GROUP PROJECT INFORMATION

• • • • • •

TURN IN ON DAY OF PRESENTATION Minimum group size 2 and maximum 4 Presentation time: maximum 10 minutes

Group topic and names due Monday 02/07/2011 Presentations : 02/ 08 – 02/10/2011

BRING A VISUAL AID: CLIENT INFORMATION – Inform – – Educate Empower

GROUP PROJECT INFORMATION

• ONE page hard copy with the following information: • The toxic agent • • How the animal may be exposed to it What clinical signs the animal might show – Which bodily systems if affects • • The treatment EACH GROUP MEMBER’S NAME MUST BE ON THE PAGE THAT IS TURNED IN TO ME (NO CREDIT WILL BE GIVEN IF THERE IS NO PARTICIPATION)

ADVERSITY

“Life’s challenges are not supposed to paralyze you, they are supposed to help you discover who you are.” - Bernice Johnson Reagon

Emergency Procedures

ABC

•

A = Establish

airway

•

B = Breathe

for animal

•

C = Maintain

circulation

with thoracic compressions and IV fluids

Triage of Emergency Patients

• Initial exam (by RVT) – Wear gloves – – – Animal muzzled (use discretion) Minimize movement of patient Initial Assessment (30-60 sec; from rostral direction) •

Mentation (level of consciousness)

– A Alert – V Verbally responsive – – P responsive to painful stimuli U Unresponsive » Extend head/neck to provide clear airway; check for patency • • •

Breathing/respiratory pattern

(shallow, labored, rapid, obstructed)

Abnormal body/limb posture (fracture, paralysis) Presence of blood or other material around patient

Triage of Emergency Patients

– Initial Assessment (continued) •

Breathing/respiratory pattern

– Total/Partial blockage of airways

(Requires immediate Rx

) » Exaggerated inspirations » » Nasal flare, open mouth, extended head/neck Cyanosis – Breathing assessment » Watch chest wall movement » Auscult lungs bilaterally to r/o hemo- or pneumothorax

Triage of Emergency Patients

– Vital signs (taken after initial assessment) •

HR, pulse rate (same as HR?), strength

• • • •

RR mm color, CRT Temp BP

– –

High HR, high BP→ pain High HR, low BP → hypovolemic shock

– Baseline data • •

ECG Chem panel, CBC

Triage of Emergency Patients

• History (mnemonic) – A Allergies – – – – M Medications P Past History L Lasts (meals, defecation, urination, medication) E Events (What is the problem now?) • • • • • How long since injury Cause of injury (HBC, dog fight, gunshot) Evidence of loss of consciousness Blood loss?

Deterioration/improvement since accident (good indicator of Prognosis)

• Any other underlying medical conditions/medications

Triage of Emergency Patients

Treatment to restore life/health – Analgesics for pain • Once

airway patency and heart beat (these are critical for life)

are

established

– Control hemorrhage • Pressure bandages (sterile gauze, laparotomy pads, towels) – If bleed thru, do not remove initial bandage, apply another on top – On distal extremity, BP cuff can be placed proximal to wound (avoid tourniquet if possible)

Triage of Emergency Patients

• Control hemorrhage • External counterpressure using body wrap of pelvic limbs, pelvis, and abdomen – Insert urinary catheter to monitor urine output – Use towels, cotton rolls, duct tape, etc – Monitor respirations (diaphragm/abdominal breathing compromised) – Leave on until hemodynamically stable (6-24 h) – Monitor BP during removal » If BP drops >5 mm Hg, stop removal; infuse more fluids » If BP continues to drop, reapply wrap

SHOCK: RECOGNITION AND TREATMENT

•

SHOCK is inadequate tissue perfusion resulting in poor oxygen delivery – – – – Cardiogenic Distributive Obstructive Hypovolemic

Shock

•

Types of Shock: – Cardiogenic—results from heart failure • ↓ blood pumped by heart • HCM, DCM, valvular insufficiency/stenosis – Distributive—blood flow maldistribution (Vasodilation) • Sepsis, anaphylaxis →↓arteriole resistance →loss of fluid from vessels to interstitial spaces →↓BP→ ↓ blood return to heart – Obstructive—physical obstruction in circ system • HW disease → heart pumping against the adult worm blockage • Gastric torsion →↓blood return to heart – Hypovolemic—decreased intravascular volume • Most common in small animals • Blood loss, dehydration from excessive vomiting/diarrhea, effusion of fluid into 3 rd spaces

Hypovolemic Shock

• • Pathophysiology of hypovolemic shock ↓blood vol →↓venous return, ↓vent filling →↓stroke vol, ↓CO →↓BP – Stage I: Compensation Baroreceptors detect hypotension (↓BP) a.

b.

Sympathetic reflex—(Epi, Norepi, cortisol released from adrenals) ↑ HR, contractility Constriction of arterioles (↑BP) to skin (cold, clammy), muscles, kidneys, GI tract; not brain, heart Renin (kidney)→angiotensin (blood)→aldosterone (adrenals) reflex ↑ Na + and water retention → ↑ intravascular vol (↑BP) – PE findings – – – Tachycardia Prolonged cap refill time Pale mm

Hypovolemic Shock

•

Pathophysiology of hypovolemic shock

• Stage II: Decompensation – – – – – Tachycardia Delayed cap refill time Muddy mm (loss of pink color, more brown than pink) BP is dropping Altered mental state • Stage III: Irreversible shock – – – PE findings worsen cannot revive death will occur

Shock

•

Treatment: the goal of therapy is to improve O 2 delivery – O 2 • supplementation Face mask • • O 2 cage/hoods Transtracheal/nasal insufflation – Venous access • Cephalic • • • Saphenous Jugular Intraosseous

Oxygen supplementation

Fluid Administration

Shock

• Treatment – Fluid resuscitation (O 2 delivery is improved by ↑CO) 1. Crystalloids • Isotonic solutions (electrolytes: Na + , Cl , K + , bicarbonate) – Examples (body

fluid=280-300 mOsm/L

) » Lactated Ringer’s (273 mOsm/L) » Normal saline (0.9%) (308 mOsm/L) – Dose: Dog 80-90 ml/kg/hr Cat 50-55 ml/kg/hr • Hypertonic solutions— when lg vol of fluid cannot be administered rapidly enough – – Examples—7.5% saline Causes fluid shift from intracellular space→ intravascular space →↑vascular vol →↑venous return → ↑CO – – Also causes vasodilation → ↑ tissue perfusion Dose: 4-6 ml/kg over 5 min •

Hypotonic solutions should never be used for hypovolemic shock

–

Examples—5% Dex in water (252 mOsm/L)

Shock

•

Treatment – Fluid resuscitation (O 2 delivery is improved by ↑CO) 2. Colloids— • • • Large molecular wt solutions that do not leave vascular system Better blood volume expanders than crystalloids 50-80% of infused volume stays in blood vessels • Examples – – – Whole blood Plasma Dextran 70

Shock

• Rx (continued) – Sympathomimetics

Use only after adequate fluid administration if BP and tissue perfusion have not returned to normal

• Dopamine (Inotropin®) – 0.5-3.0 μg/kg/min » Dilation of renal, mesenteric, coronary vessels – 3.0-7.5 μg/kg/min » ↑ contractility of heart » ↑ HR – >7.5μg/kg/min » Vasoconstriction • Dobutamine (Dobutrex®) – – 5-15 μg/kg/min ↑ contractility of heart (min effect on HR)

Shock

• Monitoring Hemodynamic/metabolic sequelae of shock are continually changing – Physical Parameters • Respiratory – Color of mm – RR – – Breathing efforts smooth?

Breathing pattern regular?

– Auscultation normal?

• Cardiovascular – HR normal?

– – ECG normal?

Color of mm – – – Cap refill time (1-2 sec) Urine production? (1-2 ml/kg/hr) Weak pulse? → ↓stroke volume

Shock

•

Monitoring –

Physiologic Monitoring Parameters • O 2 – Saturation Pulse oximetry—noninvasive – Normal: Hb saturations (SpO 2 )>95% » SpO 2 <90%--serious hypoxemia • Arterial BP—a product of CO, vascular capacity, blood volume – If one is subnormal, the other 2 try to compensate to maintain BP

Shock

• Monitoring – Laboratory Parameters • Hematocrit (PCV) – Increase →dehydration – Decrease →blood loss • Electrolytes (what is that?) – Proper balance needed for proper cell function – Fluid therapy may alter the balance; supplement fluid as needed • Arterial pH and blood gases – Pa CO2 tells how well patient is ventilating » Pa CO2 <35 mm Hg → hyperventilation » Pa CO2 >45 mm Hg → hypoventilation – Pa O2 » Tells how well patient is being oxygenated Pa O2 <90 mm Hg → hypoxemia – pH tells acid/base status of patient – – <7.35 → acidosis >7.45 → alkalosis

VISION

“It is a terrible thing to see and have no vision.” -Helen Keller

CPCR

CARDIOPULMONARY CEREBROVASCULAR RESUSCITATION

Cardiopulmonary Arrest and Resuscitation (CPR)

•

Cardiopulmonary Arrest (CPA)— sudden cessation of effective ventilation and circulation.

Causes • • • • • • • Anesthesia Trauma Infections (e.g. pneumonia) Heart disease Autoimmune disease Malignancy Trauma

Cardiopulmonary Resuscitation

•

Resuscitation Team Members – Should be 3-5 members • • Team leader—Veterinarian or RVT with most experience All members have several responsibilities – – – – – – – Provide ventilation Chest compression Establish IV line Administer drugs Attach monitoring equipment Record resuscitation efforts Monitor team’s effectiveness • Teams should practice on a regular basis to stay sharp

Cardiopulmonary Resuscitation

• • Facilities – Adequate room for entire team and equipment – – O 2 source Good lighting – Crash cart with all needed Rx (should be checked at beginning of each shift) • Defibrillators • Electrocardiogram • Suction – Table to perform chest compression • Grated surgery prep table not solid enough for chest compression – Use board underneath patient Recognition – RVT should ID patients at risk and observe any deterioration – Preventing an arrest is easier than treating one

Cardiopulmonary Resuscitation

• Standard Emergency Supplies (on crash cart) – Pharmaceuticals • • • • • • • Atropine Epinephrine Vasopressin 2% lidocaine (w/o epi) Na + bicarb Ca ++ chloride or gluconate Lactated Ringer’s, hypertonic saline, ● ● ● --Venous access supplies Butterfly cath ● ● ● ● IV caths IV drip sets Bone marrow needles Syringes Hypodermic needles (var sizes) Adhesive tape – dextran 70, hetastarch Airway access supplies • • • • Laryngoscope Endotracheal tubes (variety of sizes) Lubricating jelly Roll gauze ● ● Tourniquet --Miscellaneous supplies ● Gauze pads (3 x 3) Stethoscope ● Minor surgery pack ● ● ● Suture material Scalpel blades Surgeon’s gloves

Cardiopulmonary Resuscitation

• Basic Life Support (Phase I) – Remember the priorities (ABC; Airway, Breathing, Circulation) • Establish

patent Airway

– Endotracheal tube – – Tracheostomy tube for upper airway obstruction Suction to remove blood, mucus, pulmonary edema fluid, vomit • Artificial

ventilation (Breathing)

» Ambu-Bag » » Anesthetic machine Ventilate once every 3-5 sec – Chest compressions in between breaths if working alone » 1 to 2 times per second (80 times per minute for a large dog and 120 times for a small dog or cat) » 10 compression for every 2 breaths (or 5:1)

CPR

•

http://www.youtube.com/watch?v=VJGlsYHI9 cU

Cardiopulmonary Resuscitation Intubation

Cardiopulmonary Resuscitation

•

Basic Life Support (Phase I) –

Circulation

• External cardiac compression – Lateral recumbency—one/both hands on thorax over heart (4 th -5 th intercostal space) – – – In larger patients, arms extended, elbows locked In small patients, thumb and first 2 fingers to compress chest Rate of compression: 80-120/min

Cardiopulmonary Resuscitation

• Basic Life Support (Phase I) –

Circulation

• Internal cardiac compression – More effective than external compression » ↑CO, ↑BP, higher survival rate – Indications » Rib fractures » Pleural effusion » » Pneumothorax If not responsive after 5 min of external cardiac compression – Preparation » Clip hair ASAP, no surgical scrub » Incision at 7 th and 8 th intercostal space » With a gloved hand, compress heart between fingers and palm (Do not puncture heart with finger tips or twist heart) » After spontaneous beating returns, flush chest cavity with saline, perform sterile scrub of skin and close

Cardiopulmonary Resuscitation

•

Basic Life Support (Phase I) – Assessing effectiveness (must be done frequently) • • Improved color of mm Palpable pulse during cardiopulmonary resuscitation (difficult) • If efforts are not effective, do something differently – – – – – Use different hand Change person performing compression Ventilate with every 2 nd or 3 rd chest compression Compress chest where it is widest in lg breed dogs Apply counter-pressure to abdomen (hand, sandbag) » Prevents posterior displacement of diaphragm and increases intrathoracic pressure

Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate) –

Drugs

• Fluids – Lactated Ringer’s is standard (do not use Dextrose) » Initial dose: Dogs—40 ml/kg (rapidly IV) Cats—20 ml/kg • Atropine—parasympatholytic effects (blocks parasympathetic effects) – 0.02-0.04 mg/kg – – ↑HR ↓secretions • Epinephrine—adrenergic effects – – 0.02-0.2 mg/kg Arterial and venous vasoconstriction→ ↑BP

Cardiopulmonary Resuscitation

•

Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical— defibrillate)

–

Drugs

(continued) • 2% Lidocaine (Used to treat cardiac arrhythmias) – Dogs: 1-2 mg/kg Cats: 0.5-1.0 mg/kg • Sodium bicarb (For metabolic acidosis) – 0.5 mEq/kg per 5 min or cardiac arrest • Vasopressin (ADH) – 0.8 U/kg

Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate) –

Drugs

(continued) • Route of drug administration – Jugular vein—close to heart; drugs will get to heart quicker – Cephalic, saphenous—follow drugs with 10-30 ml saline flush – Intraosseous—intramedullary cannula into femur, humerus, wing of ilium, tibial crest – Intratracheal—for limited # of drugs: atropine, lidocaine, epinephrine – Intracardiac—last resort; several complications can occur • Depends on – Speed of access – Technical ability – – Difficulties encountered Rate of drug delivery

Cardiopulmonary Resuscitation

•

Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical— defibrillate)

–

Electrical—Defibrillate

• • • • Purpose—eliminate asynchronous electrical activity in heart muscles by depolarizing all cardiac muscle fibers; hopefully, the fibers will repolarize uniformly and start beating with coordinated contractions Paddles (with electrical gel) placed on each side of chest Yell “CLEAR” before discharging electrical current Start with low charge and increase as needed – – External: 3-5 J/kg Internal: 0.2-0.4 J/kg

Cardiopulmonary Resuscitation

DEFIBRILLATORS

Cardiopulmonary Resuscitation

NORMAL EKG VENTRICULAR FIBRILLATION

Cardiopulmonary Resuscitation

• Prolonged Life Support (Phase III) – Once heart is beating on its own, monitor the following: • HR and rhythm – Antiarrhythmic drugs – Correct electrolyte abnormalities • • BP Peripheral perfusion – Color of mm – – Cap refill time urine output • RR and character of breathing – Adequate breathing – Auscultory sounds • • Mental status Improving or deteriorating UC Davis study: survival rate at 1 wk for cardiac resuscitation patients Dogs: 3.8% Cats: 2.3%

CPR

EDUCATION

“Education is what survives after what has been learned has been forgotten.” - B.F. Skinner

Anaphylaxis/Allergic reactions

Rare, life-threatening reactions to something injected or ingested Untreated, it results in shock, resp/cardiac failure, and death • IgE Antibodies to allergen bind to mast cells; on subsequent exposure, the Ag-Ab reaction causes massive release of histamine and other inflammatory mediators Histamine → vasodilation → ↓BP Initiating factors – – – – – – Insects Vaccines Antibiotics Certain hormones Other medications Foods

Anaphylaxis/Allergic reactions

• – – – – – – Signs – Sudden onset of vom/diarrhea – Shock • • • Gums are pale Limbs are cold HR rapid, weak Face scratching (early sign) Respiratory distress Collapse Seizures Coma Death

Anaphylaxis/Allergic reactions

• • Rx (this is an extreme emergency) – – – – – – Eliminate cause Epinephrine H1 antihistamines (Diphenhydramine) IV fluids Corticosteroids Oxygen Prevention – There is no way to predict what will bring on an anaphylactic reaction the first time – Always inform vet if animal has had previous reaction to vaccine • Owners should have an ‘epi-pen’ with them at all times

Heat Stroke (Hyperthermia)

• Requires immediate treatment Dogs do not cool as well as humans (don’t sweat) Causes – – – – – – – – Left in hot car Water deprivation Obesity/older Chained without shade in hot weather Muzzled under a hot dryer Short-nosed breed (esp Pug, Bulldog)/heavy coat Heart/Resp disease or any condition that impairs breathing or ability to cool body Lack of acclimatization/exercise

Heat Stroke

•

Signs – – – – – – Rapid, frantic, noisy breathing Tongue/mm bright red, thick saliva Vomiting/diarrhea—may be bloody

Rectal temp >105°

Unsteady/stagger Coma/death

Prevention

Heat Stroke

•

Complications – – – – – – – – Multi-system organ failure Denatures proteins Hypotension Lactic acidosis Decreased oxygen delivery Electrolyte abnormalities => cerebral edema and death

Coagulopathies => DIC

If survives the first 24 hrs, prognosis is more favorable

Heat Stroke

•

TREATMENT

Mild cases: move dog to a/c building or car

– – Temp >104º, immerged in cool water, hose down Temp >106º, cool water enema (cool to 103º) –

Temp >109° leads to multiple organ failure

STOP COOLING EFFORTS AT 103º

– – IV fluids Corticosteroids

Emergency Drugs in Cats

Emergency Drugs in Dogs

Pain Management

• • Misconceptions about animal pain – Animals do not experience pain – – – – – – Pain doesn’t really affect how animal responds to treatment Signs of pain are too subjective to be assessed Pain is good because it limits activity Analgesia interferes with accurate assessment of treatment Pain management not major concern in LA (except horses) Pain shows weakness/fragility (Lab vs Collie) Fresh ideas about animal pain – – – Analgesia increases chance of recovery in critically ill Pain associated with diagnostic test should be minimized Morally correct thing to do

Pain Management

•

Signs – – – – – – – – – – Vocalization ↑HR ↑RR Restlessness, abnormal posturing, unwilling to move ↑ Body temperature ↑BP Inappetence Aggression Facial expression, trembling Depression, insomnia

Pain Management

• Sequelae to untreated pain – Neuroendocrine responses • Excessive release of pit, adr, panc hormones – Cause immunosuppression and disturbances of growth, development, and healing – Cardiovascular compromise • ↑BP, HR, intracranial pressure – Coagulopathies • ↑platelet reactivity, DIC – Long-term recumbency • Decubital ulcers – Poor appetite/nutrition • Hypoproteinemia→slow healing

Pain Management

•

Pain Relief – • • • • Nonpharmacologic interventions (differentiate pain vs stress) • Give relief from: – Boredom, Thirst, Anxiety, Need to urinate/defecate • Clean bedding/padding Reduce light/sound Stroking pet, calming speech Owner visits (±) Minimize painful events (reduce #, improve skills in injections, blood draw]

Pain Management

•

Questions the Vet Tech must continually ask (you are in charge of pain meds) – – – Is patient at acceptable comfort level Are there any contraindications to giving pain meds What is the appropriate (safe, effective) med for this patient

Pain Management

• Drug Options – Nonsteroidal Antiinflammatory Drugs (NSAIDs) • Most widely used • • • • Extremely effective for acute pain Most effective when used preemptively (before tissue injury) Usually not adequate to manage surgical pain COX-2 NSAIDs do not cause damage to stomach lining – Opioids • Most commonly used in critically injured animals – Rapid onset of action; effective; safe • 4 types of receptors –

μ: analgesia, sedation, and resp depression

– – –

Κ: analgesia

and sedation Σ: depression, excitement, anxiety Δ • Side effects – Vomiting, constipation, excitement, bradycardia, panting • Metabolized by liver; excreted by kidneys – Use caution with hepatic, renal disease

Pain Management

• Opioids – Morphine sulfate • Used for max analgesia/sedation • Inexpensive • • Side-effects: systemic hypotension, vomiting Cats particularly sensitive – Oxymorphone • 10x potency of morphine • Much more expensive; less resp depression and GI stimulation • Side-effects: depression, sensory hypersensitivity – Hydromorphone • • Similar effects of Oxymorphone More widely available, less expensive than Oxymorphone

Pain Management

• Opioids – Fentanyl citrate • Extremely potent • • Rapid onset, short duration when administered IM or IV Transdermal patch – 3-day duration – Shave hair, apply to the skin – Butorphanol Tartrate • Κ agonist; μ antagonist • Analgesic effect questionable (>1 h); good sedative (~2 h) – More expensive than morphine – Less vomiting, resp. depression – Buprenorphine • Partial mu agonist • • 30x potency of morphine; longer duration good absorption via buccal mucosa

Pain Management

•

Opioids – Antagonists • Naloxone HCl – – Reversal occurs within 1-2 min Can be used to reverse anesthesia (Inovar-Vet)

PERSEVERANCE

“Sometimes the best way out is through.”

TOXICOLOGIC EMERGENCIES

Toxicologic Emergencies

•

Signs will vary depending on character of toxic compound

•

Toxicity can result from exposure via many routes

– Ingestion – Inhalation – Skin contact – Injection

Toxicologic Emergencies

• Top 10 Toxicoses (2005) – Human medication (ibuprofen, acetominophen, anti depressants) – Insecticides—flea and tick – – – – – – – Rodenticides—anticoagulants Veterinary medication Household cleaners—bleach, detergents Plants—sago palm, lily, azalea Herbicides Chocolate—highest in food category Home improvement products—solvents, adhesives, paint, wood glue – Fertilizers

Toxicologic Emergencies

• • • • • • • HISTORY ASSESS STABILIZE – Administer oxygen – – Control seizures Correct cardiovascular abnormalities DECONTAMINATION – Emetics – – Activated charcoal Gastointestinal protectants CONTROL CLINICAL SIGNS GOOD NURSING CARE PREVENT FURTHER EXPOSURE

Toxicologic Emergencies: external exposure

•

Ocular exposure

• Rinse eyes with copious saline for 20-30 min • Chemical burns treated with lubricating ointment and suture lids closed –

Use corticosteroids only if corneal epithelium is intact

–

Skin exposure • Bathe with mild detergent (liquid dish soap) • Bather should wear protective clothing (gloves, goggles)

Toxicologic Emergencies

•

Ingestion

• Induce

vomiting—if chemical not caustic; animal conscious, not seizing

– Syrup of ipecac, apomorphine, Xylazine, H 2 O 2 recommmended) (not reliable), salt (not • • Dilute caustic substances with milk, water Gastric lavage—large bore stomach tube; light anesthesia w/ endotracheal tube • Administer absorbents—activated charcoal inhibits GI absorption – Give orally or via stom tube • Enemas/cathartics to eliminate toxins more rapidly

Toxicological Emergencies

ACTIVATED CHARCOAL WITH OR WITHOUT A CATHARTIC

Toxicologic Emergencies

•

Methylxanthines (caffeine,

–

theobromine, theophylline

Found in: coffee, tea, chocolate,

• •

other stimulants

Toxic Dose of caffeine and theobromine in dogs: 100-200 mg/kg; (other sources: 250-500mg) Milk Chocolate—44-60 mg/oz Dark chocolate-150 mg/oz Baking Chocolate—390-450 mg/oz

Toxicologic Emergencies

• •

Clinical signs of methylxanthine/chocolate toxicosis (caffeine, theobromine)

– Increased HR, RR – – – – Anxiety Vomiting/diarrhea Seizures, coma Cardiac arrhythmias

Treatment

– Induce vomiting – – Activated charcoal Control seizues – Fluid therapy

Toxicologic Emergencies

–

Rodenticides

1.

Anticoagulants (warfarin, pindone, bromadiolone, brodifacoum)

– Work by binding Vit K, which inhibits synthesis of factors II, VI, IX, X – This effect occurs within 6-40 h in a dog; effect may last 1-4 wk

Toxicological Emergencies

•

Clinical signs

(occur after depletion of clotting factors) – – – – Lethargy Vom/dia with blood; melena Anorexia Ataxia – – Dyspnea Epistaxis, scleral hemorrhage, pale mm •

Treatment

– Vit K: 3-5 mg/kg PO for up to 21 d depending on anticoagulant used – – Induce vomiting; activated charcoal Whole blood transfusion if anemic

Toxicologic Emergencies

–

Rodenticides

•

2. Cholecalciferol—Vit D 3

; used in Quintox, rampage, Rat-Be-Gone -causes Ca++ reabsorption from bone, intestine, kidneys causing hypercalcemia (>11.5 mg/dl) and cardiotoxicity

Clinical signs

– – (12-36 h after ingestion) Kidney failure » Anorexia » » Vomiting Tissue mineralization Cardiovascular abnormalities » Muscle weakness » arrhythmias

Toxicological Emergencies

• •

Diagnosis

– Hx of exposure – Usually discovered on routine Chem panel (↑blood Ca ++ )

Treatment

– Induce vom/activated charcoal if ingestion occurred with 2 h – Furosemide x 2-4 wk; increases Ca ++ excretion in urine – Prednisone x 2-4 wk; decreases Ca ++ reabsorption from bones/intesine – Calcitonin to lower blood Ca ++ concentration

Toxicologic Emergencies

–

Rodenticides

•

3. Bromethalin

-uncoupler of oxidative phosphorylation in CNS (stops production of ATP) -Causes cerebral edema -found in

Assault, Vengence, Trounce

-Toxic Dose Dog: 4.7 mg/kg Cats: 1.8 mg/kg

Clinical signs

(>24 h after ingestion of high dose; 1-5 d -low dose) – Excitement, tremors, seizures – Depression, ataxia

Rx

– – – (will take 2-3 wk to know if animal will survive) Purge GI tract if exposure recent Reduce cerebral edema with Mannitol and glucocorticoids Seizure control with Diazepam and Phenobarbital

Toxicologic Emergencies

•

Acetaminophen

• Common OTC drug for analgesia • Toxic dose: Dog—160-600 mg/kg Cat—50-60 mg/kg (2 doses in 24 h is almost always fatal) • Clinical signs (starts within 1-2 h of ingestion) – Vomiting, salivation – – – – –

Facial and paw edema

Depression Dyspnea Pale mm

Cyanosis due to methemoglobinemia

• • Px—poor Rx – – Induce vom/activated charcoal

Antidote

: N-Acetylcysteine (loading dose of140-280 mg/kg PO, IV, then at 70 mg/kg PO, IV QID x 2-3 d

Toxicological Emergencies

Toxicologic Emergencies

–

Metals

•

Lead toxicity more common in dogs than cats

– Source » Lead paint (prior to 1970’s) is primary source » Batteries, linoleum, plumbing supplies, ceramic containers, lead pipes, fishing sinkers, shotgun pellets –

Clinical signs

systems) » Anorexia » » Vom/dir Abd pain (Usually involves signs of GI and nervous -CNS signs do not show initially » Blindness, seizures, ataxia, tremors, unusual behavior

Toxicologic Emergencies

–

Metals

•

Lead toxicity

– Dx » » Large # nucleated RBC’s; basophilic stipling Blood lead conc >35 μg/ml – Rx » » Remove lead from GI tract (cathartic, Sx) Chelators (to bind the Pb in blood stream and hasten its removal) -Calcium EDTA (ethylene diamine tetra acetic acid) -Penicillamine » » IV fluids for dehydration and to speed removal via kidneys Diazepam, Phenobarbital to control seizures

Toxicologic Emergencies

–

Metals

•

Zinc Toxicosis

– Usually from ingested pennies, galvanized metal, zinc oxide ointment •

Clinical signs

– Vomiting – CNS depression – Lethargy •

Dx

– – Hx of exposure Clinical signs •

Rx

– – – Remove metal objects endoscopically or surgically IV fluid therapy Ca EDTA chelation

Toxicologic Emergencies

•

Ethylene Glycol (antifreeze; sweet taste

) • Lethal dose: Cat—1.5 ml/kg Dog—6.6 ml/kg • Signs (onset within 12 h of ingestion) – CNS depression, ataxia (may appear intoxicated) – – – – Vomiting PD/PU Seizures, coma, death Acute renal failure • Dx – – – Hx, signs Ethylene Glycol Poison Test—an 8 min test used in cats and dogs Calcium oxalate crystals •

Rx

– – – Emesis, adsorbents if ingestion within 3 h of presentation IV fluids, NaBicarb for acidosis Ethanol inhibits ethylene glycol metabolism Dogs (Cats): 20% ethanol—5.5 (5.0) ml/kg q6h x 5, then q8h x 4 – 4-methylpyrazole has been shown to be effective

Toxicological Emergencies

THE PROBLEM THE SOLUTION

Toxicologic Emergencies

•

Snail Bait (Metaldehyde, methiocarb

) – Metaldehyde mechanism unknown – Methiocarb is a carbamate and parasympathomimetic •

Signs

– – – – – – Hypersalivation Incoordination Muscle fasciculations Hyperesthesia Tachycardia Seizures •

Rx

– – Emesis and absorbents Pentobarbital, muscle relaxants to control CNS hyperactivity

Toxicologic Emergencies

•

Garbage Toxicity

– Common in dogs; not in cats –

Enterotoxin-producing bacteria include

• •

Strep, Salmonella, Bacillus

Signs (within min to h after ingestion) – Anorexia, lethargy – Vom/dia – Ataxia, tremors –

Enterotoxic shock can cause death

Rx – – – – – IV Fluid therapy Broad-spec antibiotics Intestinal protectants Muscle relaxers or Valium may be needed to control tremors Corticosteroids to counter endotoxic shock

Toxicologic Emergencies

•

Insecticides

•

Pyrethrins, Pyrethroids, Permethrins

– Common ingredients of flea/tick sprays, dips, shampoos, etc – If used according to instructions, toxicity rarely occurs; if overused, toxicity can result •

Signs

– Hypersalivation – Vom/dia – – Tremors, hyperexcitability or lethargy Later, dyspnea, tremors, seizures can occur •

Rx

– Bathe animal to remove excess – – Induce vomiting/charcoal/cathartics for ingestion Diazepam may be necessary for mild tremors – – Methocarbamol, a muscle relaxer, for moderate-severe tremors Atropine for hypersalivation and bradycardia

Toxicologic Emergencies

–

Insecticides

•

Organophosphates and Carbamates

– Inhibit cholinesterase activity (break down of Ach is inhibited) – – Highly fat-soluble; easily absorbed from skin and GI tract Found in dips, sprays, dusts, etc for fleas and ticks, and flys •

Signs

–

S

alivation – – – –

L U

acrimation rinary incontinence

Diarrhea D

yspnea – -May progress to –

E

mesis, gastrointestinal cramping Seizures, coma, resp depression, death •

Rx

– – – – Bathe animal Charcoal if ingested Atropine (0.2-0.4 mg/kg; half IV, half IM or SQ) Praloxime chloride (20 mg/kg BID till signs subside)—reactivates cholinesterase

Toxicologic Emergencies

•

Plant Toxicity

– Most common in confined and juvenile animals – – – Usually from ornamental, indoor plants Severity varies with plants ID scientific plant name (florist, greenhouse) • Araceae family (most from this family) – Dumb cane, split-leaf philodendron – Contain calcium oxalate crystals • Signs – – Hypersalivation, oral mucosal edema, local pruritis -Large amount of plant may cause: Vomiting, dysphagia, dyspnea, abd pain, vocalization, hemorrhage • Rx – – Rinse mouth with milk or water to remove Ca Oxalate crystals GI decontamination (protectants) may be needed

Dumb Cane (Dieffenbachia)

• •

aka Mother-in-law’s tongue Oral irritation; intense burning, excess salivation

• •

Split Leaf Philodendron

Oxalate crystals like Dieffenbachia Oral irritation; intense burning, excess salivation

Lily of the Valley

• • Contains cardiac glucosides Cardiac arrythmias, death

•

Azalea (Rhododendron)

Hypotension, cardiovascular collapse, death

Sago Palm

• • • ALL PARTS OF THE PLANT ARE TOXIC Coagulopathy Liver failure

Toxicologic Emergencies

•

Phone advice to give owners (legal issues) – Protect yourself from exposure before handling animal • Gloves, protective clothing – Protect yourself from animal because poisoned animals may act strangely – Protect animal from further exposure by removing pet from source – – Bring sample of vomit, feces, urine Bring container/package that toxin was in and a sample of the toxin (plant material, rat bait, etc)