Pet Poisoning and Medication Safety Tips

Thought Leadership Series: Pet poisoning and medication safety tips

By Justine A. Lee, DVM, DACVECC Associate Director of Veterinary Services Pet Poison Helpline, a division of SafetyCall International and

By Renee Lupo, R.Ph., FACA, FACVP Technical-Services Pharmacist

Wedgewood Pharmacy ©2011 Wedgewood Pharmacy Contents About the authors...... 3 About Pet Poison Helpline...... 4 About Wedgewood Pharmacy...... 4 Human medications toxic to dogs and cats...... 5 Top 10 human medications involved in pet poisonings...... 5 Additional tips for medication safety...... 7 Pet poison ﬁrst aid kit...... 8 2 Safety tips regarding handling and administering pet medications...... 10 Read the label...... 10 Follow the instructions...... 10 Additional safety tips for handling pet medications...... 11 8 Questions veterinarians should ask before treating poisoned patients...... 12 Guide to history taking for the potentially poisoned pet...... 14 Pet Information...... 14 Medication...... 15 Plant...... 15 Household or garden chemical...... 15 Rodenticides...... 16 Scenario: What exactly has transpired?...... 16 Inducing vomiting...... 17 Effective emetics and how to use them...... 18 Dogs...... 18 Cats...... 19 Alternative decontamination methods...... 19 Harmful emetic agents...... 20 Other considerations...... 20

Customer Care Specialists and pharmacists are available: Pet Poison Helpline Monday - Friday 8:00 a.m. to 8:00 p.m. Eastern Available 24/7/365 Saturday 9:00 a.m. to 5:00 p.m. Eastern 800.213.6680 PetPoisonHelpline.com 800.331.8272 WedgewoodPetRx.com 2 Justine A. Lee, DVM, DACVECC Renee Lupo, R.Ph., FACA, FACVP Associate Director of Veterinary Services Technical-Services Pharmacist Pet Poison Helpline, a division of Wedgewood Pharmacy SafetyCall International Renee Lupo, R.Ph, F.A.C.A., F.A.C.V.P., technical- Dr. Justine Lee is a board-certified emergency Services Pharmacist for Wedgewood Pharmacy, is critical care veterinary specialist, and is currently the company’s lead technical/clinical pharmacist, the Associate Director of Veterinary Services for Pet working with prescribers and their staff to develop Poison Helpline. For the previous five years, she custom formulations. She also manages all was on faculty as an Assistant Clinical Professor at technical training for the company’s pharmacy the University of Minnesota College of Veterinary professionals and is a member of the Formula- Medicine. Change Control Committee and Quality Review Board of the company. She has been in the Dr. Lee graduated from Virginia Tech with a BS in pharmacy profession since 1977 and has worked at Animal Sciences, and then obtained her veterinary degree at Cornell Wedgewood since 1994. University. She pursued her internship at Angell Memorial Animal Hospital, which is affiliated with the Massachusetts Society for the Lupo is experienced in all aspects of the compounding pharmacy Prevention of Cruelty to Animals (MSPCA). In addition, she has also specialty and has developed unique expertise in sterile compounding completed an emergency fellowship and residency at the University of and compounding formulations. Her focus on veterinary Pennsylvania. Currently, she is 1 of approximately 450 board-certified compounding includes specialization in veterinary medications veterinary specialists world wide in emergency and critical care, and and veterinary ophthalmology. She has attained certifications is a Diplomate of the American College of Veterinary Emergency and in Pharmaceutical Care and Compounds for Veterinary Patients; Critical Care (DACVECC). Advanced Canine and Advanced Feline Therapeutics; and Avian and Exotic Pet Pharmacotherapy. Previously, she was pharmacist-in-charge Dr. Lee has been published in numerous veterinary journals, for an independent pharmacy. including the Journal of American Veterinary Medical Association, the Journal of Veterinary Emergency Critical Care, and the Journal Lupo is a member of the International Academy of Compounding of Veterinary Internal Medicine. She is also the author of two Pharmacists; the New Jersey Academy of Compounding Pharmacists; humorous pet reference books entitled “It’s a Dog’s Life... but It’s Your and is a Fellow in the American College of Apothecaries; and the Carpet” and “It’s a Cat’s World... You Just Live In It.” Dr. Lee lectures American College of Veterinary Pharmacists. throughout the world on emergency and critical care, and recently was honored with the North American Veterinary Conference Small Lupo holds a B.S. degree in Pharmacy from the Philadelphia College Animal Speaker of the Year award for 2011. of Pharmacy at the University of the Sciences in Philadelphia.

Top 10 human medications involved in pet poisonings by Ahna Brutlag, DVM, MS (Toxicology) Assistant Director of Veterinary ServicesPet Poison Helpline Below is a list of the top 10 human medications most frequently ingested by pets, along with some tips from the veterinarians at Pet Poison Helpline on how to prevent pet poisoning from these common household drugs.

1. NSAIDs (e.g., Advil®, Aleve® and Motrin®) Topping our Top 10 list are common household medications called non-steroidal anti-inﬂammatories (NSAIDs), which include common names such as ibuprofen (e.g., Advil and some types of Motrin) and naproxen (Aleve). While these medications are safe for people, even one or two pills can cause serious harm to a pet. Dogs, cats, birds and other small mammals (ferrets, gerbils and hamsters) may develop serious stomach and intestinal ulcers as well as kidney failure.

2. Acetaminophen (e.g., Tylenol®) When it comes to pain medications, acetaminophen (e.g., Tylenol) is certainly popular. Even though this drug is very safe for humans, even children, this is not true for pets — especially cats. One regular strength tablet of acetaminophen may cause damage to a cat’s red blood cells, limiting their ability to carry oxygen. In dogs, acetaminophen leads to liver failure and, in large doses, red blood cell damage.

3. Antidepressants (e.g., Effexor®, Cymbalta®, Prozac®, Lexapro®) While these antidepressant drugs are occasionally used in pets, overdoses can lead to serious neurological problems such as sedation, incoordination, tremors and seizures. Some antidepressants also have a stimulant effect leading to a dangerously elevated heart rate, blood pressure and body temperature. Pets, especially cats, seem to enjoy the taste of Effexor and often eat the entire pill. Unfortunately, just one pill can cause serious poisoning.

4. ADD/ADHD medications (e.g., Concerta®, Adderall®, Ritalin®) Medications used to treat Attention Deﬁcit Disorder/Attention Deﬁcit Hyperactivity Disorder contain potent stimulants such as amphetamines and methylphenidate. Even minimal ingestions of these medications by pets can cause life-threatening tremors, seizures, elevated body temperatures and heart problems.

5. Benzodiazepines and sleep aids (e.g., Xanax®, Klonopin®, Ambien®, Lunesta®) These medications are designed to reduce anxiety and help people sleep better. However, in pets, they may have the opposite effect. About half of the dogs who ingest sleep aids become agitated instead of sedate. In addition, these drugs may cause severe lethargy, incoordination (including walking “drunk”), and slowed breathing in pets. In cats, some forms of benzodiazepines can cause liver failure when ingested.

6. Birth control (e.g., estrogen, estradiol, progesterone) Birth control pills often come in packages that dogs ﬁnd irresistible. Thankfully, small ingestions of these medications typically do not cause trouble. However, large ingestions of estrogen and estradiol can cause bone marrow suppression, particularly in birds. Additionally, female pets that are intact (not spayed), are at an increased risk of side effects from estrogen poisoning.

7. ACE Inhibitors (e.g., Zestril®, Altace®) Angiotensin-converting enzyme (or “ACE”) inhibitors are commonly used to treat high blood pressure in people and, occasionally, pets. While this category of medication is generally quite safe, large overdoses can cause low blood pressure (hypotension), dizziness, weakness, and potentially kidney injury. Pets ingesting small amounts of this medication can potentially be monitored at home, unless they have kidney failure or heart disease. All heart medications should be kept out of reach of pets.

8. Beta-blockers (e.g., Tenormin®, Toprol®, Coreg®) Beta-blockers are also used to treat high blood pressure but, unlike ACE-inhibitors, small ingestions of these drugs may cause serious poisoning in pets. Overdoses can cause life-threatening decreases in blood pressure and a very slow heart rate.

9. Thyroid hormones (e.g., Armour desiccated thyroid, Synthroid®) Pets — especially dogs — get underactive thyroids too. Interestingly, the dose of thyroid hormone needed to treat dogs is much higher than a person’s dose. Therefore, if dogs accidentally get into thyroid hormones at home, it rarely results in problems. However, large acute overdoses in cats and dogs can cause nervousness, panting, a rapid heart rate, aggression and muscle tremors.

10. Cholesterol-lowering agents (e.g., Lipitor®, Zocor®, Crestor®) These popular medications, often called “statins,” are commonly used in the United States. While pets do not typically get high cholesterol, they may still get into the pill bottle. Thankfully, most “statin” ingestions only cause mild vomiting or diarrhea. Serious side effects from these drugs come with long-term use, not one-time ingestions.

Additional tips for medication safety Always keep medications safely out of reach and never administer a medication to a pet without ﬁrst consulting your veterinarian. The following are some tips from Dr. Justine Lee at Pet Poison Helpline to help prevent pets from getting into over- the-counter or prescription medication:

•฀ Never leave loose pills in a plastic zip-type storage bag – the bags are too easy to chew into. Make sure visiting house guests do the same, keeping their medications high up or out of reach.

•฀ If you place your medication in a weekly pill container, make sure to store the container in a cabinet out of reach of your pets. Unfortunately, if they get a hold of it, some pets might consider the pill container a plastic chew toy.

•฀ Never store your medications near your pet’s medications – Pet Poison Helpline frequently receives calls from concerned pet owners who inadvertently give their own medication to their pet.

•฀ Hang up your purse. Inquisitive pets will explore the contents of your bag and simply placing your purse up and out of reach can help to avoid exposure to any potentially dangerous medication(s).

It is also important to note that while a medication may be safe for children, it may not be safe for animals. Pets metabolize medications very differently from people. Even seemingly benign over-the-counter or herbal medications may cause serious poisoning in pets. If your pet has ingested a human over-the-counter or prescription medication, please call your veterinarian or Pet Poison Helpline’s 24-hour animal poison control center at 800-213-6680 immediately.

Pet Poison Helpline is the only animal poison control with board-certiﬁed internal medicine specialists, emergency critical care specialists, and human pharmacologists on staff. With expert staff in both animal and human medicine, Pet Poison Helpline provides a unique advantage since more than 50% of all pet poisonings involve human drugs. Pet poison irst aid kit If you own a pet, make sure you have a ﬁrst aid kit at home. Pet Poison Helpline recommends the following items be kept on hand in case of various emergencies:

First aid kit contents •฀ Hydrogen peroxide 3% (within the expiration date) •฀ An oral dosing syringe or turkey baster (for administering hydrogen peroxide) •฀ Teaspoon/tablespoon set (to calculate the appropriate amount of hydrogen peroxide to give) •฀ Liquid hand dish washing detergent (e.g., Dawn, Palmolive) •฀ Rubber gloves •฀ Triple antibiotic ointment (with NO other combination ingredients - NOT for use in CATS!) •฀ Vitamin E oil •฀ Diphenhydramine tablets 25mg (with NO other combination ingredients) •฀ Ophthalmic saline solution or artiﬁcial tears •฀ Can of tuna or chicken packed in water, beef broth or tasty canned pet food •฀ Sweet electrolyte-containing beverage •฀ Karo syrup •฀ Vegetable oil

Before you attempt anything with your new first aid kit, always make sure to speak with a poison control specialist first prior to initiating any therapies at home. Never administer hydrogen peroxide to a pet without checking with a veterinary professional first, as sometimes it’s not appropriate – or even dangerous – to induce vomiting at home. Likewise, never initiate first aid or administer any over-the-counter human medications to animals without speaking to a veterinarian or Pet Poison Helpline first! If you have any questions regarding the veterinary toxicology first aid kit recommendations, please call Pet Poison Helpline.

Another important thing to keep in mind is home remedies. When it comes to our pets and poisons, we don’t want to chance endangering our pet’s lives with some made up, Internet-discovered, erroneous home remedies! We hear it all - owners who use milk, peanut butter, vegetable oil, or salt...and these remedies are all WRONG! Please know that these products should NEVER be administered as they don’t work and may actually injure your pet! Consult your veterinarian or Pet Poison Helpline to ﬁnd out:

1. if the product ingested was poisonous to begin with,

2. if emesis (inducing vomiting) is warranted or medically indicated, and

3. if an antidote is available.

Remember, there’s a lot of good AND bad information out there on the Web, and you must be able to separate the wheat from the chaff!

Follow the instructions. Read the instructions so you know how to give the medication, and pay special attention to any auxiliary labels or instructions on how to properly use or store the medication, for example: “shake well before use,” “give with food,” or “store in refrigerator.”

•฀ Do not refrigerate medications, unless instructed to do so.

•฀ Store medications away from sources of heat, light and humidity.

•฀ ALWAYS store medications out of reach of children and animals!

•฀ Store your pet’s medication in a different location than where you store your own or family members’ medications. This will help to avoid an accidental mix-up, such as you taking your pet’s medication or vice-versa. It’s an all-too-common occurrence with potentially serious consequences.

Additional safety tips for handling pet medications Another way to avoid accidentally giving the wrong medication – follow these steps each time you are ready to give your pet medication:

1. Always pick up the bottle and read the label; make sure this is the medication you wish to give to this animal.

2. Review the directions for administering and any special instructions for handling, such as “wear gloves when administering.”

3. For all medications, wash your hands after handling the medication.

4. For your own safety, never taste or use your pet’s medication. Just as some human drugs can be toxic to pets, some veterinary medications can be toxic to humans.

Some medications, like chemotherapy drugs for cancer, have additional requirements for handling the medication, disposing of your pet’s waste, and unused drug disposal. If you are treating your pet for cancer, be sure to discuss these requirements with your veterinarian or pharmacist.

If you give your pet injections at home, you’ll need to know how to safely dispose of used needles. Check with your veterinarian or pharmacist for options in your area.

Remember these 2 very important safety tips: First, read the label, then follow the instructions. If you have any questions, call your veterinarian or pharmacist.

1. When did the ingestion occur? In most cases, vomiting can safely be induced within an hour of ingestion. If it’s been several hours since the ingestion, most likely the toxicant has already moved out of the stomach and vomiting will be of limited or no beneﬁt to the pet.1,2 Certain toxins can delay gastric emptying (e.g., salicylates, opioids, anticholinergics) or remain in the stomach for a prolonged period of time (e.g., chocolate, large wads of xylitol gum, grapes or raisins, large ingestions of tablets or capsules that form a bezoar). In these speciﬁc situations, vomiting induction can be performed in asymptomatic patients up to four hours after ingestion.1

2. Does the patient have any symptoms? Induction of vomiting in a pet that’s already vomiting or symptomatic is not warranted. Pets that are sedate or have an altered state of consciousness may be at increased risk of aspiration pneumonia secondary to vomiting induction. In many situations, gastric lavage1 performed under intubation—to protect the airway— may be required. Pets that present in an excited state can have clinical signs further exacerbated during vomiting induction, thus worsening their condition. Again, as the patient is already symptomatic, they have likely already absorbed most of the drug or toxin.

3. Is there a species or breed concern with induction of vomiting? Brachycephalic breeds of dogs (e.g., bulldogs, Pekingese, Shih-Tzus) may present a higher risk of aspiration pneumonia and are candidates for sedation, airway protection, and gastric lavage. Species that can be safely induced to vomit include most dogs, cat, ferrets, and potbelly pigs. Rabbits, rodents (e.g., chinchillas, rats, gerbils), ruminants (e.g., sheep, cattle, llamas, goats), horses, and birds can’t safely be induced to vomit or may be anatomically unable to vomit.3

4. Is there an underlying medical concern or condition? Megaesophagus, laryngeal paralysis, or a previous history of aspiration pneumonia are a few examples of conditions that may increase the risk for aspiration pneumonia when inducing vomiting.1

5. Is the toxicant caustic or corrosive? Any substance that’s corrosive and capable of causing burns and caustic injury can further injure the stomach, esophagus, and mouth when inducing vomiting. Examples are batteries, undiluted drain cleaners, toilet bowl cleaners, lime-removal products, and concentrated pool products. With poisoning from this type of ingestion, vomiting induction is contraindicated.

6. Is the toxicant a hydrocarbon or petroleum distillate? These low-viscosity liquids are easy to aspirate into the lungs, and vomiting induction is not recommended. Some frequently encountered hydrocarbons and petroleum distillates include gasoline, kerosene, tiki torch fuels, motor oils, and furniture polish oils.

7. Is the toxicant zinc, calcium, or aluminum phosphide? These are active ingredients in many commercially available mole and gopher baits. Ingestion of these phosphide rodenticides can result in the formation of a toxic phosphine gas in the stomach. This gas can harm owners and clinic staff when the pet vomits, potentially causing headache, nausea, and bronchial-type reactions (like asthma). Induction of vomiting should occur outdoors or in a well-ventilated area after administration of an antacid (e.g., aluminum hydroxide, milk of magnesia).

8. How fast will the patient develop clinical signs with this toxicant? Large ingestion of human medications can result in rapid occurrence of life-threatening clinical signs. It’s important to determine if and when pharmaceutical ingestion will result in sudden changes in blood pressure, heart rate, central nervous system mentation, or neurologic abnormalities (e.g., seizures, hyperagitation, tremors). Since many medications (e.g., selective-serotonin reuptake inhibitors, quick-release drugs, sublingual pills) can cause clinical signs right away, pet owners should not be told to induce vomiting at home without appropriately consulting a veterinarian or Pet Poison Helpline.

References: 1. Lee JA. Decontamination of the Poisoned Patient. In: Osweiler G, Hovda L, Brutlag A, Lee JA, ed. Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology, 1st Ed. Iowa City: Wiley-Blackwell, 2010, pp. 5-19.. 2. Peterson ME. Toxicological Decontamination. In: Peterson ME, Talcott PA, ed. Small Animal Toxicology, 2nd Ed. St. Louis: Elsevier Saunders, 2006, pp. 127-141. 3. Bihun C, Bauck L. Basic Anatomy, Physiology, Husbandry, and Clinical Techniques. In: Quesenberry K, Carpenter JW, eds. Ferrets, Rabbits, and Rodents, 2nd Ed. St Louis: Elsevier Saunders, 2004, pp 289-290.

Pet Information 1. Species and breed

2. Sex of animal

3. Age

4. Weight

5. Underlying medical conditions (if present)

6. Animal’s name (may be multiple animals involved) and owner’s last name

7. Environmental information [Indoor? Exclusively outdoor?]

Potential Toxin: The following examples may help in determining what pertinent information to collect in any situation.

Medication 1. What is the exact name of the drug?

2. Is there any formula information? [Extended release (XR), long-acting (LA)]

3. What is the milligram strength?

4. How many tablets are potentially missing?

5. If the container is destroyed rendering identiﬁcation impossible and a pill is found, what is the pill code printed on the tablet or capsule?

Plant 1. What is the exact name of the plant? Try to find out the scientific and common name of the plant. If it is unknown what kind of a plant it is, it should be taken to the nearest greenhouse for identification once your pet has been stabilized at the veterinarian.

2. Is it a houseplant, outdoor plant, or weed?

3. Which part was ingested - bulb, leaves, ﬂowers, berries, stems, fruit?

4. Approximately how much was ingested?

Household or garden chemical 1. What is the exact name of the product with the brand name?

2. What are the active ingredients?

3. Is there an EPA register number? If the product can’t be identiﬁed by name, this number will serve as identiﬁcation.

4. What are the label warnings?

Rodenticides 1. What is the active ingredient and the concentration?

2. What was the net weight of the product to begin with and how much remains?

3. What is the exact name of the product, with the brand name?

4. If the package is destroyed, is there a visible EPA register number?

Scenario: What exactly has transpired?

1. How long ago did this ingestion occur? If it happened while the owner was away, how long was the dog or cat alone?

2. Is the pet showing any behavioral or physical abnormalities at this time? What are the vitals and physical exam ﬁndings?

3. Is there any central nervous system (CNS) depression or stimulation?

4. Is there evidence of burns to the mouth, drooling, pawing at the face, etc?

It is important to remember that when a pet has ingested something potentially harmful, the owner of the pet may not be thinking clearly. Try to calmly guide them through this by asking direct questions, which will allow for an expedient evaluation. If you have any questions regarding management of the poisoned pet, do not hesitate to contact Pet Poison Helpline at (800) 213- 6680.

While veterinarians are constantly treating vomiting in their patients, they seem to love to induce it too! One common “error” seen at Pet Poison Helpline is not knowing when not to induce emesis. Remember, if the patient is already symptomatic (e.g., ataxic, depressed, seizuring, etc.), emesis induction is likely too late (but check with a poison control ﬁrst, as sometimes gastric lavage is still recommended!). If a product contains a hydrocarbon (like gasoline, kerosene, brake ﬂuid), emesis in typically contraindicated due to the high risks of aspiration pneumonia. Finally, corrosive agents (like drain cleaners, lime-away agents, etc.) cause corrosive damage going down - and coming back up - and patients who ingested these shouldn’t have emesis induced. When in doubt, check with Pet Poison Helpline to make sure it’s warranted before you reach for that bottle of hydrogen peroxide or apomorphine!

Here are a few contraindications for inducing vomiting (this list is not all-inclusive, and appropriate medical assessment must be made of the patient):

•฀ Symptomatic from toxicosis

•฀ Hydrocarbon ingestion

•฀ Corrosive product ingestion

•฀ Unable to adequately protect the airway (e.g., megaesophagus, laryngeal paralysis, sedation, etc.)

•฀ Patient is already vomiting

•฀ Severe brachycephalic syndrome or disease

When in doubt, check with Pet Poison Helpline to see if emesis induction is warranted!

Dogs Here are the emetic agents effective for dogs:

•฀ Hydrogen peroxide (H2O2) irritates the oropharynx and gastric lining. This is the most commonly recommended emetic agent for pet owners attempting to induce vomiting in their dog at home.2 Use of hydrogen peroxide solutions in concentrations stronger than 3 percent can result in potential corrosive injury to the gastrointestinal (GI) mucosa.2 Potential side effects associated with the use of hydrogen peroxide are irritation to the gastrointestinal tract (GIT), hemorrhagic gastritis, gastric dilatation volvulus, and aspiration pneumonia.2 Hydrogen peroxide is not recommended for use in cats because it’s not a reliable emetic agent in cats, and approximately 25 percent of cats develop a hemorrhagic gastritis secondary to its use.2

•฀ Apomorphine hydrochloride is a centrally-acting emetic agent that stimulates the CRTZ and quickly results in vomiting.2 This is most commonly used in veterinary clinics for inducing of vomiting in dogs, but it’s not recommended nor effective in cats.2 Side effects of administration of apomorphine include prolonged vomiting and ocular irritation (when administered subconjunctivally). This latter side effect can be limited with a thorough ﬂushing of the subconjunctival sac.1 Apomorphine is contraindicated with ingestions of medications that can result in respiratory or CNS depression or with dopamine antagonist drugs that prevent vomiting.2

Read the veterinarian-authored drug monograph on Apomorphine for veterinary use.

Cats Emetic agents effective for cats are more limited, and there are no at-home emetic agents that should be recommended. The only recommended veterinary emetic is:

•฀ Xylazine, an alpha-2 adrenergic agonist, is a centrally-acting emetic agent that’s effective when used in cats. Xylazine is not recommended for use in dogs, as it is not an effective emetic.2 Potential adverse effects with use of xylazine include bradycardia, sedation, tremors, and respiratory depression. Xylazine is contraindicated in medication ingestions that may result in an exacerbation or compounding of these potential side effects.1,2 In patients exhibiting persistent vomiting or excessive sedation from xylazine, the use of yohimbine or atipamezole can be used to reverse the effects.2

Alternative decontamination methods Here are two alternative methods to consider if induction of vomiting is contraindicated for GI decontamination of your patient.

•฀ Gastric lavage is recommended when the patient is unconscious, sedate, having tremors or seizures, as well as in situations where induction of vomiting has been unproductive. It’s also used with ingestions of substances (e.g., bone meal, or iron) that can result in bezoar formation or with large ingestions of medications that are approaching the LD50 or lethal dose for that medication.2 Gastric lavage is performed with the patient under anesthesia with an appropriately ﬁtted endotracheal tube (to prevent aspiration) securely tied in place. Possible side effects or concerns with gastric lavage are the risk of aspiration pneumonia, the risks associated with sedation of a poisoned patient, and potential injury to the mouth, oropharynx, esophagus, or stomach.2 Gastric lavage should never be performed with ingestions of corrosive agents that increase the risk of gastric perforation, with ingestion of hydrocarbons (due to the high risk of aspiration pneumonia), or when sharp objects have been ingested.2

•฀ Whole bowel irrigation is used to prevent absorption of ingested toxins by inducing a liquid stool through administration of large quantities of polyethylene glycol (PEG) electrolyte solution. Whole bowel irrigation typically needs to be continued for eight to 12 hours, until a clear efﬂuent—ﬂuid from the colon—is produced. Whole bowel irrigation is used with ingestion of toxic doses of iron, sustained-release medications,2 or enteric-coated medications. Possible complications of whole bowel irrigation are vomiting, bloating, abdominal discomfort, and possible aspiration pneumonia. Whole bowel irrigation should not be used with foreign body obstructions, ileus, perforated bowel, shock, vomiting, or GI hemorrhage.2

Harmful emetic agents You should avoid recommending some emetic agents for your clients for “at home” vomiting induction. Here are three home remedies—often found on the Internet—that are often recommended but can potentially put the patient at further risk or harm.

•฀ Syrup of ipecac has historically been recommended for use as an emetic agent but is no longer the standard of care in human or veterinary medicine, due to its cardiotoxic potential and tendency to result in prolonged vomiting, lethargy and diarrhea.2

•฀ Digital vomiting induction (e.g., using your ﬁnger in the pet’s mouth to stimulate a gag reﬂex) can result in injury to both the patient and the owner.

•฀ Soaps, mustard powder, and table salt are not reliable and they can result in further toxicity concerns (e.g., hypernatremia with the use of salt).2

Other considerations Here’s how to use activated charcoal and cathartics in the poisoned patient.

•฀ Activated charcoal is used as an adsorbent and is the mainstay of most GI decontaminations. It may be used concomitantly with induction of vomiting or gastric lavage. Activated charcoal does not bind well with certain toxins and is not required or recommended with poisonings from heavy metals, alcohols (e.g., ethanol, ethanol, ethylene glycol), and xylitol.2 Activated charcoal may need to be administered multiple times with ingestions of extended-release or sustained-release medications or when the drug ingested undergoes enterohepatic recirculation in the liver (e.g., carprofen, ibuprofen).2 Activated charcoal shouldn’t be used in situations where abdominal surgery or endoscopic evaluations of the GIT may be needed; if there is evidence of intestinal obstructions, dehydration, or perforations of the GIT (e.g., corrosive ingestions); or with hydrocarbon ingestions.2

•฀ Cathartics (e.g., sorbitol) are used to speed up the emptying of the GIT and decrease the time a toxicant is in the GIT where it can be re-absorbed.2 Cathartics are generally administered with the ﬁrst dose of activated charcoal but discontinued with subsequent doses of activated charcoal. Repeat doses of cathartics may result in hypernatremia due to osmolality changes and free water loss into the GIT. Side effects of cathartic administration include vomiting, dehydration, abdominal cramping, hypernatremia, and possible hypotension.2

Remember, obtaining a complete toxicology history and a thorough physical examination of the patient is always imperative before initiating any decontamination methods. This is to ensure that vomiting induction and administration of activated charcoal is warranted. When decontaminating a poisoned patient, the appropriate emetic agent should be used. When in doubt, a veterinarian or Pet Poison Helpline should always be consulted prior to decontamination to ensure a positive outcome for the poisoned patient.2

References: 1. Battaglia AM. Toxicologic Emergencies. In Battaglia AM, ed. Small Animal Emergency and Critical Care for Veterinary Technicians, 2nd Ed. St Louis: WB Saunders, 2007, pp 356-367. 2. Lee JA. Decontamination of the Poisoned Patient. In: Osweiler G, Hovda L, Brutlag A, Lee JA, ed. Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology, 1st Ed. Iowa City: Wiley-Blackwell, 2010, pp. 5-19. 3. Peterson ME. Toxicological Decontamination. In: Peterson ME, Talcott PA, ed. Small Animal Toxicology, 2nd Ed. St. Louis: Elsevier Saunders, 2006, pp. 127-141.