A 2 Year Old who Presents with Seizures: What

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A 2 Year Old who Presents with Seizures Whats
that Smell?

• Suzan Mazor, MD
• Fellow, Toxicology
• Toxikon Consortium, Cook County
• Pediatric Emergency Medicine
• Childrens Memorial Hospital, Chicago

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Case Presentation

• 3 year-old presents with a GTC seizure
• Recent URI symptoms, no significant PMH
• Over the counter cold remedy
• Abrupt onset of vomiting, seizure within 30 min
• Seizure stopped after 20 minutes
• 2 doses of Lorazepam were given
• Phenobarbital load

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Physical Exam

• VS 38.0, 96/palp, 126, 28, sat 99 (100O2)
• Somnolent / post-ictal
• Aromatic odor on breath
• Pulmonary, cardiac, abdomen normal
• Localized to painful stimuli
• Spontaneous eye opening and movements
• Routine laboratory examinations all normal

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Differential Diagnosis

• What is this smell?
• Smells in toxicology
• Bitter almond
• Garlic
• Rotten eggs
• Newly mown hay

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Differential Diagnosis

• What is this smell?
• Smells in toxicology
• Bitter almond ..Cyanide
• Garlic ....Arsenic
• Rotten eggs..Hydrogen sulfide
• Newly mown hay.Phosgene

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Camphor

• Bark/leaves of Cinnamomum camphora tree
• Synthesized from hydrocarbon-pinene
• turpentine oil derivative
• Uses of camphorated oils
• aphrodisiac, contraceptive, abortifacient,
  liniment, antiseptic, cough suppressant
• Common ingredient in OTC preps, mothballs

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Camphor

• 1983 FDA banned sale of oils with gt 11 camphor
• Products with higher concentrations still
  available
• Canada, Australia, China
• Still used as liniment, herbal remedy

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Camphor

• Common camphor containing products
• Mothballs
• Antiseptics
• Campho-phenique (10.8)
• Muscle liniments
• Camphor spirits
• Cold remedies
• Vicks Vapo-rub (4.7)
• Vicks Vapo-steam (6.2)

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Camphor

• 5 cc (20 oil) killed a 19 month old
• 10 cc (2 tsp) Campho-phenique
• 16 cc (1 tbsp) Vicks Vapo-steam
• 20 cc Vicks Vapo-rub
• Lethal dose 50-500 mg/kg
• Unlikely toxicity lt30mg/kg

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Camphor

• Case reports of toxicity
• Ingestion
• Mothballs, Camphorated oils, OTC products
• Dermal
• Intranasal
• Intraperitoneal
• Transplacental
• Most poisonings due to ingesting camphorated oil
• mistaken for other med (castor oil)

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Can You Tell the Difference??
Castor oil
Camphorated oil
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Camphor

• 2001 AAPCC TESS DATA
• 8505 Exposures
• 6,518 lt 6 years old
• 89 moderate-severe symptoms, no deaths

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Camphor Toxicity

• Clinical manifestations
• Aromatic, pungent odor
• Symptoms begin abruptly
• 5-90 min post-ingestion
• GI symptoms
• Emesis with camphor odor
• Abdominal pain, oropharyngeal irritation
• CNS
• Seizures within minutes
• Confusion, agitation, CNS depression

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Camphor Toxicity

• Diagnostic testing
• Camphor and metabolites can be measured in blood
  or urine
• Levels not available in real-time
• Levels do not correlate with symptoms
• No other specific labs

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Camphor

• Management
• A,B,Cs
• Seizure management
• Decontamination
• Enhanced elimination
• Antidotes

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Camphor Toxicity

• Management
• 1. ABCs

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Camphor Toxicity

• Management
• 2. Seizure management
• Benzodiazepines
• Barbiturates
• Propofol
• What about Phenytoin?
• Usually does not work for toxin induced seizures

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Camphor Toxicity

• Management
• 3. Decontamination
• Wash substance off patient if dermal exposure
• Ipecac?
• NO! Quick changes in mental status possible
• Gastric Lavage?
• Probably not useful unless available IMMEDIATELY
• Liquid is rapidly absorbed
• ?NG suction
• Activated charcoal?
• Efficacy not studied

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Camphor Toxicity

• 4. Hemodialysis charcoal hemoperfusion
• Lipid dialysate
• Successful in case reports, no controlled studies
• Not widely available

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Camphor Toxicity

• 5. Antidotes?
• None

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Camphor Toxicity
Camphor-containing mothballs
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Other Types of Mothballs

• Naphthalene
• Metabolized to naphthols and naptholoquinone
• Oxidants
• Hemolysis and methemoglobinemia
• Caution with G6PD deficiency

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Mothball Identification
WILL IT FLOAT??
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Mothball Identification

• Camphor

IT FLOATS!!
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Mothball Identification

• Naphthalene

IT SINKS!!!
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Case Course

• The child had been found 2 hours PTA with an open
  jar of Vicks Vapo-rub.
• 1 tablespoon was missing (0.7g camphor).
• No further seizures occurred.
• Within 24 hours the lethargy resolved and she was
  discharged.

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Teaching Points

• Camphorated oils, medications, mothballs may
  cause rapid onset of vomiting, seizures, altered
  mental status
• Naphthalene in mothballs may cause hemolysis,
  methemoglobinemia

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Thank You!
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Questions???