What is Pet Poison Helpline?

Transcription

1 Back to the Basics: Approaching poisonings correctly, right from the start! February13, 2018 Renee Schmid, DVM Senior Consulting Veterinarian, Clinical Toxicology Pet Poison Helpline American Blvd. W., #725 Bloomington, MN Pet Poison Helpline 2018 What is Pet Poison Helpline? 24/7 animal poison control center Veterinary & human expertise 20 DVMs, 50 CVTs DABVT, DABT DACVECC DACVIM 7 PharmDs Case fee of $59 includes Unlimited consultation Fax or of case report Educational center Free webinars (archived) Tox tools Wheel of Vomit Pot of Poisons (toxic plants) Textbook iphone app Newsletters for vet professionals Free resources for clinics Videos Electronic material Clings us for info! Pet Poison Helpline and Nationwide 1

2 Nationwide & PET POISON HELPLINE working together Shared mission in highlighting the importance of preparing for accidents and poisonings in small animals Addressing the cost of veterinary care Nationwide covers the $59 Pet Poison Helpline fee when an insured pet is brought in to your hospital for care Enabling best medicine Pet owners with Nationwide spend twice as much on their pets than those without pet insurance 4 Pet Insurance With more than 35 years of experience protecting pets, there s nothing we haven t seen... 5 Available plans 2

3 Speaker Introduction Renee Schmid, DVM Senior Consulting Veterinarian, Clinical Toxicology DVM Supervisor Pet Poison Helpline Today s goals Discuss: Appropriate patient assessment Proper assessment of a toxicity Staff safety when handling symptomatic patients Most ideal drugs for toxicity management Common patient management needs General patient follow-up needs Patient and toxicity assessment 3

4 Much unhappiness has come into the world because of things left unsaid. Fyodor Dostoevsky, Russian novelist Questions to ask with toxin exposure: Is the patient stable? Any current/past medical concerns and medications? What is the signalment? What was the toxin and route of exposure? How much were they exposed to? How long ago did this occur? Where did the exposure occur? What other factors are involved? Patient assessment Is the patient stable? Assess vitals Current neurologic status Hydration status Lab results, if indicated Any current/past medical concerns? Longstanding medical disease Heart murmur Diabetes IMHA Recent illness or surgery Spay/Neuter Pancreatitis Current prescription and non-prescription medications 4

5 What is the patient s signalment? Patient assessment Species Species differences with toxicities Lilies Xylitol? Long Acting Anticoagulants (LAACs) Bromethalin Acetaminophen (APAP) NSAIDs Patient assessment What is the patient s signalment? Breed Brachycephalic breeds Increased risk with emesis ABCB1 (MDR-1) gene mutation risk Higher toxicity risk with certain drugs Collie 70%, long-haired whippet 65%, Australian shepherd 50% What is the patient s signalment? Age Age factors Hepatic function decreased <12-16 weeks of age Cardiac output more HR dependent in young animals Tachycardia vs bradycardia Potentially lower toxic dose for neonates or geriatric patients Renal compromise and hepatic impairment in older patients Patient assessment 5

6 Patient assessment What is the patient s signalment? Weight Difference between toxicity and non-toxic ingestions is often a thin line Accurate weights allow for proper assessment of toxicity risk Decontamination preferences in large vs small breed Added risks/concerns with obesity? Toxicity assessment What was the toxin? Rodenticides LAAC Bromethalin Cholecalciferol Corn cellulose Lilies True lilies (Lilium and Hemerocallis sp.) Calla (Zantedeschia sp.) and Peace lily (Spathiphyllum sp.) Peruvian (Alstromeria sp.) Lily of the Valley (Convallaria sp.) Gum Sugar-free does NOT mean xylitol Sugar alcohol does NOT mean xylitol Brand and flavor are important What is the route of exposure? Exposure route affects toxicity concern Liquid on the skin/haircoat Dermal, oral, ocular? Expansive glues Dermal vs. oral Hydrocarbons Dermal vs oral Corrosives Dermal vs oral Toxicity assessment 6

7 The dose makes the poison. Paracelsus, ( ) the father of toxicology Toxicity assessment What was the dose or amount exposed to? Chewed medication container Full bottle/almost empty/size when new Baits 1 block/1 pellet/1 bag/1 bucket Liquid ingestions Bowlful/few laps Diluted vs concentrated Toxicity assessment How long ago did this occur? Time frame is a large factor Rate of absorption Rapid/Immediate Regular ER/XR Effective decontamination methods When signs would be expected 7

8 Toxicity assessment Where did the exposure occur? Address other potential confounding factors Recognize potential severity differences Agricultural/industrial concentrations vs. residential Toxicity assessment Other factors to consider? Other animals involved Was the exposure accidental or malicious Other environmental factors Extenuating circumstances Toxicity assessment Easier to assess when dealing with medications and foods Strength Amount More difficult with chemicals Important to read the label and look for telling symbols or statements on containers Give little weight to expiration dates Studies done on many different rodenticides, chemicals and medications showed full potency many years after expiration dates Play it safe and consider full potency when determining severity 8

9 Caution Indicates a mild hazard Reading chemical labels Signal word usually found on cleaning products Product not likely to cause permanent damage as a result of accidental exposure if appropriate first aid is given Many laundry and automatic dishwasher detergents, disinfectants and all purpose cleaners fall in to this category Danger- Corrosive Reading chemical labels Indicates that greater precaution should be taken Signal word most often found on specialty products intended for rough jobs, such as oven cleaners and drain openers Accidental exposure to the eye or skin to the undiluted product or swallowing the undiluted product could cause long-term damage May be found on products which could ignite if exposed to open flame Don t let their panic become your panic!! 9

10 Staff safety Precautions when handling symptomatic patients Staff safety Dermal exposure Inhalation exposure Patient behavior changes Staff safety: Dermal exposure Corrosive exposures require Gloves Gowns or long sleeves Goggles 10

11 Staff safety: Inhalation exposure Masks Well ventilated area Phosphide pesticides Create phosphine gas Gas smells like garlic or rotten eggs Asthmatic-like symptoms Nausea Headache Zinc phosphide common ingestion and used in gopher bait peanuts Phosphine Gas Death Jan. 2, 2017 Amarillo, TX 4 children died, numerous others hospitalized Liquid aluminum phosphide product sprayed underneath mobile home EPA lists as a toxic category I Most dangerous types of chemicals Restricted use pesticide License required to purchase Staff safety: Patient behavior changes Example of toxins that alter patient behavior with aggression or dysphoria Amphetamines Caffeine Anti-depressants Theobromine Baclofen Recreational drugs CNS stimulants 11

12 Staff safety: Patient behavior changes Use caution: Medicating Restraining Monitoring vitals Moving Mentation and behavior can change suddenly Ideal drugs for poisoning management Decontamination needs Neurologic Renal Hepatic Cardiac Gastrointestinal Decontamination Ocular Tap water Eye wash Inhalation Oxygen Dermal Degreasing liquid dishwashing detergent 12

13 Emetics Decontamination Apomorphine Dogs only 0.03 mg/kg IV/0.04 mg/kg IM Xylazine (Rompun ) Cats only 0.44mg/kg IM Dexmedetomine (Dexdomitor ) Cats only 7mcg/kg IM (5-10mcg/kg IM) 3% Hydrogen peroxide Dogs only 1-2ml/kg (0.5-1tsp/10 pounds) Not to exceed 2 doses Anti-emetic Maropitant (Cerenia ) 1mg/kg SQ Metoclopramide (Reglan ) mg/kg SQ or IV Ondansetron (Zofran ) 0.5-1mg/kg PO or IV dogs 0.1-1mg/kg PO,IV,IM or SQ Dolasetron (Anzemet ) 0.6mg/kg PO, IV or SQ Decontamination Activated charcoal +/- Cathartic Toxiban Liqui-Char-Vet 1-5g/kg PPH typically recommends 1-2g/kg Consider 0.5g/kg for repeat doses in mildly symptomatic or very small patients Sorbitol: 1-3ml/kg Agitation Hyperactivity Neurologic management Acepromazine mg/kg IM, SQ, IV May need up to 1mg/kg in severely affected animals (amphetamines) Chlorpromazine 0.5-1mg/kg IM, IV May need as high as 10mg/kg in severe cases Butorphanol mg/kg IM, SQ, IV Cardiovascular sparing Ideal if hypotension/cv disease is a concern Ideal for short duration sedation Reverse with naloxone if needed 13

14 Neurologic management Tremors Methocarbamol mg/kg IV, PO, rectal slurry IV administration preferred Benzodiazepines? Diazepam and midazolam Generally less effective May worsen neurologic signs with some toxins Amphetamines SSRIs Seizures Neurologic management Diazepam/Midazolam (Valium /Versed ) 0.5-1mg/kg IV to effect Avoid use in most toxicities with stimulatory effects i.e. amphetamines, methylphenidate, SSRI, SSNRI Exception: Caffeine and methylxanthines Phenobarbital 3-4mg/kg IV to effect, up to 8mg/kg Levetiracetam (Keppra ) 30-60mg/kg IV to effect Neurologic management Cerebral edema Mannitol mg/kg IV slowly over minutes Repeat q 4-6 hours as needed Ensure patient is hydrated and stable before administering IV fluids should be discontinued during administration 14

15 Steroids and CNS Toxins Steroids are not recommended for improving outcome or reducing ICP in humans Not shown to be beneficial with bromethalin toxicity Possible complications: GI bleeding Immunosuppression Delayed wound healing Perpetuation of a catabolic state Hyperglycemia Renal management Fluid therapy Crystalloids Furosemide 2-4mg/kg IV 0.3-1mg/kg/hr IV CRI Mannitol gm/kg IV slowly over 20 minutes Up to 1-2g/kg IV Hepatic management Mild hepatic enzyme elevations S-Adenosyl-Methionine (SAMe) Denosyl SAMe with Milk thistle Denamarin 15

16 Hepatic management Risk for Hepatic necrosis 20% solution should be diluted to N-Acetylcysteine (NAC) 140mg/kg IV or PO followed by 70mg/kg q 6 hours 7 doses if liver elevations do not occur 17 doses if liver elevations occur 5% before administering IV or PO IV administration requires a filter needle Capsules available OTC in many health stores PO may be an option due to ease in administration unless activated charcoal is given or uncontrolled emesis Can be given at home Tachycardia Cardiac management Acepromazine mg/kg IV, IM, SQ Used when in conjunction with agitation +/- hypertension Butorphanol mg/kg IV, IM, SQ Used in conjunction with agitation +/- hypertension Beta blockers Esmolol mg/kg IV over 1-2 minutes followed by CRI at mg/kg/min Propranolol 0.02mg/kg IV over 2-3 minutes. Repeat in 20 minutes until effect is seen, up to 0.1mg/kg Metoprolol 5-50mg TOTAL PO divided q8-12 hours Cardiac management Bradycardia Atropine mg/kg IV Calcium gluconate 10% Reserved for calcium channel blocker toxicities ml/kg IV slowly followed by ml/kg/hr CRI Monitor ECG during administration 16

17 Cardiac management Hypertension Acepromazine mg/kg IV, IM, SQ Amlodipine (arterial vasodilator) Dogs mg/kg PO q hours Systolic 160mmHg (Normal 120mmHg) MAP >130mmHg (Normal 100mmHg) Cats mg PER cat q hours May take several hours for full effect DO NOT give if bradycardic! Beta blocker Esmolol mg/kg IV over 2-5 minutes followed by mcg/kg/min CRI Propranolol mg/kg IV q 8-12 hours Oral Dogs mg/kg q 8-12 hours Cats 0.25mg PER cat PO q 8-12 hours Others Hydralazine, ACE inhibitors, isoflurane Hypotension Systolic 90mmHg or MAP 60mmHg Normal 120mmHg or MAP 80mmHg Cardiac management IV fluids Crystalloids 20ml/kg bolus over minutes Repeat 2-3x as needed Colloids (VetStarch = 6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride injection) 5ml/kg bolus over 15 minutes Repeat 2-3x as needed Vasopressors Dopamine, norepinephrine, dobutamine, vasopressin, epinephrine, digoxin Gastrointestinal management Anti-emetic Maropitant (Cerenia ) 1mg/kg SQ Dogs 2mg/kg PO Cats 1mg/kg PO (extra-label) SQ labelled for 5 days Metoclopramide (Reglan ) mg/kg q 6-8 hours SQ, SC, IM, PO mg/kg/hour CRI Extra-label in cats with same dosages Ondansetron (Zofran ) mg/kg q 12 hours IV 0.5-1mg/kg PO Extra-label for dogs and cats Dolasetron mesylate (Anzemet ) 0.6mg/kg q 24 hours IV, SQ, PO 17

18 GI protectants Gastrointestinal management H2 blocker Famotidine 0.5-1mg/kg q hours IM, SQ, IV, PO Cimetidine 5-10mg/kg q 6-8 hours PO Ranitidine 1-2mg/kg q 8-12 hours dogs PO 3.5mg/kg q 12 hours PO Sucralfate 0.5-1g total q 8 hours PO Proton pump inhibitors Omeprazole 0.5-1mg/kg q 24 hours PO PG E1 analog Misoprostol 3-5mcg/kg q 8 hours PO Prolonged use may lead to diarrhea Avoid handling if pregnant Gastrointestinal management Anti-diarrheals Ileus Metronidazole Probiotics Fiber Bland diet Potential ileus Metoclopramide Intralipid emulsion Used for certain fat-soluble toxins 18

19 General patient follow-up needs Labwork often re-evaluated after discharge GI protectants Hepatoprotectants Monitoring for redevelopment of signs Permethrin toxicity in cats Dermal and oral ulceration monitoring Labwork monitoring Vitamin D3/cholecalciferol Renal toxicities Hepatic toxicities Long-term follow-up needs are rare Quarterly Newsletters Sign up for Video Series Tox Goodies! Free to order: 19

20 Blackwell s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology 2 nd Edition Drs. Lynn Hovda, Ahna Brutlag, Robert Poppenga, Katherine Peterson Provides concise, bulleted information focused on the most important facts needed when treating a poisoned cat or dog Carefully organized for ease of use in an emergency, with important toxicants arranged alphabetically within categories Details clinically relevant information on the most common toxicants encountered by small animals Presents a wealth of color photographs to aid in plant identification Includes 14 new topics to this edition covering cyclosporine A, sleep aids, tacrolimus, bath salts, synthetic marijuana, poisonous lizards, imidacloprid, spring bulbs, and sodium monofluoroacetate Paperback May pages $ CAN $ PPH is hiring! Veterinary technician openings-work from the comfort of your home! Hire from 23 states Daytime and evening shifts available FT & PT weekend positions We offer competitive pay and benefits! Summer seasonal positions now available for DVM/CVT students (not available for remote employment) Questions? Need more info? Visit our careers page at petpoisonhelpline.com/veterinarians/jobopportunities or careers@safetycall.com CE Schedule Free, RACE-Approved Webinars 20

21 Thank you for attending! CE credit FAQs 1. When will I get my CE certificate? We ll it to you by the end of the day tomorrow. 2. I attended the webinar but wasn t the person who logged in. Can I still get interactive CE credit? Yes. Send your name and address to info@petpoisonhelpline.com by 1pm central time on February 14, 2018 (strict deadline). 3. Can I watch the recorded webinar online for CE credit? Yes. You can receive noninteractive CE credit. Go to the For Vets page on our website, for more info. Comments? Questions? us! info@petpoisonhelpline.com 21