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Sarah K. Rice BA, CVT

Principles

Exposures

Goals

Veterinary team approach

Triage

Management

Nursing considerations

Top 10 toxins of 2018

Exposure

Goals

Triage

Management

Nursing considerations

PRINCIPLES OF TOXICOLOGY

▪ 4 routes of exposure:

▪ Ingestion

▪ Inhalation

▪ Injection

▪ Topical (mm, skin, eyes)

▪ Goals of veterinary intervention: limit absorption, progression of toxicity

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▪ TIME! Limit suggestion of home tx during phone triage

▪ Prevent further exposure

▪ Instruct owners to protect themselves

▪ Topical or inhaled toxin

▪ Protective gear- gloves, mask, etc.

▪ Bathe if stable, topical exposure

▪ Handling of patients displaying abnormal behavior

▪ Collect packaging (ingredient info) if available

▪ Collect post exposure eliminations

▪ +/- contact poison control

Primary Evaluation

• mentation

• A, B, C

• Presenting complaint

• Intervention & stabilization

• Intubation, positive pressure ventilation, anti-convulsant administration, oxygen, CPR, IV catheter placement

Secondary Evaluation

• Detailed history and Physical Exam

• Diagnostic sampling, continued monitoring

▪ Most pertinent: history, patient clinical signs, responses to treatment

▪ Often difficult to identify cause of clinical signs if unknown toxin exposure

▪ Specific chemical analysis and laboratory findings

▪ Illegal drug identification

▪ Ethylene glycol

▪ Toxin levels (lead, zinc, specific substances)

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Decontamination procedures

Controlling clinical signs

Anticdote if available

Patient monitoring

Repeated treatments when necessary

Follow up monitoring/post hospitalization care

DECONTAMINATION PROCEDURES

▪ Prevent initial or continued absorption of a toxin

▪ Procedure dependent on route of exposure

▪ Dermal- bathe with mild dishwashing detergent (Dawn)

▪ Protective equipment for care team

▪ Ocular

▪ - flush with 0.9% NaCl or warm water x 15-30 min.

▪ Ingestions-

▪ Emetics- gastrointestinal emptying

▪ Apomorphine IV

▪ Xylazine IV in cats, yohimbine or atipamizole

▪ Hydromorphone, morphine IV or SQ

▪ Hydrogen peroxide PO

▪ Contraindications-corrosives, strong acids/bases, dyspnea, comatose/severe mental depression, hypoxia, lack gag reflex

▪ Emetics not recommended in rodents or rabbits

▪ Gastric lavage +/- enema administration

▪ Dilution techniques

▪ Activated charcoal

▪ +/-Cathartic (sorbitol)

▪ Poor efficacy for metals, small molecule intoxications

▪ Emetics

▪ Most effective shortly after toxin ingestion

▪ Food present in stomach

▪ Removal of stomach contents to remove toxin prior to digestion/absorption

▪ 40-60% stomach contents

▪ Emesis

▪ Two mechanisms of action:

▪ Stimulation of dopamine receptors in chemoreceptor trigger zone (Apomorphine)

▪ Gastric irritation (H202)

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▪ Many toxins lack anticdote

▪ Observation in hospital

▪ Supportive care

▪ Liver metabolism, kidney excretion

▪ IV fluid tx: replace fluid losses, maintain UOP 2-4ml/kg/hr

▪ Analgesia

▪ Anti-convulsant therapy

▪ Intravenous lipid therapy- fat soluble toxins

▪ Lipid emulsion- bolus dose (1.5-4 ml/kg IV) followed by CRI (0.25ml/kg/min) x 30-60 min

▪ Therapeutic plasma exchange, hemodialysis

▪ Mechanical ventilation

COMMON MEDS USED IN

TOXICOLOGICAL EMERGENCIES

▪ Activated charcoal

▪ Apomorphine

▪ Atipamezole

▪ Atropine Sulfate

▪ Calcium EDTA

▪ Calcitonin

▪ Ethanol

▪ Fomepizole (4-MP)

▪ Flumazenil

▪ Hydrogen Peroxide

▪ Naloxone

▪ N-acetylcysteine

▪ Pralidoxime (2-PAM)

▪ Vitamin K1

▪ Yohimbine

▪ Respiratory status

▪ Oxygenation and ventilation

▪ fatigue

▪ Cardiovascular status

▪ ECG

▪ Blood pressure

▪ mm/CRT

▪ Renal status

▪ GI status

▪ v/d

▪ Coagulopathy

▪ Neurological/mentation status

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CONTROLLING CLINICAL SIGNS

▪ Continuous monitoring in hospital when indicated

▪ Significant technician role- not just initial triage!!

▪ Repeated assessment

▪ Vital signs

▪ Mentation

▪ Repeated treatment

▪ Reversal agent administration

▪ Anticonvulsants +/- escalated control efforts

▪ Intralipid administration (exception: serum lipemia, dose range)

▪ New clinical signs secondary to toxin exposure

▪ Potential for altered tx plan/nursing considerations

▪ Ex: Dermal injury development, aspiration pneumonia, cardiac arrhythmia, electrolyte derangements, ventilatory/oxygenation status

Legal implicationspharmaceuticals

Landscape Agricultural production

Population Socioeconomic status

Environmental factorsweather

• Dogs > Cats

• 365 days a year, 24 hours a day

• 888.426.4436

• Consultation with toxicologist, associated fee

• 2018- 213, 773 cases evaluated

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COMMON TOXINS…

TOP 10

▪ OTC Medications

▪ RX medicationss

▪ Food items & additives

▪ Chocolate

▪ Veterinary products

▪ Household items

▪ Rodenticide exposure

▪ Insecticide exposure

▪ Plants

▪ Garden products

▪ Non-Steroidal Anti-Inflammatory Drug (NSAID)

▪ Acetaminophen (Tylenol)

NSAID

▪ Ibuprofen, naproxen

▪ Carprofen, meloxicam, deracoxib

▪ Toxic doses & clinical signs:▪ 20-125mg/kg: v/d, abd pain

▪ >125mg/kg: hematemesis, melena, AKI

▪ 400-500mg/kg: CNS signs, acidosis

▪ Tx: Decontamination, AC q6-8 hrs, GI protectants, diuresis

▪ +/- barbituates if seizures

▪ Hemodyalisis

Acetaminophin

▪ Methemoglobinemia in cats▪ Cats >susceptibility than dogs

▪ Both species: oxidative and liver cell damage▪ Anticipate peak LE elevation at 72 hrs

▪ Dyspnea, cyanosis, dark brownish MM, edema

▪ KCS

▪ Tx: decontamination, AC multiple doses,▪ IV fluids, gi & hepatic protectants

▪ N-acetylecysteine (PO or IV)▪ Improves excretion, separate from AC

▪ 5% solution: 140mg/kg, then 70mg/kg q 6 hours for 7+ doses

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2. PRESCRIPTION MEDICATIONS

▪ Anti-Depressants

▪ Opioids

▪ Adderall

▪ Cardiac medications

▪ Antithrombotics

▪ Antihypertensives

▪ Bronchodilators

▪ Example: ALBUTEROL inhaler

▪ Tachycardia

▪ hypokalemia

▪ hyperexcitable

▪ pupil dilation

▪ Tremors, restlessness, ataxia

▪ hypertension

▪ vomiting

▪ Panting

4 groups: MAOIs, TCAs, SSRIs,atypical

▪ Adjust levels of serotonin, norepinephrine, dopamine, epinepherine

▪ Varying clinical signs: depression, restlessness, arrhythmia, respiratory depression, death, ataxia, seizures

▪ SEROTONIN SYNDROME

▪ Mentation changes, neuromuscular abnormalities, autonomic instability, ataxia, tremors/seizures

▪ Thermoregulation center → hyperthermia

▪ Tx: decontamination, AC, supportive care,

▪ Cyproheptadine: serotonin receptor antagonist

▪ Dog: 1.1mg/kg, cat: 2-4mg/kg q 4-6hr

▪ Propranolol: serotonin receptor antagonist, tx hypertension, tachycardia

▪ Phenothiazines (humans)- caution with hypotensive patient

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3. FOODS/FOOD ADDITIVES

▪ Grapes & Raisins

▪ Allium species

▪ Xylitol

▪ Salt

▪ Unbaked bread dough

▪ High fat substances

▪ bones

Xylitol

▪ Vomiting, ataxia, collapse, seizures

▪ Potential liver failure: coagulopathy, increase ALT, tbili

▪ Hypoglycemia, Hypokalemia, hypophosphatemia

▪ Dogs: insulin release up to 6x greater than equal dose of glucose == rapid drop in BG

▪ GI tract absorption

▪ Onset clinical signs 30 min-12 hrs post ingestion

▪ toxic dose 0.1g/kg; hepatotoxic >0.5g/kg ▪ gum= 0.3g, 1cup granulated xylitol= 190g

▪ Tx: +/- emesis, baseline labwork, IV fluids w/dextrose, liver protectants, antioxidants

Salts

▪ GI irritant, often cause emesis

▪ V, polydypsia, hypernatremia

▪ Salt toxicosis: ataxia, CNS sighs dehydration/overhydration, protracted v+

▪ Tx: decontamination, supportive care▪ Electrolyte balance restoration with

diuresis: decrease slowly to avoid cerebral edema

▪ Max 8-12mEq/L/24hrs decrease

▪ Mannitol, furosemide

▪ Ex: homemade play-doh▪ 2c. Flour, 1 c. salt, ½ c. H20

▪ Toxic dose 2g NaCl/kg

▪ 10lb dog: ¾ tsp of dough

4. CHOCOLATE

Methylxanthines: caffeine & theobromine

-caffeinated soda, chocolate, cocoa beans, teas

-Chocolate: theobromine toxicity ≥ 100mg/kg (dogs & cats)

-Milk chocolate=45-60mg/oz

-Semisweet (dark)=130-185 mg/oz

-Baking choc (unsweet)= 400-450mg/oz

Clinical signs: increased muscular contractility

-vomiting, diarrhea, hyperactivity, restlessness, ataxia, muscle tremors, ventricular cardiac arrhythmias

-tx: decontamination (emesis, gastric lavage, AC), IV fluid therapy, anticonvulsants, ECG and BP monitoring

-urinary catheter with closed collection: methylxanthines reabsorb via bladder

- antiemetics, GI protectants for ongoing v/d

- possible tx up to 72 hrs

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▪ Prescription medications

▪ oral, ocular, dermal, injectable

▪ adverse reactions, administration/dosing errors

▪ Topical Flea/Tick Medications

▪ Permethrins, Pyrethrins

▪ Flea tick collars

▪ Avermectin

▪ Organophosphates

5. VETERINARY PRODUCTS

▪ (see insecticides)

▪ Labeled for flea & tick control

▪ Indicated for dogs

▪ Toxic to cats via direct or secondary exposure; low toxicity in most

mammals

▪ Available formulations: as spot-on application alone or in combination

with other compounds, topical and premise sprays

▪ https://youtu.be/BifuRgxIYwU

• Topical toxin exposure

• Dermal decontamination: bathe

• Supportive care

• Hyperthermia control

• Dehydration

• Nutrition

• Anti-tremorgenic, anticonvulsant

• Flea control recommendations & home care advice

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6. HOUSEHOLD GOODS

▪ Ethylene Glycol/Antifreeze

▪ Zinc

▪ Lead

▪ Bleach/cleaning products

▪ Nonionic, anionic, cationic detergents detergents

▪ Glues

▪ Mothballs

▪ Phthalates

▪ Batteries

▪ Kerosene

▪ Tobacco/nicotine

Ethylene Glycol

▪ Antifreeze, de-icers, solvents, brake fluid, condensers

▪ Toxic dose: 4ml/kg (dog), 1.5ml/kg (cat)

▪ Liver metabolism→calcium oxalate crystal →AKI, severe metabolic acidosis

▪ Stage 1: 0-12 hrs, neurologic changes

▪ Stage 2: 12-72 hrs, worsening of AKI signs to oliguric renal failure

▪ In house tests: false results

▪ TX: immediate decontamination, aggressive IV fluid tx, Fomepazole (4-MP), 30% ethanol

▪ hemodialysis

Zinc

▪ Metals, pennies after 1983

▪ Toxic dose: 0.7-1g/kg

▪ Labs: inflammatory leukogram, anemia (regenerative), spherocytes, hemoglobinuria (renal tubule damage)

▪ Increased serum Zinc levels

▪ Acute hemolysis

▪ Clinical signs: anorexia, v/d, CNS depression, pale mm, icterus

▪ Tx: FB decontamination (ex lap or endoscopy), supportive care

▪ Concern for DIC, renal failure

▪ Anemia – blood product administration

▪ Chelation therapy

▪ Expandable Glues: Gorilla Glue

▪ Vomiting, retching, abdominal pain & distention, excessive drooling, pawing at face

▪ Tx: Supportive care, anti-emetics, IV fluid replacement therapy

▪ Large ingestion requires gastrotomy followed by analgesia & surgical recovery

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▪ Anticoagulant Rodenticides

▪ Bromethalin

▪ Zinc-Phosphide

▪ Cholecalciferol

7. RODENTICIDES

Anticoagulant Rodenticides

▪ Inhibit Vit K dependent coagulation factors from activation (II, VII, IX, X)

▪ Prothrombin time tests this pathway (elevation)

▪ 2nd generation products worse > duration of action than 1st, lower toxic dose

▪ Clinical signs (3-7d. Post exposure): bleeding into body cavities (lethargy, resp distress)

▪ Tx: decontamination +/- AC, PO Vit K (with food)▪ +/- transfusion FWB, FFP

▪ Supportive care (thoracocentesis, etc)

▪ PT baseline, 48, 72 hrs, and 48 hrs post Vit K tx

▪ Vit K x 14 days (1st gen) or 30 days (2nd gen)

Bromethalin

▪ For use against warfarin resistant rodents

▪ Cerebral edema, increased intracranial pressure

▪ Clinical signs:

▪ High dose: muscle tremors, seizures, hyperexcitability, hyperthermia

▪ Low dose: ataxia, paresis/paralysis, CNS depression

▪ Tx: aggressive decontamination w/gastric lavage, AC x 48 hrs, control of seizures, supportive care (O2, IV fluids)

▪ Cerebral edema mgmt: mannitol, head elevation, avoid jugular vein pressure,

▪ Normocapnia

▪ Poor prognosis with severe signs

8. INSECTICIDES

▪ Carbamates

▪ Organophosphates

▪ Permethrins

▪ Pyrethrins

▪ Ivermectin

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Permethrins

▪ Uses livestock, companion pets, agriculture, home gardens

▪ Permethrins: OTC spray, dust, gel, dip, shampoo, topical tx

▪ Pyrethroids: synthetic permethrin, increased potency and toxicity

▪ Cats more profoundly affected than dogs, primary or secondary exposure▪ Increased sensitivity with high flea burden

▪ Rapid absorption

▪ Clinical signs: hyperesthesia, generalized twitching (tail, skin, ears), tremors and seizures▪ Potential for rolonged signs (3-5 days), less if

aggressive care

▪ Tx: decontamination (dish detergent bath), temperature regulation, muscle relaxers (methocarbomol)▪ IV fluid support

▪ IV lipid therapy

▪ AC not beneficial

Ivermectin

▪ Broad spectrum anti-parasitic, endo and ecto-parasite tx; small and large animal treatment formulations

▪ OTC

▪ Toxic dose: dogs 2.5mg/kg, cats 1.3mg/kg (varies due to individual sensitivity)

▪ Enterohepatic circulation

▪ Clinical signs: ataxia, agitation, disorientation, mydriasis, acute blindness, bradycardia; seizure, coma

▪ Tx: decontamination, AC

▪ seizure control (avoid benzodiazepines)

▪ Phenobarbital, propofol

▪ IV lipid therapy

▪ Mechanical ventilation (severe aspiration peneumonia, hypoventilation)

9. PLANTS

▪ Lilies-Easter, Tiger

▪ Rhododendrons, Azaleas

▪ Sago Palm

▪ Oleander, Foxglove, Lily of the Valley

▪ Philodendron

▪ Aloe

▪ Castor Bean Plant

Sago palm

▪ Tropical, subtropical, decorative environments

▪ All parts of plant are toxic, seeds have highest concentration of toxin

▪ Clinical signs: v/d, depression, LE elevation

▪ Liver damage with encephalopathy, coagulopathy

▪ Tx: aggressive decontamination, multiple AC doses, supportive care with IV fluid tx, liver protectants

▪ Prognosis dependent on extent of liver damage

Lillies

▪ Easter, stargazer, Asiatic, tiger, rubrum, Japanese (all parts of plant)

▪ Renal tubular injury, AKI, death in cats

▪ Initial clinical signs: v, lethargy, anorexia

▪ 24-72 hrs post ingestion: pu/pd, azotemia, hyperphosphatemia

▪ Tx: decontamination, AC, aggressive fluid dialysis, +/- peritoneal dialysis

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10. GARDEN PRODUCTS

▪ Fertilizers

▪ Tremorgenic mycotoxins

▪ Metaldehyde

▪ Insecticides/rodenticides

▪ Strychnine

Tremorgenic Mycotoxins

▪ Fungal metabolism

▪ Moldy garbage, foods, compost, grains

▪ Primarily canine ingestions

▪ Enterohepatic recirculation

▪ Labs: lactate accumulation, increased creatnine, AST, dehydration markers

▪ Clinical signs: onset 30min-3 hrs▪ Early: vomiting, panting, weakness,

hyperexcitability, muscle tremors, rigidity

▪ Later: opisthotonos, seizures, nystagmus, recumbency

▪ Muscle activity results in hyperthermia, metabolic changes, dehydration, rhabdomyolosis

▪ Tx: decontamination (emesis or gastric lavage), multiple AC doses, anticonvulsants, muscle relaxants, IV fluid therapy

▪ early decontamination= good prognosis

Metaldyhyde

▪ Snail/slug bait

▪ Highly palatable, acetaldehyde odor

▪ Toxic dose: 100mg/kg

▪ Clinical Signs: CNS signs--seizures, hypersalivation, incoofdination, muscle fasciculations, metabolic acidosis, tachycardia▪ Hyperthermia, hyperesthesia,

▪ Progression to respiratory failure, liver damage

▪ Tx: decontamination, supportive care, control of hyperthermia▪ Good prognosis with tx

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