarrhea, dyspnea, tachycardia and dyspnea and hyperpnea.

GI decontamination if early after ingestion.

Apply local and/or systemic antiinflammatory agents based on clinical condition of patient. Monitor and control gastrointestinal effects; medicate as needed for tachycardia and dyspnea.

(Continued)

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Plant and Characteristics Clinical Signs Antidotes and/or Treatment

Tobacco (Nicotiana tabacum)

Garden plant, weed, cigarettes.

Entire plant toxic.

Nicotine alkaloid is toxic principle.

Rapid onset of salivation, nausea, emesis, tremors, incoordination, ataxia, collapse and respiratory failure.

Assist ventilation, provide vascular support. Gastric lavage with activated charcoal.

Wisteria (Wisteria spp.)

Woody vine or shrub with bluish purple to white legume flowers.

Entire plant is toxic.

Toxin is a glycoprotein lectin

Nausea, abdominal pain, prolonged vomiting; diarrhea.

Signs may persist 2–3 days.

Antiemetics and fluid replacement therapy.

Yellow jessamine (Gelsemium sempervirens)

Mild temperate to subtropical climates; mainly SE United States. Yellow trumpet‐shaped flowers grow on evergreen vines.

Neurotoxic alkaloids and semipervirine, and indole, are toxins.

Weakness, ataxia, clonic/tonic seizures, paralysis, respiratory failure.

GI decontamination early in course of toxicosis. Symptomatic and supportive therapy for respiration.

fluid replacement therapy as needed.

Supplemental Resources

■ Barr AC. Household and garden plants. In: Peterson ME, Talcott PA, eds. Small Animal Toxicology, 3rd edn. Elsevier, 2013; pp. 357–400.

■ Burrows GE, Tyrl RJ. Toxic Plants of North America. Iowa State University Press, 2001. ■ Frohne D, Pfander HJ. Poisonous Plants, 2nd edn. Timber Press. 2005. ■ Williams MC, Olsen JD. Horse chestnut: a multidisciplinary clinical review. Am J Vet Res

1984; 45(3):539–542.

Authors: Gary D. Osweiler, DVM, PhD, DABVT; Lynn R. Hovda, RPh, DVM, MS, DACVIM

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933

Index by Toxicant 933 8 February 2016 2:56 PM

Note: Chapter titles are bolded and chapter paging shows inclusive pages. Page numbers followed by “t” refer to tables; page numbers followed by “f” are figures.

1,25-dihydroxycholecalciferol (calcitriol). See  Cholecalciferol, 850–855

2,4-D. See Herbicides, 565–5705-Fluorouracil, 119–125

antimetabolite, antineoplastic agent, 119colony stimulating factors (filgrastim), 123myelosuppression, 119–121

Abamectin. See Ivermectin/Milbemycin/Moxidectin, 374–384

Abrus precatorius (rosary pea, precatory bean), 925t. See Appendix 4, Toxic Plants, 919–926

ACE inhibitors. See Angiotensin Converting Enzyme (ACE) Inhibitors, 132–136

Aconitum spp. (monkshood), 924t. See Appendix 4, Toxic Plants, 919–926

Actea spp. (baneberry, doll’s eye, cohosh), 919t. See Appendix 4, Toxic Plants, 919–916

Acetaminophen, 307–312anemia, 308–310COX-3, 307cyanosis, 309–310edema, facial and paw, 308–311glutathione, 308Heinz body, 308–310hepatic failure, 308–311methemoglobinemia, 308–311N-acetylcysteine (NAC), 310NAPQI, 308

Acetamiprid. See Imidacloprid and Other Neonicotinoids, 677–682

neonicotinoid, 678–682toxicity, 680

Acetylcholinesterase. See Organophosphate and Carbamate Insecticides, 689–696

Acids, 601–608corrosive injury, 603esophageal effects, 604esophageal stricture, 606pH, 601–603

Aconitum spp. (monkshood), 924t. See Appendix 4, Toxic Plants, 919–926

Adderall. See Amphetamines, 126–131Adhesives. See Glues and Adhesives, 95–100

Adonis spp. (pheasant’s eye, yellow oxeye), 921t. See Appendix 4, Toxic Plants, 919–926

Aesculus spp. (horse chestnut, Ohio buckeye), 922t. See Appendix 4, Toxic Plants, 919–926

Afoxolaner. See Miscellaneous Insecticides, 683–688diagnosis, 686prognosis, 688toxicity, 688

Air plant (Kalanchoe spp.), 919t. See Appendix 4, Toxic Plants, 919–926

Albuterol, 155. See Beta2 Receptor Agonists (Albuterol

and Others), 155–161

Alcohols, 71–77blood–brain barrier, 72diagnosis, 74ethanol, 71–73, 75hemodialysis 75isopropanol, 71–74metabolic acidosis 75methanol, 71–72neurotoxicity, 72prognosis, 76sources, 71toxicity, 72wood alcohol, 71

Alkalis, 609–616corrosive injury, 609–612esophageal effects, 612esophageal stricture, 615hyperchloremic acidosis, 610liquefaction necrosis, 610ph, 609–611

Allium spp. See Onions and Garlic, 515–520Aloe spp. (aloe, octopus plant, candelabra plant), 919t.

See Appendix 4, Toxic Plants, 919–926Alpha

2-Adrenergic Agonists, 369–373

atipamezole, 372atrioventricular (AV) block, 370–371bradycardia, 369–371brimonidine, 369CNS depression, 370–371detomidine, 369dexmedetomidine, 369

Index by Toxins and Toxicants

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Alpha2-Adrenergic Agonists (continued)

hypotension, 370–372reversal agents, 372romifidine, 369vomiting, 370–371xylazine, 369yohimbine, 372

Alprazolam, 150t. See Benzodiazepines, 149–154Aluminum phosphide. See Phosphides, 862–870Amanitins, 778, 780–783, 785. See Mushrooms,

778–786Amaryllis (Hippeastrum spp.), 812, 814f, 815. See Spring

Bulbs, 812–820Amaryllis spp. (belladonna lily), 920t. See Appendix 4,

Toxic Plants, 919–926Ambien (zolpidem), 212,213. See Nonbenzodiazepine

Sleep Aids, 212–216Amitraz, 665–671

alpha2-adrengernic antagonist, 665

atipamezole, 669diagnosis, 668neurotoxicity, 666prognosis, 671seizures, 669sources, 665toxicity, 666tremors, 669yohimbine, 669

Amlodipine, 179t, 180. See Calcium Channel Blockers, 178–186

Amphetamines, 126–131ADHD (attention-deficit hyperactive disorder),

126human urine test kit, 128methamphetamine, 126stimulants, 126–129sympathomimetic amines, 126serotonin, 126, 129

Analgesics, 928t. See Appendix 5, Topical Toxins, 927–931

Antibiotics, 928t. See Appendix 5, Topical ToxinsAnticoagulant Rodenticides, 835–843, 927–931

antidote, 841blood products, 841coagulation tests, 840, 842coagulopathy, 839diagnosis, 840first generation, 835half-lives, 836prognosis, 843protein binding, 836, 838second generation, 835toxicity, 836–837vitamin K

1, 841

vitamin K epoxide reductase, 836

Antidotes and Other Useful Drugs, 36–48; see also Appendix 3, Metallic Toxicants, 913–918; see also Iron, 707–715; see also Lead, 716–722; see also Zinc, 723–728

antivenin (specific) – black widow spider, 37–38antivenin (specific) – crotalids, 37anitvenin (specific) – elapids, 37antivenin (specific) – scorpions, 38atipamezole, 43atropine, 44bisphosphonates, 41calcitonin, 41calcium disodium EDTA, 38, 720, 727, 917tcyproheptadine, 42d-penicillamine, 38, 918tdantrolene, 43deferoxamine, 39, 712digoxin immune Fab fragments, 40–41dimercaprol (BAL), 39, 917tdimercaptosuccinic acid (DMSA), 39–40ethanol, 44fomepizole (4-methyl pyrazole), 44–45flumazenil, 45intravenous fat emulsion (IFE), 42leucovorin, 45methocarbamol, 43methylene blue, 45N-acetylcysteine, 45, 918tnaloxone, 46phytonadione (vitamin K

1), 42–43

pralidoxime (2 PAM), 46pyridostigmine, 46pyridoxine, 47protamine sulfate, 41sodium thiosulfate, 918tsuccimer, 720, 917ttrientine, 40tolazoline, 43yohimbine, 43

Antifungals, 928t. See Angiotensin Converting Enzyme (ACE) Inhibitors, 132–136,

Appendix 5, Topical Toxins, 927–931angiotensin I, 132angiotensin II, 132benzepril, 132–134captopril, 132–134enalapril, 132–134hypotension,132–135imidapril, 132–133lisinopril, 132–133, 135ramipril, 132–133

Antihistamines, 929t. See Appendix 5, Topical Toxins, 927–931

Antiseptics, 929t. See Appendix 5, Topical Toxins, 927–931

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Antitussives and Expectorants (Dextromethorphan), 313–319

ataxia, 315CNS depression/agitation/aggression, 314cold/flu medications, 313ketamine analog, 313

APAP. See Acetaminophen, 307–312Arrowhead (Syngonium spp.), 787, 788f. See Oxalates –

Insoluble, 787–796Arsenic, 913t. See Appendix 3, Metallic Toxicants,

913–918Aspergillus spp. See Mycotoxins – Aflatoxins, 502–507Aspirin, 313–319

acute renal failure (ARF), 321–325COX inhibition, 320GI hemorrhage, 321Heinz bodies, 321–323hepatotoxicity, 323melena, 321–322metabolic acidosis, 323, 325prostaglandin inhibitor, 320vomiting, 321, 322

Atlantic ivy (Hedera helix), 921t. See Appendix 4, Toxic Plants, 919–926

Atenolol, 163t. See Beta Receptor Antagonists (Beta-Blockers), 162–171

Atypical Antipsychotics, 137–142aripiprazole, 137–138asenapine, 137clozapine, 137dopamine receptors, 137intralipid emulsion (ILE), 141olanzapine,137–138paliperidone,137quetiapine, 137–138risperidone, 137–138second-generation antipsychotics, 137serotonin receptors, 137ziprasidone, 137–138

Autumn crocus (Colchium aumunale), 187. See Colchicine, 187–191; see also Spring Bulbs, 812–820; see also 919t, Appendix 4, Toxic Plants, 919–926

Azaleas and Rhododendrons, 745–750arrhythmias, 747–748azalea, 745fgastroenteritis, 747grayanotoxins, 745–747mad honey disease, 747rhododendrons, 746f

Bacitracin, 928t. See Appendix 5, Topical Toxins, 927–931

Baclofen, 143–148cyprohepatine, 146flaccid paralysis, 144

GABA receptors, 143hemodialysis, hemoperfusion, 146mutilple sclerosis, 143–144respiratory arrest, 145–146

Baneberry (Actea spp.), 919t. See Appendix 4, Toxic Plants, 919–916

Barium, 914. See Appendix 3, Metallic Toxicants, 913–918; see also Matches and Fireworks, 624–629

Bath salts. See Club Drugs (MDMA, GHB, Flunitrazepam and Bath Salts), 245–252

Batteries, 617–623esophageal ulceration, 618heavy metals, 617potassium and sodium hydroxide, 617tracheoesophageal fistulas, 617–619

Bees. See Wasps, Hornets, and Bees, 457–465Belladonna lily (Amaryllis spp.), 920t. See Appendix 4,

Toxic Plants, 919–926Benzocaine, 930t. See Appendix 5, Topical Toxins,

927–931Benzodiazepines, 149–154

CNS depression, 149-153flumazenil, 153GABA modulation, 149hepatic failure (cat), 149, 151, 153human urine drug screen, 152

Benzoyl peroxide, 929. See Appendix 5, Topical Toxins, 927–931

Beta2 Receptor Agonists (Albuterol and Others), 155–161

asthma, 155cAMP, 155hypokalemia, 158–159inhaler, 155–156, 157f, 158tachyarrhythmias, 155–156, 159

Beta Receptor Antagonists (Beta-Blockers), 162–171atenolol, 163t, 165–166AV block, 167carvedilol, 163t, 165–166esmolol, 164t, 165–166hyperkalemia, 162intravenous fat emulsion (ILE), 169metoprolol, 164t, 165–166propranolol, 164t, 165–166sotalol, 164t, 165–166

Bezoars. See Foreign Objects, 537–543Biotin. See Vitamins and Minerals, 313–324Bitter almond oil. See Essential Oils/Liquid Potpourri,

585–591Bittersweet (Celestrus spp.), 920t. See Appendix 4, Toxic

Plants, 919–926Black Widow Spiders, 407–411

alpha-latrotoxin (venom), 408antivenom, 410hour glass mark, 407

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Index by Toxicant 936 8 February 2016 2:56 PM

Black Widow Spiders (continued)Latrodectus spp., 407f, 407, 409neurotoxin, 408

Bleeding heart (Dicentra spp.). See Appendix 4, Toxic Plants, 919–926

Blood meal. See Bone and Blood Meal, 547–551Blue-green Algae (Cyanobacteria), 751–759

algal bloom, 751, 751f, 753f, 756, 758anatoxin-a, 752–758anatoxins, 752–758Cyanobacteria, 751dermatotoxins, 752–753, 755hepatotoxin, 751–752, 754–755microcystins, 752–758neurotoxin, 751–752, 755

Bluebonnet (Lupinus spp.), 923t. See Appendix 4, Toxic Plants, 919–926

Bone and Blood Meal, 547–551bone and blood meal, 547ffertilizer, 447–548, 550foreign body, 547–550herbicides, 547–548, 550pancreatitis, 547–549pesticides, 547vomiting, 548–550

Bread Dough, 469–473alcohol, 469–471, 473ataxia, 470–471blind, 470bloat/GDV, 469–472dextrose supplementation, 472ethanol, 469–471, 473hemodialysis, 471, 473hypoglycemia, 469–470, 472yeast ,469, 471

Brodifacoum. See Anticoagulants, 835–843Bromethalin, 844–849

clinical syndromes, 846diagnosis, 847intravenous lipid emulsion (ILE), 847mechanism of toxic effect, 844neurotoxicity, 846toxicity, 845treatment 847–848

Bromonidine. See Alpha2-Adrenergic Agonists, 369–373

Brown Recluse Spiders, 412–417

Loxosceles reclusa, 412–413dermal necrosis, 412, 414–417venom, 412, 414violin shape mark, 412, 413f

Brugmansia spp. (golden angel’s trumpet), 921t. See Appendix 4, Toxic Plants, 919–926

Bufo spp. Toads, 418–423bufotenines, bufagenins, bufotoxins, 419Colorado river toad (Incilius alvarius; formerly Bufo

alvarius), 418–419, 422

digoxin specific FAB fragments, 422marine toad (Rhinella marina, formerly Bufo marinus),

418f, 418–419, 421–422Sonoran desert toad, 422

Buprenorphine injection (cats), 217, 220–222. See Opiates and Opioids, 217–226.

Butoconazole, 928t. See Appendix 5, Topical Toxins, 927–931

Cadmium, 914t. See Appendix 3, Metallic Toxicants, 913–918

Caffeine. See Chocolate and Caffeine, 479–484Calcifediol. See Cholecalciferol, 850–855Calcipotriene, Calcipotriol, 172–177

bisphosphonates, 175–176cholecalciferol, 172diuresis, 175hypercalcemia, 172–176hyperphosphatemia, 172–176mineralization, 172–173, 177vitamin D

3, 172

Calcitriol. See Cholecalciferol, 850–855Calcium. See Vitamins and Minerals, 313–324Calcium carbonate. See Calcium Supplements, 474–478Calcium Channel Blockers, 178–186

amlodipine, 179t, 179–180AV block, 180, 182calcium infusions, 183–184diltiazem, 179t, 179–180, 185insulin, high dose, 184intravenous fat emulsion (IFE), 186transvenous pacemaker, 183verapamil, 179–180

Calcium citrate. See Calcium Supplements, 474–478Calcium gluconate. See Calcium Supplements,

474–478Calcium oxalate crystals. See Oxalates – Soluble,

797–803; see also Oxalates – Insoluble, 787, 796; see also Spring Bulbs, 812–820

Calcium Supplements, 474–478arrhythmia, 475gastroenteritis, 474, 476–477hypercalcemia, 474–478PU/PD, 475–476vitamin D

3/cholecalciferol, 474–477

vitamin D3 IU equivalent, 477

vitamins and minerals, calcium, 474–478vomiting 475–476

Calla lily (Zantedeschia spp.), 787, 789f. See Oxalates – Insoluble, 787–796

Camphor, 928t. See Appendix 5, Topical Toxins, 927–931

Candelabra plant (Aloe spp.), 919t. See Appendix 4, Toxic Plants, 919–926

Cannabis sativa (marijuana), 264, 265f. See Marijuana, 264–270

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Carbamate. See Organophosphorous and Carbamate Insecticides, 689–696

2-PAM, 694acetylcholine, 689–690antidote, 694atropine, 694cholinesterase inhibition, 689diagnosis, 692–693intermediate syndrome, 692muscarinic receptor, 689, 691neurotoxicity, 690–691nicotinic receptor, 689, 692pralidoxime chloride, 694prognosis, 695SLUDGE, 691sources, 689toxicity, 690

Carbon Monoxide, 881–884carboxyhemoglobin, 881–884co-oximetry, 882deafness, 881–882hypoxia, 881neurotoxicity, 881–882, 884oxygen treatment, 883–884smoke inhalation, 881–882, 884

Cardiac Glycosides, 760–769; see also Appendix 4, Toxic Plants, 919–926

arrhythmias, 760, 765, 767–768AV block, 765bradycardia, 765, 767desert rose (Adenium obesum), 760, 761fdogbane (Apocynum spp.), 760common foxglove (Digitalis purpurea), 760, 761f, 762fdigoxin, digitoxin, 760Fab fragments, 767, 768fructose-1,6-diphosphate therapy, 768giant milkweed (Calatropis spp.), 760hyperkalemia, 766kalanchoe (Kalanchoe spp.), 760, 762f, 919tlily of the valley (Convallaria majalis), 760, 763f, 923tmilkweed (Asclepias spp.), 760oleander (Nerium oleander), 760, 763f, 764f, 765star of Bethlehem (Ornithogalum umbellatum), 760wooly foxglove (Digitalis lantana), 760yellow oleander (Thevetia peruviana), 760

Carprofen, 396–397. See Veterinary NSAIDs, 396–403Carvedilol, 163t. See Beta Receptor Antagonists

(Beta-Blockers), 162–171Castor bean (Ricinus communis). 920t. See Appendix 4,

Toxic Plants, 919–926Cathedral bells (Kalanchoe spp.), 919t. See Appendix 4,

Toxic Plants, 919–926Cathinone. See Club Drugs (MDMA, GHB,

Flunitrazepam, and Bath Salts), 245–252Celestrus spp. (bittersweet), 920t. See Appendix 4, Toxic

Plants, 919–926

Certifect. See Amitraz, 665–671Chinaberry tree (Melia azedarach), 920t. See Appendix 4,

Toxic Plants, 919–926Chinese evergreen (Aglaoenema commutatum), 787, 789f.

See Oxalates – Insoluble, 787–796Chlorates. See Matches and Fireworks,

624–629Chlorophacinone. See Anticoagulants, 835–843Chlorpyrifos. See Organophosphorous and Carbamate

Insecticides, 689–696Chocolate and Caffeine, 479–484

arrhythmia, 479–481, 483–484caffeine, 479–484caffeine content, 480tchocolate, 479–482, 484cocoa bean mulch, 479–481 food, 480hyperactivity/agitation, 479–481methylxanthine, 479–480, 483–484seizures, 479–481, 483–484supplements, dietary, 480tachycardia, 479–481, 483theobromine, 479–481, 483–484theobromine content, 480tvomiting, 479–482

Cholecalciferol, 850–8551,25-dihydroxycholecalciferol, 85025-monohydroxycholecalciferol, 850bisphosphonates, 853cardiotoxicity, 851diagnosis, 852GI protectants, 853hypercalcemia, 851, 853nephrotoxicity, 851pamidronate, 853prognosis, 854salmon calcitonin, 854sources, 850

Christmas rose (Helleborus niger), 920t. See Appendix 4, Toxic Plants, 919–926

Chromium, 915t. See Appendix 3, Metallic Toxicants, 913–918

Chrysanthemum genus. See Pyrethrins and Pyrethroids, 697–704

Cinnamon oil. See Essential Oils/Liquid Potpourri, 585–591

Citrus oil. See Essential Oils/Liquid Potpourri, 585–591

Cleaners. See Soaps, Detergents, Fabric Softeners, Enzymatic Cleaners, and Deodorizers, 655–668

Clothianidin. See Imidacloprid and Other Neonicotinoids, 677–682

neonicotinoid, 678–682toxicity, 680

Clotrimazole, 928t. See Appendix 5, Topical Toxins, 927–931

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Clove oil. See Essential Oils/Liquid Potpourri, 585–591Club Drugs (MDMA, GHB, Flunitrazepam, and Bath

Salts), 245–252bath salts, 245–251cathinones, 245date rape drug, 245flumazenil, 250flunitrazepam, 245–251GHB (gamma-hydroxybutyric acid), 245–251MDMA (methylenedioxymethamphetamine), 245–251mephedrone, 245methylone, 245Narcozep (flunitrazepam), 245Rohypnol (flunitrazepam), 245

Cocaine, 253–258adulterants, 253CNS stimulation, 255–256crack, 253, 254fErythroxylon coca, E. monogynum, 253free basing, 253police dogs, 255, 257–258

Cohosh (Actea spp.), 919t. See Appendix 4, Toxic Plants, 919–916

Colchicine, 187–191bone marrow suppression, 190Colchicum autumnale (autumn crocus), 187Gloriosa superba (glory lily), 187multiorgan dysfunction, 187–188pancytopenia, 190

Colchicum autumnale (autumn crocus), 187. See Colchicine, 187–191; see also Spring Bulbs, 812–820; see also 919t, Appendix 4, Toxic Plants, 919–926

Common ivy (Hedera helix), 921t. See Appendix 4, Toxic Plants, 919–926

Compound 1080. See Sodium Monofluoroacetate (Compound 1080), 856–861

Concerta. See Amphetamines, 126–131Convallaria majalis (lily of the valley). See Cardiac

glycosides, 760–769; see also 921t, Appendix 4, Toxic Plants, 919–926

Copper, 914. See Appendix 3, Metallic Toxicants, 913–918; see also Vitamins and Minerals, 313–324

Corticosteroids, 929t. See Appendix 5, Topical Toxins, 927–931

Crocus (Crocus spp.). See Spring Bulbs, 812–820Crotalids (Pit Vipers), 424–435

antivenoms, 432–434coagulopathic venom, 428–429copperhead, 425fcottonmouth, 424fneurotoxin, 426rattlesnake, 425f–428fwater moccasin, 424f

Currants. See Grapes and Raisins, 485–490Cyanobacteria. See Blue-green Algae, 751–759Cycas spp., 804f, 805f. See Sago Palm, 804–811

Cyclamen persicum (Persian violet, sowbread), 924t. See Appendix 4, Toxic Plants, 919–926

Cyclosporine A, 192–196calcineurin inhibitor, 192GI distress, 192–194

Cymbalta (duloxetine), 227. See SSRI and SNRI Antidepressants, 227–232

d-limonene. See Essential Oils/Liquid Potpourri, 585–591

Daffodil (Narcissus spp.), 812, 815f, 815. See Spring Bulbs, 812–820; see also 924t, Appendix 4, Toxic Plants, 919–926

Daphne mezereum (Daphne), 921t. See Appendix 4, Toxic Plants, 919–926

Datura stramonium (thorn apple, jimsonweed), 925t. See Appendix 4, Toxic Plants, 919–926; see also Miscellaneous Hallucinogens and Dissociative Agents, 278–285

Daylily (Hemerocallis spp.), 770, 773f. See Lilies, 770–776Death cap (A. phalloides), 778–779, 786. See Mushrooms,

778–786Decongestants (Imidazolines), 333–338

alpha-2 adrenergic antagonists, 303atipamezole, 336bradycardia , 300–303hypotension, 333–336lethargy, 333–334sympathomimetics, 333yohimbine, 336

Decongestants (Pseudoephedrine, Phenylephrine), 327–332

hyperactivity/agitation hypertension, 328–329

hyperthermia, 328–331increased vascular resistance, 328lethargy, 329mydriasis, 328–329seizures, 328–329sympathomimetic, 327–329vomiting, 329

Decontamination and Detoxification of the Poisoned Patient, 3-18

activated charcoal, 13–15cathartics, 15–16cholestyramine, 15decontamination, 3–6emesis, 6–7emetics, 7–10fluid therapy, 16–17gastric lavage, 7–13, 11fsurgical decontamination, 17whole bowel irrigation, 13

Delphinum spp. (delphinium/larkspur), 921t. See Appendix 4, Toxic Plants, 919–926

Deodorizer. See Soaps, Detergents, Fabric Softeners, Enzymatic Cleaners, and Deodorizers, 655–662.

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Deracoxib, 396–397. See Veterinary NSAIDs, 396–403

Deramaxx, 396. See Veterinary NSAIDs, 396–403Dessicated thyroid (T3/T4), 238–240. See Thyroid

Hormones (T3 and T4), 238–242Detergent. See Soaps, Detergents, Fabric Softeners,

Enzymatic Cleaners, and Deodorizers, 655–662

Detomidine. See Alpha2-Adrenergic Agonists, 369–373

Dexedrine. See Amphetamines, 126–131Dexmedetomidine. See Alpha

2-Adrenergic Agonists,

369–373Dextromethorphan. See Antitussives and Expectorants

(Dextromethorphan), 313–319Diazepam, 150t. See Benzodiazepines, 149–154Diazinon. See Organophosphorous and Carbamate

Insecticides, 689–696Dibucaine, 930t. See Appendix 5, Topical Toxins,

927–931Dibutyl phthalate. See Glow Jewelry, 731–735Dicamba. See Herbicides 565–570Dicentra spp. (bleeding heart), 920t. See Appendix 4,

Toxic Plants, 919–926Diethylene glycol. See Ethylene Glycol and Diethylene

Glycol, 78–84Difethialone. See Anticoagulants, 835–843Diltiazem, 179t, 180, 185. See Calcium Channel Blockers,

178–186Dinotefuran. See Imidacloprid and Other

Neonicotinoids, 677–682neonicotinoid, 678–682toxicity, 680

Diphacinone. See Anticoagulants, 835–843Diphenhydramine, 929t. See Appendix 5, Topical Toxins,

927–931Diquat and Paraquat, 552–559

comparative toxicity of paraquat 554tfree radical, 552hemodialysis, 557–558herbicide, 552, 559oxygen contraindicated, 558toxicity of paraquat, 554tpathophysiology of paraquat toxicity, 554fpulmonary fibrosis, 553–554, 556respiratory failure, 552–556, 558–559

Dissociative agents. See Miscellaneous Hallucinogens and Dissociative Drugs, 278–285

Diuretics, 197–203azotemia, 197dehydration, 199–203furosemide, 197, 198t, 199t, 200, 202hydrochlorthiazide, 197, 198t, 199tspironolactone (cats), 198t, 200

Doll’s eye (Actea spp.), 919t. See Appendix 4, Toxic Plants, 919–916

Doramectin. See Ivermectin/Milbemycin/Moxidectin, 374–384

Duloxetine (Cymbalta), 227. See SSRI and SNRI Antidepressants, 227–232

Dumbcane (Dieffenbacchia spp.), 787, 789f. See Oxalates –Insoluble, 787–796

E-juice (nicotine). See Nicotine and Tobacco, 347–353E-liquid (nicotine). See Nicotine and Tobacco,

347–353Easter lily (L. longiflorum), 770, 771f, 776. See Lilies,

770–776Econazole, 928t. See Appendix 5, Topical Toxins, 927–931Effexor (venlafaxine), 227. See SSRI and SNRI

Antidepressants, 227–232Elapids (Coral Snakes), 436–443

antivenoms, 441Eastern coral snake (Micrurus fulvius), 436fneurotoxin, 438–439red, yellow and black bands, 436–438Sonoran coral snake (Micruroides euryxanthus), 437fTexas coral snake (Micrurus tener), 437f

Emergency Management of the Poisoned Patient, 19-35acid–base, 27–28airway, 19analgesics, 33antihypertensives, 25arterial blood gas, 27–28blood pressure, 19, 23–25breathing, 20cardiovascular, 30central venous pressure, 19, 28–29circulation, 21CVP, 19, 28–29dysfunction, 21–22ECG, 23end-tidal CO

2 (ETCO

2), 27

fluid therapy, 29gastrointestinal, 31monitoring, 19neurological, 32pulse oximetry, 19, 26sedation, 33urine output, 19, 26venous blood gas, 27–28

English holly (Ilex spp.), 921t. See Appendix 4, Toxic Plants, 919–926

English ivy (Hedera helix), 921t. See Appendix 4, Toxic Plants, 919–926

Enzymatic cleaners. See Soaps, Detergents, Fabric Softeners, Enzymatic Cleaners, and Deodorizers, 655–662

Ephedra/Ma Huang, 579–584cardiac stimulation, 579, 581CNS excitation, 579, 581Ephedra sinica, 579ephedrine, 579FDA ban, 579pseudoephedrine, 579

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Ephedra sinica. See Ephedra/Ma Huang, 579–584Ephedrine. See Ephedra/Ma Huang, 579–584Eprinomectin. See Ivermectin/Milbemycin/Moxidectin,

374–384Esmolol, 164t. See Beta Receptor Antagonists

(Beta-Blockers), 162–171Essential Oils/Liquid Potpourri, 585–591

cationic detergents, 586citrus oil, 586–587corrosive injury, 587feline sensitivity, 586hepatic failure, 586–587pennyroyal oil, 585–591

Eszopiclone (Lunesta), 212–213. See Nonbenzodiazepine Sleep Aids, 212–216

Ethanol. See Alcohols (Ethanol, Methanol, Isopropanol), 71–77; see also Bread Dough, 469–473

diagnosis, 74neurotoxicity, 73prognosis, 76sources, 71toxicity, 72treatment, 75

Ethylene Glycol and Diethylene Glycol, 76–84acute renal failure, 79acidosis, 80, 82antidote, 81–83anion gap, 80calcium gluconate, 82calcium oxalate crystaluria, 81clinical phases, 79diagnosis, 80–81ethanol, 81–82fomepizole, 81–82hypocalcemia, 81–82prognosis, 84serum ethylene glycol, 81sources, 78toxicity, 79

Euphorbia pulcherrima (poinsettia), 925t. See Appendix 4, Toxic Plants, 919–926

Expectorants. See Antitussives/Expectorants (Dextromethorphan), 313–319

Fabric softener. See Soaps, Detergents, Fabric Softeners, Enzymatic Cleaners, and Deodorizers, 655–662

Fentanyl transdermal solution (dogs), 217, 220–221. See Opiates and Opioids, 217–216

Fertilizers, 560–564blood/bone meal, 562herbicides, 560–562, 564milorganite, 560–563pesticides, 561vomiting, 561–563

Fipronil. See Miscellaneous Insecticides, 683–688diagnosis, 686prognosis, 688rabbits, 683toxicity, 684

Fireworks. See Matches and Fireworks, 624–629Firocoxib, 396–397. See Veterinary NSAIDs, 396–403Flamingo flower (Anthurium spp.), 787, 788f.

See Oxalates – Insoluble, 787–796Flunitrazepam. See Club Drugs (MDMA, GHB,

Flunitrazepam, and Bath Salts), 245–252Fluoride, 736–741

calcium, 736–741fluoride sources, 736–737hypocalcemia, 736–738hyperkalemia, 736–738

Fluoxetine (Prozac), 227. See SSRI and SNRI Antidepressants, 227–232

Focalin. See Amphetamines, 126–131Folic acid. See Vitamins and Minerals, 313–324Foreign Objects, 537–543

cat litter, 538charcoal, 538crayons, 538endoscopy, 541–542esophageal foreign body, 537, 539–543firestarter log, 539foreign body obstruction, 537–543markers, 538pencils, 538pens, 538silica gel, 538small intestine foreign body, 537–542surgery 539, 541–543toxic foreign body examples, 537–538vomiting 537–540, 543

Foxglove (Digitalis purpurea), 760, 761f, 762f. See Cardiac Glycosides, 760–769

Francodex. See Amitraz, 665–671

Gamma-hydroxybutyric acid (GHB). See Club Drugs (MDMA, GHB, Flunitrazepam, and Bath Salts), 245–252

Garlic. See Onions and Garlic, 515–520Gases, toxic. See Carbon Monoxide 881–884; see also

Smoke Inhalation 885–895Gelsemium sempervirens (yellow jasmine), 926t.

See Appendix 4, Toxic Plants, 919–926Gloriosa superba (glory lily), 187. See Colchicine,

187–191; see also Spring Bulbs, 812–820Glow Jewelry (Dibutyl Phthalate), 731–735

dibutyl phthalate, 731–732, 734–735GI irritation, 732–733glow jewelry photos, 731f, 732fhypersalivation, 732–733ocular irritation, 732–735

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Glues and Adhesives, 95–100construction glue, 95cyanoacrylate glue, 95–97,100diisocyanate glue, 95–97, 100GI obstruction, 98glue traps, 95, 100Gorilla Glue, 98f, 100mechanism of action, 95polyvinyl acetate (PVA) glue, 95,100super glue, 95tissue adhesion, 96wood glue, 95

Glufosinate. See Herbicides 565–570Glycol ethers. See Ethylene Glycol and Diethylene

Glycol, 78–84; see also Propylene Glycol, 85–91Glyphosate. See Herbicides 565–570Gold, 915t. See Appendix 3, Metallic Toxicants, 913–918Golden angel’s trumpet (Brugmansia spp.), 921t.

See Appendix 4, Toxic Plants, 919–926Gorilla Glue, 100, 102f. See Glues and Adhesives,

95–100Grapes and Raisins, 485–490

acute renal failure, 485–490currants, 485dialysis, 488–489grape seed extract, 485hypercalcemia, 495–487renal/kidney, 485–490Vitis spp., 485–486, 489–490

Grayanotoxins, 745–747. See Azaleas and Rhododendrons, 745–750

Hallucinogens. See Miscellaneous Hallucinogens and Dissociative Agents, 278–285

Hedera helix (English ivy, common ivy, Irish ivy, Atlantic ivy), 921t. See Appendix 4, Toxic Plants, 919–926

Helleborus niger (Christmas rose), 920t. See Appendix 4, Toxic Plants, 919–926

Herbicides, 565–5702, 4-D, 565–566, 568–570dermal irritation, 565–567herbicide risk, 566tMCPA, 565–566, 569MCPP, 565–566, 569muscle pain, 565–567ocular irritation, 565–567pesticides, 565renal/kidney, 565, 567–568vomiting, 565–568

Hops, 491–496agitation, 491–494Bryonia dioica, 491dantrolene sodium, 494–495cyproheptadine, 495DIC, 492–493, 495hops plant, 492f

hypercalcemia, 492–493hyperkalemia, 492–493hyperthermia, 491–493, 495Humulus lupulus, 491–492malignant hyperthermia, 491–494, 496

Hornets. See Wasps, Hornets, and Bees, 457–465Horse chestnut (Aesculus spp.), 922t. See Appendix 4,

Toxic Plants, 919–926Human NSAIDS, 339–346

acute renal failure, 340–342Advil (ibuprofen), 339Aleve (naproxen), 339Anaprox (naproxen), 339CNS signs, 340–341, 343feline sensitivity, 340, 341gastrointestinal ulceration, 340–342ibuprofen, 339–340, 342, 344Menstridol (naproxen), 339Midol (ibuprofen or naproxen), 339Napralen (naproxen), 339Naprosyn (naproxen), 339Nuprin (ibuprofen), 339naproxen sodium, 339–340, 344

Humulus lupulus. See Hops, 491–496Hurricane plant (Monstera deliciosa). See Oxalates –

Insoluble, 787–796; see also 923t, Appendix 4, Toxic Plants, 919–926.

Hyacinth (Hyacinthus spp.), 812, 814f, 815. See Spring Bulbs, 812–820

Hydrocarbons, 101–107arrhythmias, 101–106aspiration, 101–106CNS depression, 102pulmonary edema, 102viscosity, 101

Hydrocortisone, 929t. See Appendix 5, Topical Toxins, 927–931

Hydrofluoric Acid, 108–115calcium gluconate, 111cardiotoxicity, 109corrosive, 109electrolyte abnormalities, 109

Hymenoptera. See Wasps, Hornets, and Bees, 457–465

Ibuprofen. See Human NSAIDs, 339–346Ilex spp. (English holly), 921t. See Appendix 4, Toxic

Plants, 919–926Imidacloprid. See Imidacloprid and Other

Neonicotinoids, 677–682diagnosis, 681neonicotinoids, 678neurotoxicity, 678, 680nicotinic receptors, 678prognosis, 681sources, 678toxicity, 679

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Imidazolines. See Decongestants (Imidazolines), 333–338

Incilius alvarius; formerly Bufo alvarius (Colorado river toad), 418–419, 422. See Bufo spp. Toads, 418–423

Iodine. See Vitamins and Minerals, 313–324Ipomoea spp. (morning glory), 924t. See Appendix 4,

Toxic Plants, 919–926; see also Miscellaneous Hallucinogens and Dissociative Agents, 278–285

Iris spp. (iris), 922t. See Appendix 4, Toxic Plants, 919–926

Irish ivy (Hedera helix), 921t. See Appendix 4, Toxic Plants, 919–926

Irish potato (Solanum tuberosum), 922t. See Appendix 4, Toxic Plants, 919–926

Iron, 707–715. See also Vitamins and Minerals, 313–324chelation, 712clinical stages, 710deferoxamine mesylate, 712diagnosis, 711iron salts, 708oxidative damage, 708prognosis, 714sources, 707systems affected, 709–710total iron binding capacity, 708, 711toxicity, 709

Isopropanol. See Alcohols (Ethanol, Methanol, Isopropanol), 71–77

diagnosis, 74neurotoxicity, 73prognosis, 76toxicity, 73treatment, 75

Ivermectin/Milbemycin/Moxidectin, 374–384ABCB1-1Δ or MDR1 mutation, 375ataxia, 375–378blindness, 375–381intravenous lipid therapy (ILE), 380–381ketoconazole (drug interaction), 378mydriasis, 375–378p-glycoprotein, 375–379seizures, 375–382spinosad (drug interaction), 378tremors, 376–381

Japanese yew (T. cuspidata). 827, 827f, 828f. See Yew, 827–832

Jerusalem cherry (Solanum pseudocapsicum), 922t. See Appendix 4, Toxic Plants, 919–926

Jimsonweed (Datura stramonium), 925t. See Appendix 4, Toxic Plants, 919–926; see also Miscellaneous Hallucinogens and Dissociative Agents, 278–285

Jonquil (Narcissus spp.). See Spring Bulbs, 812–820; see also 924t, Appendix 4, Toxic Plants, 919–926

Kalanchoe spp. See Cardiac Glycosides, 760–769; see also 919t, Appendix 4, Toxic Plants, 919–926

Kalmia spp. (mountain laurel), 924t. See Appendix 4, Toxic Plants, 919–926

Ketoconazole, 928t. See Appendix 5, Topical Toxins, 927–931

Ketofen, 396–397. See Veterinary NSAIDs, 396–403Ketoprofen, 396. See Veterinary NSAIDs, 396–403

Lantana camara (lantana), 923t. See Appendix 4, Toxic Plants, 919–926

Larkspur (Delphinium spp.), 921t. See Appendix 4, Toxic Plants, 919–926

Latrodectus spp. (black widow spider), 407fLead, 716–722

blood levels, 719calcium disodium EDTA, 720elimination, 717GI signs, 718mechanism of toxic effect, 716nervous signs, 716public health, 721red blood cell, 717–718sources, 716succimer, 720toxicity, 717

Levothyroxine (T4), 238–240. See Thyroid Hormones (T3 and T4)

Lidocaine, 930t. See Appendix 5, Topical Toxins, 927–931Lilies, 770–776

acute kidney injury, 770–771, 775aqueous floral extract, 770Asiatic lily (L. asiatic), 770, 771fcats, 770, 774–775daylily (Hemerocallis spp.), 770, 773fEaster lily (L. longiflorum), 770, 771f, 776Hemerocallis spp., 770Japanese show lily (L. speciosum), 770, 772fLilium spp., 770nephrotoxic, 771, 774–775Oriental lily (L. orientalis), 770red lily (L. umbellatum), 770renal tubular necrosis, 770stargazer lily (Lilium spp.)tiger lily (L. tigrinum), 770,wood lily (L. philadelphicum), 770

Lily of the valley (Convallaria majalis), 760, 763f. See Cardiac Glycosides, 760–769; see also 921t, Appendix 4, Toxic Plants, 919–926

Liothyronine (T3), 238–240. See Thyroid Hormones (T3 and T4), 238–242

Liquid potpourri. See Essential Oils/Liquid Potpourri, 585–591

Lithium, 916t. See Appendix 3, Metallic Toxicants, 913–918

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Local anesthetics, 930t. See Appendix 5, Topical Toxins, 927–931

Loxicom, 396. See Veterinary NSAIDs, 396–403Loxosceles reclusa (brown recluse spider), 413fLunesta (eszopiclone), 212, 213. See Nonbenzodiazepine

Sleep Aids, 212–216Lupinus spp. (lupin, bluebonnet), 923t. See Appendix 4,

Toxic Plants, 919–926LSD (Lysergic Acid Diethylamide), 259–263

Hawaiian baby rose wood (Agyreia nervosa), 259morning glory (Ipomea violacia, I. carnea), 259police dogs, 260, 263sensory perceptions altered, 259–261sleepygrass (Stipa robusta), 259

Ma Huang. See Ephedra/Ma Huang, 579–584Macadamia integrifolia. See Macadamia Nuts, 497–501Macadamia Nuts, 497–501

ataxia, 497–498chocolate/methylxanthine, 499hyperthermia, 497–499muscle tremors, 497–498weakness 497–498

Macadamia tetraphyalla. See Macadamia Nuts, 497–501Macrozamia spp. See Sago Palms (Cycads), 804–811Magnesium. See Vitamins and Minerals, 313–324Marijuana, 264–270

Cannabis sativa, 264, 265fgreen butter, 265hash extract, 265fpsychoactive effects, 264, 266–267tetrahydrocannibinol, 264THC, 264

Matches and Fireworks, 624–629barium intoxication, 624chlorate intoxication, 624hemorrhagic gastroenteritis, 626methemoglobinemia, 624possible ingredients, 625t

MCPA. See Herbicides, 565–570MCPP. See Herbicides, 565–570MDMA. See Club Drugs (MDMA, GHB, Flunitrazepam,

and Bath Salts), 245–252Melaleuca oil. See Tea Tree Oil/Melaleuca Oil, 592–597Melia azedarach (chinaberry tree), 920t. See Appendix 4,

Toxic Plants, 919–926Meloxicam, 396–398. See Veterinary NSAIDs, 396–403Mercury, 916. See Appendix 3, Metallic Toxicants,

913–918Metacam, 396. See Veterinary NSAIDs, 396–403Metaldehyde, 672–677

acidosis, 672, 674, 676anticonvulsants, 676complications, 677diagnosis, 674–675

hyperthermia, 672, 674, 676multiple organ failure, 674neurotoxicity, 672seizures, 672, 674, 676sources, 672toxicity, 673tremors, 674, 676

Metallic toxicants. See Appendix 3, Metallic Toxicants, 913–918

Methamphetamine, 271–277crystal meth, 271, 272fephedrine, 271human urine drug kit, 274hyperactivity, 272, 275

Methanol. See Alcohols, 71–77diagnosis, 74neurotoxicity, 73prognosis, 76sources, 71toxicity, 72treatment, 75

Methionine, 571–575aciduria, 572–573dietary supplement, 571–572, 574–575hepatic insufficiency/encephalopathy, 571–574methemoglobinemia, 571–573neurologic, 572–573urine acidifier, 571vomiting, 571–575

Metoprolol, 164t. See Beta Receptor Antagonists (Beta-Blockers), 162–171

Mexican breadfruit (Monstera deliciosa). See Oxalates – Insoluble, 787–796; see also 923t, Appendix 4, Toxic Plants, 919–926

Miconazole, 928t. See Appendix 5, Topical Toxins, 927–931

Midazolam 150t. See Benzodiazpeines, 149–154Milbemycin. See Ivermectin/Milbemycin/Moxidectin,

374–384Milorganite. See Fertilizers, 560–564Minerals. See Vitamins and Minerals, 354–365Minoxidil, 204–211

arteriolar dilator, 204cats, 206hypotension, 204–205, 207, 209tachycardia, 205–209

Miscellaneous Hallucinogens and Dissociative Agents, 278–285

dextromethorphan, 279dissociative agents, 278–279hallucinogens, 278–279jimsonweed (Datura stramonium), 278ketamine, 278, 280–282lysergic acid amide (LSAs), 278, 280–282morning glory (Ipomoea spp.), 278, 279f

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Miscellaneous Hallucinogens and Dissociative Agents (continued)

nutmeg (Myristica fragrans), 278peyote (Lophophora williamsi), 279, 280fpsilocybin, 279salvia (Salvia divinorum), 278, 280–282

Miscellaneous Insecticides, 683–688alfoxalaner, 683–688dermal irritation, 684–687fipronil, 685–687GABA mediated, 683gastroenteritis, 684–687high dose ivermectin, 685rabbits, 685–687spinosad, 683–685

Mistletoe (Phoradendron spp.), 923t. See Appendix 4, Toxic Plants, 919–926

Mitaban. See Amitraz, 665–671Mitac. See Amitraz, 665–671Mitacur. See Amitraz, 665–671Molluscacides. See Metaldehyde, 672–677Monkshood (Aconitum spp.), 924t. See Appendix 4, Toxic

Plants, 919–926Monstera deliciosa (Mexican breadfruit, Swiss cheese plant,

hurricane plant). See Oxalates – Insoluble, 787–796; see also 923t, Appendix 4, Toxic Plants, 919–926

Morning glory (Ipomoea spp.), 924t. See Appendix 4, Toxic Plants, 919–926; see also Miscellaneous Hallucinogens and Dissociative Agents, 278–285

Mothballs, 630–636camphor, 630CNS effects, 631Heinz bodies, 631hemolysis, 631hepatotoxicity, 630–633methemoglobinemia, 631naphthalene , 630paradichlorobenzene, 630

Mountain laurel (Kalmia spp.), 924t. See Appendix 4, Toxic Plants, 919–926

Moxidectin. See Ivermectin/Milbemycin/Moxidectin, 374–384

Mushrooms, 778–786amanitins, 778, 780–783, 785biliary drainage, 785death cap (A. phalloides), 778–779, 786false morel (Gyromita spp.), 779gastroenteritis, 781–782hepatotoxic cyclopeptides, 778liver, 778, 781–783muscarine, 778silibinin, 784

Mycotoxins – Aflatoxin, 502–507Aspergillus spp., 502food, 502, 504–505icterus, 503–504

liver/hepatic, 502–507mold, 502–502N-acetylcysteine, 506Penicillium spp., 502pet food, 502–503, 506SAMe, 505–506

Mycotoxins – Tremorgenic, 508–514compost, 509–510, 512–513food, 508–510, 513methocarbamol, 512–513mold, 508–510, 513–514Penicillium spp., 508, 514Penitrem A, 508–511, 514Roquefortine, 508, 511, 514tachycardia, 509–510, 512tremors, 508–512vomiting, 509–511, 513

Naphthalene mothballs. See Mothballs, 630–636Naproxen. See Human NSAIDS, 339–346Narcissus spp. (daffodil, jonquil, narcissus, paperwhite).

See Spring Bulbs, 812–820; see also 924t, Appendix 4, Toxic Plants, 919–926

Neomycin, 928. See Appendix 5, Topical Toxins, 927–931Neonicotinoids. See Imidacloprid and Other

Neonicotinoids, 677–682Nettle (Urtica spp.), 924t, See Appendix 4, Toxic Plants,

919–926Nicotine and Tobacco, 347–353

CNS stimulation/depression, 347–349nicotine content of selected products, 348paralysis of skeletal respiratory muscles, 349–350tachycardia, 349–350tremors, 349vomiting, 348–350

Nitenpyram. See Imidacloprid and Other Neonicotinoids, 677–682

diagnosis, 681neonicotinoids, 678neurotoxicity, 678, 680nicotinic receptors, 678prognosis, 681sources, 678toxicity, 679

Nonbenzodiazepine Sleep Aids, 212–216CNS depression, 212–213, 215eszopiclone (Lunesta), 212–213flumazenil, 215GABA, 212zaleplon (Sonata), 212–213zolpidem (Ambien), 212–213

Norocarp, 396. See Veterinary NSAIDs, 396–403Novocox, 396. See Veterinary NSAIDs, 396–403NSAIDs, Human. See Human NSAIDS, 339–346NSAIDs, Veterinary. See Veterinary NSAIDs,

396–403

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Octopus plant (Aloe spp.), 919t. See Appendix 4, Toxic Plants, 919–926

Ohio buckeye (Aesculus spp.), 922t. See Appendix 4, Toxic Plants, 919–926

Oil of wintergreen. See Essential Oils/Liquid Potpourri, 585–591; see also Aspirin, 313–319

Oleander (Nerium oleander), 760, 763–765. See Cardiac Glycosides, 760–769

Onions and Garlic, 515–520Allium spp., 515–517, 519–520blood transfusion, 518chives, 515, 519dietary supplement, 515, 517garlic, 515–517, 519–520hemolytic anemia, 515, 517–518, 520icteric, 517–518leeks, 515methemoglobin, 515–516, 518onions, 515–517, 519–520pigmenturia/hemoglobinuria, 516–519

Onsior, 396. See Veterinary NSAIDs, 396–403Opiates and Opioids, 217–226

analgesics, 217buprenorphine injection (cats), 217, 220–221CNS depression, 220, 222CNS excitement, 220, 222fentanyl, transdermal (dogs), 217, 220–221human urine test kit, 223loperamide (ABCB1-1Δ), 221naloxone, 223receptors – delta, 217, 218t, 219receptors – episilon, 217receptors – kappa, 217, 218t, 219t, 219receptors – mu, 217, 218t, 219t, 219receptors – sigma, 217, 219

Opiates and Opioids (Illicit), 286–294black tar heroin, 286, 287fheroin, 286, 289, 293human urine test kit, 291naloxone, 292opium, 286poppy plant (Papaver somniferum), 286, 287f

OraCAM, 396. See Veterinary NSAIDs, 396–403Organophosphorous and Carbamate Insecticides,

689–6962-PAM, 694acetylcholine, 689–690antidote, 694atropine, 694cholinesterase inhibition, 689diagnosis, 692–693intermediate syndrome, 692muscarinic receptor agonism, 689, 691neurotoxicity, 690–691nicotinic receptor agonism, 689, 692pralidoxime chloride, 694

prognosis, 695SLUDGE, 691sources, 689toxicity, 690

Ovasyn. See Amitraz, 665–671Oxalates – Insoluble, 787–796

arrowhead (Syngonium spp.), 787, 788fcalcium oxalate crystals, 787–788calla lily (Zantedeschia spp.), 787, 789fChinese evergreen (Aglaoenema commutatum),

787, 789fdumbcane (Dieffenbacchia spp.), 787, 789fflamingo flower (Anthurium spp.), 787, 788fhypersalivation, 793–794idioblasts, 787–788Mexican breadfruit (Monstera deliciosa) oral pain,

793–794peace lily (Spathiphyllum spp.), 787, 787fphilodendron (Philodendron spp.), 787, 791f, 793pothos (Epipremnum spp.), 787, 792fumbrella plant (Schefflera actinophylla), 787, 792fupright elephant’s ear (Xanthosoma spp.), 787, 793f

Oxalates – Soluble, 797–803acute renal failure, 800–801calcium oxalate crystals, 797hypocalcemia, 801–803Oxalis spp., 798, 800–801Rhubarb (Rheum rhabarbarum), 797f, 798, 800shamrock plant (Oxalis spp.), 797f, 798, 798fstar fruit (Averrhoa carambola), 798, 799f, 800f

Paintballs, 637–645blindness, 639fluid replacement, 642glycerin, 637glycerol, 637hyperchloremia, 639hypernatremia, 639hyperosmolality, 639hypovolemia, 639idiogenic osmoles, 642intracranial pressure, 644metabolic acidosis, 639polydipsia, 639polyethylene glycol, 637sorbitol, 637tremors, 637vomiting, 639

Pantothenic acid. See Vitamins and Minerals, 313–324

Paperwhite (Narcissus spp.). See Spring Bulbs, 812–820; see also 924t, Appendix 4, Toxic Plants, 919–926

Paradichlorobenzene (PDB) mothballs. See Mothballs, 630–636

Paraquat. See Diquat and Paraquat, 552–559

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Paroxetine (Paxil), 227. See SSRI and SNRI Antidepressants, 227–232

Paxil (paroxetine), 227. See SSRI and SNRI Antidepressants, 227–232

PCP (Phencyclidine), 295–2991-[phenylcyclohexyl] piperidine, 295angel dust, 299ketamine, 295police dogs, 296, 298sernylan, 295

Peace lily (Spathiphyllum spp.), 787, 787f. See Oxalates – Insoluble, 787–796

Penicillium spp. See Mycotoxins – Aflatoxin, 502–507; see also Mycotoxins – Tremorgenic, 508–514

Penitrem A. See Mycotoxins – Tremorgenic, 508–514

Pennyroyal oil. See Essential Oils/Liquid Potpourri, 585–591

Peppermint oil. See Essential Oils/Liquid Potpourri, 585–591

Permethrin. See Pyrethrins/Pyrethroids, 697–704Persian violet (Cyclamen persicum), 924t. See Appendix 4,

Toxic Plants, 919–926Pheasant’s eye (Adonis spp.), 921t. See Appendix 4, Toxic

Plants, 919–926Phenols/Pine Oil, 646–654

corrosive injury, 646dermal absorption, 647dermal ulceration, 648feline sensitivity, 646gastrointestinal effects, 648hepatotoxicity, 648Pine Sol, 646polyethylene glycol for dermal decontamination, 650

Phenoxy herbicide. See Herbicides, 565–570Phenylephrine. See Decongestants (Pseudoephedrine,

Phenylephrine), 327–332Phenylpropanolamine, 385–390

alpha-adrenergic agonist, 385beta-1 agonist, 385bradycardia, 385–387CNS stimulation, 386seizures, 387tachycardia/tachyarrhythmia, 385–387

Philodendron spp. (philodendron), 787, 791f, 793. See Oxalates – Insoluble, 787–796; see also 925t, Appendix 4, Toxic Plants, 919–926

Phoradendron spp. (mistletoe), 923t. See Appendix 4, Toxic Plants, 919–926

Phosphides, 862–870antacids, 866anticonvulsants, 867diagnosis, 865gastroprotectants, 867hepatic support, 867human exposure, 866neurotoxicity, 863

phosphine gas, 862, 866pneumotoxicity, 863prognosis, 869sources, 862toxicity, 863

Phosphine gas. See Phosphides, 862–870Phosphorus. See Vitamins and Minerals, 313–324Pimobendan, 391–403

arrhythmia, 393congestive heart failure, therapy, 391hypotension, 391–393inodilator, 391phosphodiesterase (PDE) III inhibition, 391tachycardia, 393vomiting, 393

Pine oil. See Phenols/Pine Oils, 646–654Plant toxicants. See Appendix 4, Toxic Plants, 919–926Poinsettia (Euphorbia pulcherrima), 925t. See Appendix 4,

Toxic Plants, 919–926Polymyxin B, 928t. See Appendix 5, Topical Toxins,

927–931Pothos (Epipremnum spp.), 787, 792f. See Oxalates –

Insoluble, 787–796PPA. See Phenylpropanolamine, 385–390Precatory bean (Abrus precatorius), 925t. See Appendix 4,

Toxic Plants, 919–926Preventic. See Amitraz, 665–671Previcox, 396. See Veterinary NSAIDs, 396–403Prilocaine, 930t. See Appendix 5, Topical Toxins,

927–931Proin. See Phenylpropanolamine, 385–390Propranolol, 164t. See Beta Receptor Antagonists

(Beta-Blockers), 162–171Propylene Glycol, 85–91

antioxidants, 89cats, 86, 87, 88diagnosis, 88hemodialysis, 89neurotoxicity, 86prognosis, 90sources, 85–86toxicity, 86

Prozac (fluoxetine), 227. See SSRI and SNRI Antidepressants, 227–232

Pseudoephedrine. See Decongestants (Pseudoephedrine, Phenylephrine), 327–332; see also Ephedra/Ma Huang, 579–584

Pyrethrins and Pyrethroids, 697–704cats, 698, 699, 701diagnosis, 700–701intravenous lipid emulsion (ILE), 703methocarbamol, 702neurotoxicity, 698paresthesia, 700, 702prognosis, 704sources, 697thermoregulation, 702

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tremors, 702toxicity, 698Type 1 classification, 697, 698, 699Type 2 classification, 697, 698, 699Type 1 toxicosis, 699Type 2 toxicosis, 699

Pyrethroid. See Pyrethrins and Pyrethroids, 697–704

Quellin, 396. See Veterinary NSAIDs, 396–403

Raisins. See Grapes and Raisins, 485–490Recuvyra (fentanyl transdermal solution for dogs), 217,

220–221. See Opiates and Opioids, 217–216Reference Information. See Appendix 2, Information

Resources for Toxicology, 905–912Rhubarb (Rheum rhabarbarum), 797f, 798, 800.

See Oxalates – Soluble, 797–803Ricinus communis (castor bean), 920t. See Appendix 4,

Toxic Plants, 919–926Rimadyl, 396. See Veterinary NSAIDs, 396–403Ritalin. See Amphetamines, 126–131Robenicoxib, 396, 398. See Veterinary NSAIDs,

396–403Romifidine. See Alpha

2-Adrenergic Agonists, 369–373

Roquefortine. See Mycotoxins – Tremorgenic, 508–514

Rosary pea (Abrus precatorius), 925t. See Appendix 4, Toxic Plants, 919–926

Sago Palm (Cycads), 804–811Cycads, 804Cycas spp., 804f, 805fCycas revulota, 805cycasin, 806dog, 805–806gastroenteritis, 806hepatic necrosis, 805–806icterus, 807–808Macrozamia spp., 804–805Zamia spp., 804–805

Salt, 521–528ataxia, 523–524D5W, 522, 526de-icer, 521, 523free water, 522, 524–526free water deficit replacement, 525–526homemade play dough, 521, 521f, 523, 525, 527–528hypernatremia, 522–528hypertonic saline, 521, 523, 525, 528PU/PD, 523salt emetics, 523, 527sodium, 521–528sodium bicarbonate (baking soda), 521, 523tremors, 522–524, 526–527vomiting ,522–524, 526–527

Scorpions, 444–449antivenom, 448

Arizona bark scorpion (Centruroides exilicauda), 444f, 445f

neurotoxins, 445Selamectin. See Ivermectin/Milbemycin/Moxidectin,

374–384Selective serotonin reuptake inhibitors. See SSRI and

SNRI Antidepressants, 277–282Selenium, 917t. See Appendix 3, Metallic Toxicants,

913–918Serotonin and norepinephrine reuptake inhibitors.

See SSRI and SNRI Antidepressants, 277–282Sertraline (Zoloft), 227. See SSRI and SNRI

Antidepressants, 277–282Simbadol (buprenorphine injection for cats), 217,

220–222. See Opiates and Opioids, 217–226.Slug bait. See Metaldehyde, 672–677Smoke Inhalation, 885–895

carbon dioxide (CO2), 886

carbon monoxide, 885–887, 890, 892cyanide, 885–887, 890, 892–893hypoxia, 886–887hyperemic/brick red mucous membranes, 887–888hypersalivation, 888–889, 889fmethemoglobinemia, 887, 893–894neurologic signs, 885, 889, 893–895oxygen therapy, 885, 892, 894pulmonary injury/respiratory distress, 885–889, 891f,

892thermal injury/burns 885–887, 889–890, 890f, 892–

893, 895Snail bait. See Metaldehyde, 672–677Snakes, copperhead. See Crotalids (Pit Vipers), 424–435Snakes, coral. See Elapids (Coral Snakes), 436–443Snakes, cottonmouth. See Crotalids (Pit Vipers), 424–435Snakes, rattlesnake. See Crotalids (Pit Vipers), 424–435Snakes, water moccasin. See Crotalids (Pit Vipers),

424–435Soaps, Detergents, Fabric Softeners, Enzymatic

Cleaners, and Deodorizers, 655–662anionic surfactant, 656cationic surfactant, 656corrosive, effects, 656–658esophageal effects, 656hypocalcemia, 655muscle weakness and paralysis, 655quaternary ammonium compounds, 657surfactant, 656

Sodium fluoride. See Fluoride, 736–741Sodium hydroxide. See Alkalis, 609–616Sodium Monofluoroacetate (Compound 1080), 856–861

diagnosis, 858fluorocitrate, 856neurotoxicity, 858prognosis, 860sources, 856toxicity, 857tricarboxylic acid cycle, 856

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Solanum pseudocapsicum (Jerusalem cherry), 922t. See Appendix 4, Toxic Plants, 919–926

Solanum tuberosum (Irish potato), 922t. See Appendix 4, Toxic Plants, 919–926

Sonata (zaleplon), 212–213. See Nonbenzodiazepine Sleep Aids, 212–216

Sotalol, 164t. See Beta Receptor Antagonists (Beta–Blockers), 162–171

Sowbread (Cyclamen persicum), 924t. See Appendix 4, Toxic Plants, 919–926

Spinosad. See Miscellaneous Insecticides, 683–688diagnosis, 686prognosis, 688toxicity, 684

Spring Bulbs, 812–820amaryllis (Hippeastrum spp.), 812, 814f, 815arrhythmias, 815–817calcium oxalate crystals, 815, 817contact dermatitis, 815–816daffodil, jonquil, narcissus, paperwhite (Narcissus

spp.), 812, 815f, 815gastroenteritis, 815–817hyacinth (Hyacinthus spp.), 812, 814f, 815spring crocus (Crocus spp.), 812, 813f, 815tulip (Tulipa spp.), 812, 815f, 815

SSRI and SNRI Antidepressants, 277–282citalopram (Celexa), 227duloxetine (Cymbalta), 227escitalopram (Lexapro), 227fluoxetine (Prozac), 227fluvoaxamine (Luvox), 227hypotension, 228norepinephrine inhibitor, 227paroxetine (Paxil), 227serotonin inhibitor, 227serotonin syndrome, 227, 230sertraline (Zoloft), 227venlafaxine (Effexor), 227vilazodone (Viibryd), 227vortioxetine (Brintellix), 227

Strattera. See Amphetamines, 126–131Strychnine, 871–977

decontamination, 874diagnosis, 874glycine antagonism, 871ion-trapping, 875neurotoxicity, 871–872, 873prognosis, 876seizure control, 875sources, 871tremor control, 875

Strychnos nux-vomica. See Strychnine, 871–977

Sugarless gum. See Xylitol, 529–534Surfactants. See Soaps, Detergents, Fabric Softeners,

Enzymatic Cleaners, and Deodorizers, 655–662

Swiss cheese plant (Monstera deliciosa). See Oxalates – Insoluble, 787– 796; see also 923t, Appendix 4, Toxic Plants, 919–926

Synthetic Cannabinoids, 300–304CB1 and CB2 agonists, 300–301K2, 300, 303spice, 300, 303

Synthetic cathinones. See Club Drugs (MDMA, GHB, Flunitrazepam, and Bath Salts), 245–252

Tacrolimus, 233–237calcineurin, 233immunosuppressant, 233intussusception (dogs), 233–236Streptomyces tsukubaensis, 233

Taktic. See Amitraz, 665–671Taxines, 828–829. See Yew, 827–832Tea Tree/Melaleuca Oil, 592–597

CNS depression, 593hepatotoxicity, 593“natural remedy”, 594transdermal absorption, 592

Tepoxalin, 396–397. See Veterinary NSAIDs, 396–403Terbinafine, 928t. See Appendix 5, Topical Toxins,

927–931Theobromine. See Chocolate and Caffeine, 479–484Thiacloprid. See Imidacloprid and Other Neonicotinoids,

677–682neonicotinoid, 678–682toxicity, 680

Thiamethoxam. See Imidacloprid and Other Neonicotinoids, 677–682

neonicotinoid, 678–682toxicity, 680

Thyroid Hormones (T3 and T4), 238–242deiodination, 238desiccated thyroid (T3/T4), 238–239liothyronine (T3), 238–240levothyroxine (T4), 238–240

Tin, 917t. See Appendix 3, Metallic Toxicants, 913–918Thorn apple (Datura stramonium), 925t. See Appendix

4, Toxic Plants, 919–926; see also Miscellaneous Hallucinogens and Dissociative Agents, 278–285

Tioconazole, 928t. See Appendix 5, Topical Toxins, 927–931

Toads, Bufo spp. See Bufo Toads, 418–423Tobacco. See Nicotine and Tobacco, 347–353; see also

926t, Tobacco; see also Appendix 4, Toxic Plants, 919–926

Tolnaftate, 928t. See Appendix 5, Topical Toxins, 927–931

Toothpaste. See Fluoride, 736–741Topical toxins. See Appendix 5, Topical Toxins, 927–931

analgesics, 928antibiotics, 928antifungals, 928

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Index by Toxicant 949 8 February 2016 2:56 PM

antihistamines, 929antiseptics, 929bacitracin, 928benzocaine, 930benzoyl peroxide, 929butoconazole, 928camphor, 928clotrimazole, 928corticosteroids, 929dibucaine, 930diphenhydramine, 929econazole, 928hydrocortisone, 929ketoconazole, 928lidocaine, 930local anesthetics, 930miconazole, 928neomycin, 928polymyxin b, 928prilocaine, 930terbinafine, 928tioconazole, 928tolnaftate, 928

Toxic gases. See Carbon Monoxide, 881–884; see also Smoke Inhalation, 885–895

Toxicants, metallic. See Appendix 3, Metallic Toxicants, 913–918

Toxicants, plant. See Appendix 4, Toxic Plants, 919–926Toxicants, topical. See Appendix 5, Topical Toxins,

927–931Toxicology Information. See Appendix 2, Information

Resources for Toxicology, 905–912Tremorgens. See Mycotoxins – Tremorgenic, 508–514Triatix. See Amitraz, 665–671Triatox. See Amitraz, 665–671Tulip (Tulipa spp.), 812, 815f, 815. See Spring Bulbs, 812–

820; see also 925t, Appendix 4, Toxic Plants, 919–926

Umbrella plant (Schefflera actinophylla), 787, 792f. See Oxalates – Insoluble, 787–796

Upright elephant’s ear (Xanthosoma spp.), 787, 793f. See Oxalates – Insoluble, 787–796

Urtica spp. (nettle), 924t. See Appendix 4, Toxic Plants, 919–926

Venlafaxine (Effexor), 227. See SSRI and SNRI Antidepressants, 227–232

Venomous Lizards (Heloderma), 450–456Gila monster (Heloderma suspectum), 450fgilatoxins, 452Mexican beaded lizard (Heloderma horridum), 451f

Verapamil, 179t, 180. See Calcium Channel Blockers, 178–186

Veterinary NSAIDs, 396–403acute renal failure, 398–400carprofen, 396–397CNS signs, 396, 398–399

deracoxib, 396–397Deramaxx (deracoxib), 396feline sensitivity, 398firocoxib, 396–397GI effects, 398–400hepatotoxicity, 396, 400ketoprofen, 396Ketofen (ketoprofen), 396meloxicam, 396–398Metacam (meloxicam), 396–397Norocarp (carprofen), 396Novocox (carprofen), 396Previcox (firocoxib), 396Quellin (carprofen), 396Onsior (robenacoxib), 396Rimadyl (carprofen), 396robenacoxib, 396, 398tepoxalin, 396 –397Zubrin (tepoxalin), 396

Vitamins and Minerals, 354–365anemia (vitamin A intoxication), 357, 360coagulopathy (vitamin A and E intoxication), 359hepatotoxicity (vitamin A and copper intoxication),

360hypercalcemia (calcium and vitamin D intoxication),

358, 360, 363–364prenatal, 355–356rough hair coat (chronic iodine intoxication), 359secondary hyperparathyroidism (phosphorus

intoxication), 359uroliths (vitamin C intoxication), 358, 361

Vitamin A. See Vitamins and Minerals, 313–324Vitamin B

1 (thiamine). See Vitamins and Minerals,

313–324Vitamin B

2 (riboflavin). See Vitamins and Minerals,

313–324Vitamin B

3 (niacin). See Vitamins and Minerals,

313–324Vitamin B

6 (pyridoxine). See Vitamins and Minerals,

313–324Vitamin B

12 (cobalamin). See Vitamins and Minerals,

313–324Vitamin C (ascorbic acid). See Vitamins and Minerals,

313–324Vitamin D

3 (cholecalciferol). See Vitamins and Minerals,

313–324; see also Calcium Supplements, 474–478Vitamin E. See Vitamins and Minerals, 313–324Vitus genus. See Grapes and Raisins, 485–490Vyvanase. See Amphetamines, 126–131

Warfarin. See Anticoagulants, 835–843Wasps, Hornets, and Bees, 457–465

African Killer Bees, 457,461fanaphylaxis, 461

Apoidea (bees), 458f, 460fHymenoptera venom, 458–459Vespidae (wasps, hornets, yellow jackets), 457f

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Websites, toxicology. See Appendix 2, Information Resources for Toxicology, 905–912

Wintergreen oil. See Essential Oils/Liquid Potpourri, 585–591; see also Aspirin, 313–319

Wisteria spp. (wisteria), 926t. See Appendix 4, Toxic Plants, 919–926

Wormwood oil. See Essential Oils/Liquid Potpourri, 585–591

Xylazine. See Alpha2-Adrenergic Agonists, 369–373;

see also Antidotes, 36–48Xylitol, 529–534

dextrose, 532–533elevated liver enzymes, 530–531food, 529–530glucose, 531–533gum, 529–530hepatic/liver, 529–534hypoglycemia, 529–532N-acetylcysteine, 533SAMe, 532seizures, 529–530, 532vomiting, 529–531

Yellow jessamine (Gelsemium sempervirens), 926t. See Appendix 4, Toxic Plants, 919–926

Yellow oxeye (Adonis spp.), 921t. See Appendix 4, Toxic Plants, 919–926

Yesterday, Today, and Tomorrow Plant, 821–826atropine, 825brunfelsamidine, 822Brunfelsia spp., 821, 821f, 822f, 823, 825hopeanine, 822scopoletin, 822

Yew, 827–832bradycardia, 829, 831cardiovascular collapse, 829Japanese yew (T. cuspidata), 827, 827f, 828fPacific yew (T. brevifolia), 827, 829peracute collapse/death, 832paclitaxel, 828taxines, 828–829Taxus spp., 827, 830, 832

Zaleplon (Sonata), 212–213. See Nonbenzodiazepine Sleep Aids, 212–216

Zamia spp. See Sago Palms (Cycads), 804–811

Zinc, 723–728; see also Vitamins and Minerals, 313–324

calcium disodium EDTA, 727chelation, 727diagnosis, 725–726endoscopy, 726GI toxicity, 725gastroprotectants, 726–727intravascular hemolysis, 723prognosis, 727sources, 723toxicity, 724

Zinc phosphide. See Phosphides, 862–870Zolazepam, 150t. See Benzodiazpeines, 149–154Zoloft (sertraline), 227. See SSRI and SNRI

Antidepressants, 277–282Zolpidem (Ambien), 212, 213. See Nonbenzodiazepine

Sleep Aids, 212–216Zubrin, 396. See Veterinary NSAIDs 396–403