One of the most common
presentations to the ERs are
toxicities. Mostly they are
your garden variety toxins
including rodenticides and
snail baits, but we are seeing
a dramatic rise in both
recreational and medicinal
poisonings with pets.
Recreational drug use and pet intoxication are always a sensitive area with clients. Some clients are very secretive about their personal habits, while other clients inadvertently find they have siblings with a not so secret stash at home.
While we use a set of guiding principles to treat an unknown toxin, identification can aid in long term management.
Both of our emergency centres stock a test kit for urine (Dipscan). The Dipscan device is easy to use test that can rapidly identify the most common recreational drugs. The product is simple to use and is something that could be utilised at every clinic.
With toxicities, our general approach is as follows:
1. Assess the patient
4. Obtain detailed history
2. Stabilise the patient
5. Reduce exposure and enhance excretion
3. Obtain minimum database
6. Administer antidote if available
GENERAL TRIAGE AND INITIAL TREATMENT
Place an IV catheter in every animal with a suspected intoxication even if you don't think you will need it.
Many intoxicated animals present with altered mentation or seizuring. An animal that has seizured at home, and is now
normal has generally not been poisoned! The differential diagnoses for seizures include:
Central nervous system disease
e.g. meningitis, epilepsy
POISONS WHICH MAY RESULT IN SEIZURES INCLUDE (but are not limited to):
Snail baits (carbamate, metaldehyde
Illicit and prescription drugs e.g. amphetamines ("diet pills"),
and sometimes iron)
cocaine, marijuana, iron supplements, antidepressants
Chlorinated hydrocarbons e.g. DDT, lindane
Garbage or compost
Pesticides: OP's, carbamates, pyrethrins,
strychnine, 1080, amitraz.
TREATING THE INTOXICATED ANIMAL
1. Assess the patient:
Get a quick history. Assess cardiovascular and respiratory stability. Observe level of consciousness, whether the animal is
Mucous membrane colour and capillary refill check mouth for evidence of ingested material, obstructions and the presence of a gag reflex auscultate the chest feel for pulse rate and quality check temperature observe pupil size, direct and consensual pupillary light reflex (PLR) and test the menace reflex
2. Stabilise the patient:
Is oxygen required?
Does the patient need ventilating? Monitor respiratory effort, SPO2 and ETCO2 if intubated.
Is cardiovascular support required? Monitor blood pressure; assess heart rate and rhythm, ideally with an ECG, and treat
any arrhythmias appropriately.
Is there seizure activity?
Diazepam 0.5 - 1.0 mg/kg IV repeated up to 3 times in half an hour. Phenobarbitone 10 – 20 mg/kg IV may be required if the diazepam is ineffective or if the animal is in status epilepticus. If the animal has peripheral muscle spasms, methocarbamol (44 mg/kg; up to 330 mg/kg/day) or guaphenesin 1 ml/kg may be indicated. If central seizures cannot be controlled, you will need to anaesthetise the animal with a barbiturate (eg propofol).
Is body temperature within the normal range? Warm or cool as indicated. Remember, proteins can be denatured with
temperatures above 41ºC, so anything approaching this is an emergency.
Are pupils fixed and unresponsive or pinpoint? Pinpoint pupils are an indication of potential cerebral oedema and
increased intracranial pressure. Mannitol or hypertonic saline may be indicated – use only in adequately hydrated animals.
3. Obtain a minimum data base:
PCV/TS Blood gas and electrolytes APTT +/- Biochemistry and Haemogram Urine, especially if illicit drug exposure is suspected. A pre-treatment specific gravity is helpful if renal failure
is a differential diagnosis.
4. Obtain a detailed history from the owner.
When was the animal last seen to be normal?
When was the animal last fed?
Are there any potential toxins at home? Be specific and list the possibilities as many people are not aware of
how many potentially toxic substances they have about the house.
Has the animal had any seizures at home? How long has the seizure activity been present? Gradual or rapid
onset of any clinical signs?
Recent weight loss? Increased water intake?
Lethargy over preceding weeks may all indicate a long term illness that has today reached a crisis rather than the accu-rate onset of a critical illness
5. Reduce further exposure to the toxin
Induce emesis if safe to do so i.e. the patient is conscious, ambulatory and has a normal gag reflex. Ideally this is done within 1 hour of ingestion, and is usually pointless if greater than 4 hours have elapsed. Marijuana seems to slow gastric emptying and remain in the stomach for up to 8 hours.
Do not induce emesis if the ingested toxin is caustic (acid or alkali), or a petrochemical.
Choices of emetics include:
Apomorphine 0.04 mg/kg IM or SC, 0.03 mg/kg IV. Avoid in cats – unreliable. Sodium carbonate crystals ("Lectric Soda"). Give one small crystal to a small dog, a larger one to larger dogs.
The crystals are potentially caustic so give them only once and wash down with water.
Xylazine: Cats 0.4 – 1.0 mg/kg IM or SQ. May cause profound depression.
Consider gastric lavage if ingestion occurred within the last 4 hours.
An enterotomy may be required to remove large objects e.g. lead fishing sinkers.
Carbosorb: activated charcoal at 2 g/kg combined with the osmotic cathartic sorbitol
If repeated doses of activated charcoal are indicted, use activated charcoal that does not contain sorbitol.
Administer in food, or via syringe. DO NOT force feed a struggling animal activated charcoal – the risk of
aspiration pneumonitis is high. Never give to an unconscious animal via a stomach tube.
Wash the patient with warm (not hot) water and regular shampoo. Repeat as many times as necessary.
Dishwashing liquid is effective for oily substances. If any trace of the toxin remains on the animal, place an Elizabethan collar to prevent ingestion by grooming.
This is especially important in cats.
Rinse eyes with normal saline for up to 20 minutes.
If a dry powder is on the skin, brush it off. Wear gloves and do not breathe in any powder. Thoroughly rinse the animal in water, and then use soap. Continue to soap and rinse for 15 minutes.
AID EXCRETION OF ABSORBED TOXIN:
IV fluids to maintain urinary output of at least 2 ml/kg/hr. Acidification of the urine (ammonium chloride, 100 mg/kg in dogs, 20-40 mg/kg in cats q 12 hours PO)
may help with excretion of alkaline agents e.g. amphetamines. Monitor for systemic acidosis.
Alkalinising the urine may be of use with acidic agents e.g. aspirin, paracetamol (acetaminophen).
6. Administer a specific antidote if available.
Even if an antidote is available, the mainstay of treatment is still supportive, symptomatic care.
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