Toxicological Emergencies in Veterinary Medicine

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Toxicological Emergencies in Veterinary Medicine

• Amber Craddock, LVT

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Veterinary Technicians Role

• Client Education
• Assess the Situation
• Obtain Client Information
• Vital Statistics
• Stabilization of the patient
• Detoxification
• Nursing Care while Hospitalized

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Client Education

• Prevention is the Goal!!
• What Toxin?
• When is the right time?
• How much is too much?
• National Animal Poison Control Center
• WA Poison Control
• Time wasted is life lost

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Assessment

• Airway
• Breathing
• Circulation
• Level of Consciousness
• Mentation
• Brief Physical Examination

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Vital Statistics

• Pulse
• Respiration Quantity and Quality
• Temperature
• Mucous Membrane Color and Texture
• Blood Pressure
• Responsiveness

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Client Information

• What was the patient exposed to?
• When was the toxin ingested?
• How much of the toxin was ingested?
• What treatments have been done?
• What are the symptoms observed?
• What medications is the patient on and for what?

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Stabilization

• Venous Access
• Sedation/Anti Convulsants/Muscle Relaxants
• Fluid Resuscitation
• Thermoregulation
• Overall Homeostasis

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Detoxification

• Emesis
• Bathe
• Gastric Lavage
• Activated Charcoal
• Intravenous Fluid Diuresis
• Antidote Administration

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Emesis

• Apomorphine
• Hydrogen Peroxide
• Ipecac Syrup
• Salt Water

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Apomorphine

• Subcutaneous Injection
• Intravenous Injection
• Conjunctiva Administration

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Activated Charcoal Administration
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Routes of Administration

• Mixed with food
• Syringe Feeding
• Orogastric
• NG / esophageal

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Nasogastric/Nasoesophageal

• Red rubber catheter
• Lidocaine Jelly
• Proparacaine
• 3ml syringe of Saline
• Catheter Tip Syringe
• Muzzle

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Orogastric

• Mouth Gag
• Large bore tube or red rubber catheter
• Lubricating Gel
• Roll Gauze
• Tape
• Catheter Tip Syringe

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Gastric Lavage

• Complete Sedation/ Anesthesia
• Endotracheal Tube
• Monitoring Equipment
• Large Bore Gastric Lavage Tube w/ pump
• Two BucketsOne with lukewarm water
• Lubricating Gel
• Jaw Jack

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SPECIFIC TOXINS -

• Some of the more common toxicities seen at the
  AEC !
• ( phone 24/7 -- 253 474-0791 ! )

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Xylitol

• A sugar substitute found in many chewing gums and
  sugar free candies. It may be purchased in powder
  form for baking.
• It effects dogs much differently than humans and
  causes large amounts of insulin to be released
• Most common symptom seen is profound hypoglycemia
  but hepatic injury has been noted at high dose
  ingestions

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Treatment

• Baseline blood glucose
• Full chemistry if a large amount has been
  ingested
• Emesis
• Check BGs frequently
• Intravenous fluid support with or without
  dextrose may be indicated if symptoms of
  hypoglycemia are shown
• More aggressive treatments may be needed if signs
  of liver damage are determined

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Ethylene Glycol

• Three-step progression
• 30min-12hrs after ingestion neurological
  symptoms including ataxia, confusion,
  inappropriate mentation, vomiting, and/or general
  malaise
• 12hr-24hrs after ingestion tachycardia,
  hypertension, tachypnea, and metabolic acidosis
• 24hr-72hrs after ingestion formation of calcium
  oxalate crystals in the kidneys thus resulting in
  acute renal failure

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Diagnostics

• Woods Lamp of vomitus or urine
• Microscopic evaluation of urine for crystals
• Needle-like calcium oxalate crystals
• Ethylene Glycol Test Kit
• Kacey Ethylene Glycol Test Strips

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Treatment

• Decontamination by means of emesis or gastric
  Lavage
• Intravenous Fluid Diuresis to correct electrolyte
  imbalances and metabolic acidosis
• 20 Ethyl Alcohol intravenous solution or
  Antizol administration
• Hemodialysis

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Acetaminophen

• Commonly used analgesic in humans (sometimes used
  in dogs with codeine for arthritis relief)
• Metobolization occurs largely in the liver
• Symptoms in dogs can be vague including vomiting,
  diarrhea, tachycardia, and/or tachypnea. If
  methemoglobinemia is present, icterus, abdominal
  pain, and swelling of the face/paws may be
  observed.
• In cats, symptoms usually are a result of
  hemolysis resulting in anemia. Unusual /
  characteristic change to cat MM color.

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Diagnosis/Treatment

• Diagnosis relies heavily on client history
• Emesis induction (if consumption occurred within
  the four hour window)
• Activated Charcoal administration
• N-acetylcysteine therapy
• Includes loading dose followed by five to seven
  tapering doses
• Liver Values should be closely monitored for
  48hrs

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Theobromine

• An alkaloid found in cocoa and chocolate
• Higher concentrations in dark and bakers
  chocolate
• Used in the medical field in the form of
  Theophylline as an adenosine antagonist
• Symptomsmild /moderate gastrointestinal
  disruption, muscle tremors, tachycardia,
  hyperactivity, seizures, coma

Toxic Doses
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Treatment

• Emesis
• Activated Charcoal
• Gastric Lavage
• Sedation
• Intravenous Fluid Diuresis
• Urinary Catheter/ Frequent Walks
• Cardiac Blood Pressure Monitoring

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Permethrin / Pyrethrin

• Sold in the form of over the counter flea control
  indicated for dogs
• Most commonly affects cats
• Tremorgenic Effects (not to be confused with
  seizures)
• Easily recognized affliction

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Treatment

• Intravenous Methocarbamol (Robaxin)
• Bathe w/ Dawn dish soap
• Intravenous Fluid support
• Thermoregulation

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Tremorgenic Toxins in Dogs

• SLUD (salivation, lacrimation, urination,
  defecation)
• Mushrooms
• most common culprit is the Amanita mushroom
• Tremoring and/or muscle spasm
• Liver injury/failure can be a result of untreated
  ingestion
• Molluscicides
• Main offensive ingredient Metaldehyde
• rapid onset of neurological symptoms that begin 1
  to 4 hours after exposure
• Compost/Trash Consumption
• Tremorgenic mycotoxins in mold

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• Emesis
• Brown, blue, or green granules, mushrooms, trash,
  food wrappers, etc
• Gastric Lavage
• Activated Charcoal w/ Sorbitol
• Anticonvulsants/ Muscle Relaxants
• Thermoregulation
• Intravenous Fluid Support
• Gastrointestinal Protectants
• sucralfate, famotidine, etc

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Rodenticides

• Two main subdivisions
• Anticoagulants Generations I and II
• brodifacoum, coumatetralyl, and wafarin, fumarin,
  chlorophacinone, diphacinone, pindone,
  bromadiolone
• Neurodegenerative Agents
• Bromethalin
• Mechanism of Action
• Anticoagulant rodenticides block the enzymes
  K1-2, 3-epoxide-reductase and K1-quinone-reductase
  depriving the animal of Vitamin K
• Neurodegenerative rodenticides uncouple
  oxidativephosphorylation in the mitochondria of
  the central nervous system decreasing the
  production of ATP thus resulting in buildup of
  cerebral spinal fluid and vacuolization of myelin
• Prognosis differs largely between the two

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Symptoms/Diagnosis

• Wide range of symptoms may be observed
• pale mucous membranes, generalized weakness,
  coughing, epistaxis, hematuria, hematochezia,
  hemorrhagic diarrhea, distended abdomen, rapid
  subcutaneous mass development, lameness with
  swollen joint(s), or collapse depending on the
  site where the bleeding is occurring
• Elevated , activated clotting time (ACT),
  prothrombin (PT) and activated partial
  thromboplastin (PTT) clotting times

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Treatment

• Emesis
• Gastric Lavage
• Only if early ingestion!!
• Activated Charcoal
• Vitamin K administration
• Initial dose may be given subcutaneously,
  followed by a 3wk course of oral supplementation
• Fresh Frozen Plasma
• Intravenous Fluid Support
• Whole Blood or Packed Red Blood Cells may also be
  indicated

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Veterinary Medications

• Owner Compliance
• Specified patient use only
• Legible Instructions
• When, why, how much?
• Route of administration
• Refrigeration
• Potential Side Effects
• Index of safety
• Laboratory analysis
• Follow up

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Commonly Misused Medications

• Non-steroidal Anti Inflammatory Drugs
• carprofen, etodolac, meloxicam, deracoxib,
  tepoxalin, firocoxib
• Most common side effects include vomiting,
  diarrhea, gastric ulcers, kidney and/or liver
  damage
• Antibiotics
• metronidazole, amoxicillin, doxycycline,
  cephalexin, enrofloxacin,
• Most common side effects are vomiting and
  diarrhea
• metronidazole toxicity effects the brain and
  equilibrium signs may present as ataxia,
  nystagmus, seizures

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Treatment

• Emesis if acute ingestion
• Activated Charcoal
• Gastric Lavage
• Intravenous Fluid Diuresis
• Gastrointestinal protectants
• ie sucralfate, famotidine, cimetidine, pepcid,
  etc
• Frequent monitoring of kidney and liver enzymes

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Conclusion

• By far the most important treatment that you can
  provide to any patient who has ingested a toxin
  is DECONTAMINATION
• Veterinary technicians are a valuable resource to
  any veterinary hospital and can make a huge
  difference in the life of the patients you care
  for.