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Intoxication, caution when giving prognosis as full effects of poisoning…
Intoxication
specific treatments
decontamination
activated charcoal
GIT demulcent and adsorbent
gastric lavage
use if emesis unsuccessful or contraindicated
GA so airway can be protected w an ET tube
onlu small quantities of lavage fluid (warm water/saline at 5-10ml/kg) should be used at a time and it should be drained from stomach as this reduces the possibility of increasing gastric pressure and forcing toxic material through pylorus into small intestines
repeat irrigation process several times until lavage fluid is clear
bathing
dilution
reliable emetics
dogs: injection of apomorphine
(0.04mg/kg IM or IV
can lead to prolonged or distressing retching
cats IM xylazine
has a sedative effect, do not use if toxin itself has a sedative effect
acid/alkali
corrosive burns on skin or in mouth, ptyalism, vomiting, diarrhoea
wash skin, mouth, eyes with copious amounts of water
GI protection with sucralfate and H2 receptor antagonists
arsenic
vomiting, abdominal pain, watery diarrhoea, hypothermia, weak pulses and dehydration
dimercaptosuccinic acid - use if signs progressive or with very high exposure
control shock, acid base and electrolyte disturbances
control hypothermia
induce emesis
activated charcoal
management of vomiting and diarrhoea
chocolate
bloating, vomiting, diarrhoea, PD, agitation, tachycardia, tachypnoea, cardiac arrhythmia, hypertension, ataxia, tremor, seizure
control neuro signs and cardiac arrhythmias
reduce body temperature
induce emesis or gastric lavage
activated charcoal
ethylene glycol
stupor, stumbling, ataxia, collapse, PD/PU, V+, acute renal failure
antidote - fomepizole, ethanol
induce emesis, control acid base disturbances, aggressive fluid therapy
grapes and raisins
vomiting, anorexia, diarrhoea, abdominal pain, acute renal failure
induce emesis, activated charcoal, treatment of acute renal failure
lead
anorexia, tremors, seizures, v+, d+, abdominal pain
antidote
succimer (meso-2,3 dimercaptosuccinic acid, DMSA) Ca-EDTA
Manage seizures, induce emesis
Lilies
only seen in cats, V+, anorexia, lethargy, PU/PD, acute renal failure, seizures
induce emesis, activated charcoal, IV fluids, treatment of acute renal failure
macadamia nuts
v+, d+, hindlimb weakness
induce emesis, activated charcoal, supportive care
marijuana
ataxia, CNS depression, tremors, vomiting, urinary incontinence, bradycardia, hypothermia, mydriasis
induce emesis, supportive care and control neurological signs
metaldehyde (slug pellets)
muscle tremors, extensor rigidity, seizures, hyperthermia
induce emesis, activated charcoal, control tremors/seizures, control hyperthermia, supportive care
NSAIDs
vomiting, haematemesis, diarrhoea (melaena), PD/PU/ pale mm,
induce emesis, activated charcoal, H2 receptor antagonist, sucralfate, fluid therapy, supportive care
onion/garlic
vomiting, lethargy, pale mm and brown urine due to haemolytic anaemia
induce emesis, activated charcoal, fluid therapy, blood transfusion if necessary
paracetamol
lethargy, depression, inappetence, dyspnoea, vomiting, pale/blue/borwn mm, keratoconjunctivitis sicca
N-acetylcysteine
induce emesis, S-adenosyl methionine, cimetidine, vitamin c, Supportive care
petroleum products and turpentine
salivation, excessive licking, vomiting, inflamed skin or oral cavity, panting, wheezing, coughing
respiratory support, fluid therapy, pain relief, management of aspiration pneumonia, antibiotics, bathing to remove products from skin
pyrethroids
mainly cats
tremors, ataxia, hyperexicitability, seizures, hyperthermia, hyper salivation
bathing to remove topically applied products, induce emesis if ingested, control CNS signs and supportive care
may need E collar, clip fur to prevent self grooming
yew
vomiting, muscle weakness, seizures, bradycardia or tachycardia, respiratory distress, coma. death
induce emesis, treat cardiac dysrhythmias
emesis
do not induce if
toxin is corrosive in nature
severe CNS depression is apparent, due to risk of inhalation pneumonia
animal seizuring
animal has reduced gag reflex
animal is bradycardic
anticoagulant rodenticide poisoning
clinical signs unlikely to develop until 4-5 days following ingestion
clinical signs are associated with defective secondary haemostasis
e.g. acute haemorrhage into body cavities such as pleural space, mediastinum, abdomen, joints
subcutaneous bleeding or from mucosal surfaces
hypovolaemic shock
cough, dyspnoea, lameness
petechial haemorrhages uncommon, some will have mild-marked thrombocytopenia of unknown aetiology associated with rodenticide toxicity
differentials
Intra-cavitary haemorrhage
trauma
neoplasia e.g. ruptured splenic haemangiosarcoma, diffuse tumours such as mesothelioma
pericardial disease
other disorders of secondary haemostasis
hepatic disease (the liver is responsible for synthesis or most clotting factors, as well as being the site of activation of vitamin K dependent factors)
DIC
angiostrongylus vasorum infection
inherited coagulopathies e.g. haemophilia a and b
vitamin k deficiency (due to failure to absorb vitamin K from small intestine e.g. EPI, severe inflammatory bowel disease, bile duct obstruction
disorders of primary haemostasis
vascular and platelet response to bleeding, defects which commonly cause bleeding from mucosal surfaces and petechial/ecchymotic haemorrhages
thrombocytopaenia: destruction of platelets e.g. immune mediated thrombocytopaenia, sequestration of platelets e.g. DIC, vasculitis or lack of production (bone marrow disease)
impaired platelet function
inherited disorders e.g. von willebrands disease or acquired disorders e.g. ehrlichiosis, hepatic disease, pancreatitis, DIC
diagnosis
haematology
PCV and TS
EDTA sample and fresh smears submitted to an external lab for full haematological analysis
any anaemia should become regenerative 3-5 days following bleeding (anisocytosis, polychromatic and increased reticulocyte count)
some patients with rodenticide poisoning will be thrombocytopenia for unknown reasons
evaluation of haemostasis
PT +APTT
Blood collected in citrate tubes
will be prolonged
search for source of haemorrhage
abdominal USS or thoracic/abdominal radiography
treatment
gastric decontamination only in patients known to have ingested toxin in last 3 hours
vitaminK
supportive care
History
signalment (age, breed, sex) and weight
previous medical hx
vaccination hx
dietary hx
brand/home made etc, if suspect nutritional intoxication obtain product label and lot number
current medications
other animals in household
timeline of clinical signs and type
number of affected animals including neighbouring animals
pets environment (indoor v outdoor) and time of year
urban v rural location
recent renovations/updates etc, indoor and outdoor plants
human medications/supplements in pets environment
recent use of chemicals e.g. rodenticides, insecticides, herbicides
stabilise patient
Patent airway and adequate ventilation
HR, heart rhythm and blood pressure and cardiac arrhythmias
tx systemic hypo or hypertension as needed
hydration status, serum electrolyte concentrations, acid base balance
CNS abnormalities
seizure, excitation, depression
hypo or hyperthermia
supportive care and other diagnostics once stable (CBC, biochem, urinalysis, radiographs, USS), PT and clotting times
specific toxological testing
Whole blood for heavy metal analysis (lead)
blood cholinesterase's (organophosphate poisoning)
presence of pesticides (anticoagulant rodenticides)
serum or plasma can be analysed for levels of some metals (zinc), drugs, alkaloids and electrolytes (useful for sodium chloride poisoning or water intoxication)
stomach contents (vomitus, freeze upon collection) can be used for detecting pesticides, metals, baits, alkaloids and drugs
urine (chilled or frozen) can be used for some metal analysis, drugs and their metabolites and alkaloids
CNS abnormalities (excitation and seizures)
toxicologic R/O
strychnine (rapid onset, rigidity, hyperaesthesia, wooden horse like stance)
metaldehyde (hyperthermia, tremors)
amphetamines or cocaine (sympathomimetic effects and hyperthermia)
tremorgenic mycotoxins from eating mouldy foods e.g. GI signs, hyperthermia and tremors
cold medications (sympathomimetic effects, hyperthermia)
organophosphate or carbamate pesticides
pyrethrin/pyrethyroid type pesticides (permethrin in cats, tremor, shaking, ataxia, seizures, GI signs)
organochlorine pesticides (tremors, shaking, ataxia, seizures)
chocolate, caffein, theobromine, methylxathines
PU/PD, GI and CV effects
zinc phosphide (GI signs, shaking, dyspnoea due to pulmonary oedema)
bromethalin toxicosis (rat/mouse bait) - paresis, weakness, ataxia, tremor
lead
GI signs, haematology abnormalities (nucleated RBCs, basophilic stippling and anemia)
metronidazole toxicosis
dogs with repeated/high dosage
nystagmus, ataxia, weakness, paresis, seizures
nicotine
spontaneous vomiting, tremors, CV effects
tricyclic antidepressant toxicosis
agitation, nervousness, ataxia, CV effects
non toxicologic R/O
trauma/head trauma
meningitis (fever, hyperaesthesia, neck stiffness, pain, funds lesions possible if optic nerve affected
hydrocephalus
large, rounded head, divergent strabismus, seizures, brain USS possible if open fontanelle
intracranial neoplasia
primary or secondary brain tumour, typically older animals and near deficits almost always asymmetrical
congenital PSS (<6m, small liver, certain breeds)
rabies (acute behaviour changes, excitation, paralysis, endemic region)
canine distemper
young dogs, fever, respiratory +/- GI signs usually precede CNS signs
hypocalcaemia or hypercalcaemia
hypo - tremor/tetancy
hypercalcaemia induced kidney injury can cause uraemia signs
hypoglycaemia
disorientation, ataxia, seizures, serum glucose <60mg/dL
idiopathic epilepsy
dogs 1-5 years of age, diagnosis of exclusion
primary or secondary erythrocytosis causing hyperviscosity
PCV 65%->80%, brick red mm
uraemia
secondary to AKI or CKD
endotoxaemia/septic shock (haemorrhagic GI signs, progressive weakness, abdominal pain)
CNS abnormalities e.g. CNS depression and or seizures
toxicologic R/O
ivermectin/moxidectin and other avermectin toxicosis
ataxia, weakness, depression, tremors, seizures, blindness
marijuana ingestion (ataxia, hypothermia, urinary incontinence)
benzodiazepines ingestion
hyporeflexia, ataxia, CNS excitation, paradoxical reaction
barbiturate overdose
short or long acting
coma, hypothermia, weakness, ataxia
ethylene glycol
ataxia, disorientation, GI signs
methanol or ethanol ingestion
GI signs, ataxia, weakness, depression
propylene glycol (antifreeze)
depression, ataxia, GI signs
baclofen or other centrally acting muscle relaxant ingestion in dogs
vocalisation, ataxia, disorientation, coma, hyperthermia
amitraz insecticide exposure (depression, ataxia, CV effects, paralytic ileus
non-toxicologic R/O
thiamine deficiency in cats (cats mainly raw fish diet)
polyradiculoneuritis/coonhound paralysis
ascending flaccid paralysis, often evidence of muscle pain
FIP
blepharospasm due to iritis, fever, weight loss, ataxia, seizures
feline leukaemia
lymphadenopathy, non-regenerative anaemia
feline panleukopenia
fever, GI signs, ataxia, neutropenia
Muscle weakness, paresis, paralysis
toxicologic R/O
metronidazole
bromethalin rodenticide
macadamia nut ingestion in dogs (weakness, ataxia)
concentrated tea tree oil exposure: melaleuca oil both cats and dogs - weakness, ataxia, CNS depression
non-toxicologic R/O
polyradiculoneuritis
botulism (ascending paresis and paralysis, muscles of pharynx can be affected)
tick paralysis
flaccid ascending paralysis
rapid improvement of signs <24h later after tick removal
aortic thromboembolism
cold extremities, weakness, firm and painful gastrocnemius muscles
profound anaemia
measure PCV
severe hypokalaemia, hyponatraemia, hypovolaemia, hypo or hyperthermia (measure parameter)
degenerative spinal cord diseases e.g. mentation, cranial nerve function intact
acute blindness
toxicologic R/O
lead (seizures)
ivermectin, moxidectin and other ivermectin toxicosis (seizures)
salt poisoning in dogs PD, GI signs, tremors, ataxia, seizures, serum sodium >160 mEq/L is strongly supportive
non-toxicologic R/O
retinal detachment or haemorrhage (fundic exam, ocular USS)
Glaucoma - measure IOP
Trauma
penetrating injury of head, face
acute cataract (opthalmic exam)
optic neuritis (fundic exam)
optic visual pathway disorders
optic chiasm, optic radiation, occipital cortex
sudden acquired retinal degeneration (hyperadrenocorticism-like signs, electroretinogram to confirm)
acute kidney injury, acute uraemia
toxicological r/o
ethylene glycol toxicosis (ataxia, altered mentation/depression, GI signs, urine may fluoresce with woods lamp, azotemia, calcium oxalate monohydrate crystalluria appear after kidney injury has occured)
easter lily, tiger lilies, rubric or japanese show lilies, day litlies
ingestion in cats - initially GI signs, azotaemia generally 24-72h after ingestion
cholecalciferol rodenticide and other vitamin D3 analogues
initial GI signs, azotaemia, hypercalcaemia with hyperphosphataemia (differentiates from hypercalcaemia of malignancy and hyperparathyroidism)
grapes and raisins
initial GI signs, then azotaemia in >24h, possible pancreatitis
NSAIDs
ibuprofen etc
initially GI signs then azotaemia in 24-73h after acute ingestions
zinc toxicosis
acute haemoglobulinaemia
non-toxicological r/o
renal infiltration
lymphoma - usually symmetrical nephromegaly, CNS signs common due to brain mets
renal thromboembolism
infectious
pyelonephritis, leptospirosis, borreliosis, rocky mountain spotted fever, feline infectious peritonitis
urinary tract obstruction (bladder palpation, abdominal USS to evaluate kidneys, ureters
CKD - end stage
ischaemic kidney injury and uraemia
hypotension, trauma, shock, anaphylaxis, myoglobulinaemia, urinalysis for renal casts, discolouration
amyloidosis
notably sharper dogs, abyssinian cats
hypercalcaemia
Lymphadenopathy, hepatosplenomegaly possible with lymphoma, rectal palpation for anal sac mass with anal sac adenocarcinoma, malignancy and primary hyperparathyroidism typically cause concurrent hypophosphataemia
transfusion reaction
acute hepatic injury
toxic r/o
mushrooms (delayed onset GI signs 12h after eating, acute liver injury in 1-3 days)
blue-green algae (stagnant water) acute onset GI signs, hypovolaemic shock
iron (e.g. multivitamin ingestion)
GI signs, hypovolaemic shock, acute liver injury in 1-2 days
acetaminophen toxicosis
cats > dogs
methaemoglobinaemia within a few hours, GI signs, increased liver enzymes in 1-3 days
alfatoxin
xylitol
other drugs
non - toxic r/o
hepatic lipidosis
cats - period of stress, anorexia, obesity
hepatic neoplasia
infectious hepatitis
leptospirosis, infectious canine hepatitis, canine herpes virus, feline cholangiohepatitis, liver abscess, histoplasmosis, coccidioidomycosis, babesiosis, toxoplasmosis, some rickettsial dz, FIP
septicaemia, endotoxaemia
vomiting, diarrhoea, hypothermia, collapse
copper storage diseases e.g. bedlington terrier
heatstroke - high body temp
shock
weak pulse, poor capillary refill time, progressive weakness
presence of acute oral lesions/ulcers
toxic r/o
acid ingestion (corrosive lesions on lips, gums, tongue, salivation, vomiting, fever
alkali ingestion (same as with acid, oesophageal perforation more likely)
cationic detergents
several disinfectants
oral burns, salivation, vomiting, fever
alkaline battery chewing/ingestion (oral burns, salivation, vomiting)
potpurri ingestion (cats>dogs) oral burns, salivation, vomiting, tongue protrusion, fever
bleaches
bleachlike smell, salivation, vomiting, wheezing, gagging,
ingestion of phenolic compound esp cats - heinz body anaemia and haemolysis may be seen
non toxic r/o
uraemia stomatitis
uraemia halitosis, azotaemia, GI signs
periodontal disease - dental calculus/gingival lesions
trauma - fb, recent tooth fracture
electrical cord chewing (sharply dermarcated ulcers, dyspnoea due to noncardiogenic pulmonary oedema
systemic lupus erythematous and other autoimmune disease (lesions are characteristically at the mucocutaneous junction, joint pain, other systemic signs can be present
infectious
feline calicivirus infection, FeLV, FIV, nocardiasis, ulcerative necrotising stomatitis, fusobacterium spp infection
acute methemoglobinaemia (heinz body anaemia, haemolysis or blood loss (anaemia)
toxic r/o
acetaminophen
chocolate brown coloured mm within hours, dyspnoea
naphthalene mothball ingestion
haemolysis
onions and garlic toxicosis
haemolysis in 2-3 days, anaemia, coffee coloured urine
zinc toxicosis
metallic object in GIT, gastritis, pancreatitis, haemolysis, haemoglobulinuria
iron
anticoagulant rodenticides
Lethargy, dyspnoea due to pulmonary haemorrhage, persistent bleeding at venupuncture site, increased PT +/- aPTT
envenomation
other drugs e.g. local anaesthetic toxicosis
non-toxic r/o
trauma
IMHA (spherocytosis +/- agglutination on blood smear)
thrombocytopaenia (immune mediated or infectious, commonly drug induced, platelet count)
CKD (smaller kidneys, azotaemia, uraemia halitosis, oral ulcers
infectious
erlichiosis, FeLV, hookworms, mycoplasma haemofelis, babesiosis, serological testing, faecal floatation, blood smear
DIC (2ry to schock, neoplasia, septicaemia, viral infections, pancreatitis
inherited bleeding disorders
cause of epistaxis (trauma, infectious, nasal polyps, malignant neoplasm, systemic bleeding disorder, systemic hypertension
cardiac arrhythmias
toxic r/o
foxglove
lily of valley
oleander
bufo toads
azalea
antidepressant toxicosis
non-toxic ro
automobile trauma
gastric dilation and volvulus (abdominal distension, dyspnoea, shock, radiographs)
severe anaemia
severe hypokalaemia
acidosis
hypoxaemia
primary heart disease (cardiomyopathy, valvular heart disease, congenital heart problems, heart worm infestation)
murmur, cardiomegaly or evidence of congestive heart failure
dyspnoea due to pulmonary oedema
toxic r/o
petroleum (hydrocarbon smell on breath, salivation, voiting, CNS depression, diarrhoea, aspiration)
zinc phosphide
smoke inhalation (dyspnoea, collapse, panting, shock, smell of smoke on fur)
organophosphate or carabamate pesticides
paraquat herbicide (progresive dyspnoea, panting, delayed onset after exposure)
some organic arsenals
non toxic r/o
cardiogenic
multiple causes of LSCHF
non cariogenic e.g. seizures, head trauma, electrical shock, drowning and near drowning
Gastrointestinal signs
toxic r/o
garbage poisoning
vomiting, diarrhoea, dehydration and abdominal pain
chocolate toxicosis (PD/PU, vomiting, hyperactivity, tachycardia)
fertiliser, v+, d+, PD
NSAID toxicosis
initial stages GI signs with or without blood in vomitus, diarrhoea
endotoxins and enterotoxins STAPHYLOCOCCAL, CLOSTRIDIAL, ECOLI, SALMONELLA
severe GIT signs, progressive lethargy, dehydration, hypothermia
zinc oxide (diaper rash cream) mild to severe gastritis
iron toxicosis
asenical herbicides
castor beans
initial GIT signs within several hours
insoluble calcium oxalate containing plants
philodendron, peace lily
vomiting, diarrhoea, oral swelling, salivation
zinc phosphate
GIT + CNS, pulmonary oedema, liver and kidney damage possible
non toxic r/o
dietary indiscretion (recent change in diet)
intestinal parasites
FB
infectious e.g. feline panleukopenia, canine distemper, canine parvovirus, canine coronavirus, infectious canine hepatitis, leptospirosis, salmonellosis
GDV
intussception
liver disease (2ry to gastric ulceration, evaluate liver parameters in serum and pre and post prandial bile acids)
kidney diseases
endocrine e.g. DKA, hypoadrenocorticism
sudden change in environment
IBD
Hypernatraemia (measured serum sodium over 160mEq/L in dogs and over 165mEq/L in cats
toxic r/o
paintball ingestion (hx, PD, v+, d+ ataxia)
salt toxicosis
activated charcoal administration
sea water ingestion
non toxic r/o
due to pure water loss (nephrogenic diabetes insidious, heatstroke, fever, burns, no access to water)
hypotonic water loss (severe diarrhoea, vomiting, diabetes mellitus, polyuric kidney disease, hyperadrenocorticism)
hypoglycaemia
toxic r/o
ingestion of xylitol containing products - dogs - seizures, acute hepatic damage and coagulopathy
ingestion of oral diabetic/hypohlycaemic agents (sulfonylureas)
non toxic r/o
insulinoma
acute hepatic disease, PSS
functional hypoglycaemia e.g. idiopathic in neonates, insufficient caloric intake in young puppies and kittens, severe exercise
intestinal parasitism
hypoadrenocorticism
leiomyosarcoma/smooth muscle cell tumour
endotoxaemia
caution when giving prognosis as full effects of poisoning may not be apparent immediately. Some poisons have delayed or long term effects e.g. non-regenerative anaemia following ingestion of oestrogens, renal failure following ingestion on NSAIDs
when to suspect poisoning: history, severe V+/D+ without prior signs of malaise (vomitus may contain abnormal material or be abnormally coloured), acute CNS signs, significant clinical signs which do not fit a common presentation.
usually sudden onset and progress rapidly, prodromal signs usually absent
see 'toxicology' notes