7/1/15

Introducon Summer toxicants affecng small animals Jusne A. Lee, DVM, DACVECC, DABT CEO, VETgirl Justine Lee, DVM, DACVECC CEO, VETgirl [email protected]

Garret Pachtinger, VMD, DACVECC COO, VETgirl [email protected]

Conflict of Interest Disclosure Introducon

Garret Pachnger, VMD, DACVECC

COO, VETgirl

VETgirl…on the RUN! VETgirl ELITE

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Call in from Smart Phone! Summer toxicants

• Inseccides • Compost • Mushrooms • Blue-green algae • Ferlizers • Bone meal • Organophosphates

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Free advice!

• Call the company (e.g., EPA, FDA)

• Look at the concentraon – Does it end with a “-thrin” – Can you find the MDSD online? – Dose dependent INSECTICIDES – Make sure not an OP or carbamate (rare)

Inseccides Inseccides: cats vs. dogs • It’s the dose that makes the poison! • Cats SYSTEMIC toxicity – > 5-10% toxicosis • High concentraon – Twitching, tremors, seizures – Topical canine flea/ck treatment (40-50% concentraon) – Bier taste severe hypersalivaon – Clinical signs start at the head • Low concentraon products around the house (< 1-2% progresses to tail concentraon) • Ant traps • Dogs not systemically absorbed • Home insect sprays – Tolerate 40-60% permethrin! • Shampoos – Dermal effects of paresthesia • Powders – Intense itching, anxiety, skin twitching • Sprays – Bier taste severe hypersalivaon – Save your $$$ – Gets on paws (“unable to walk!”)

Inseccide: Treatment Insect bait stations • Cats: • Abamectin – If presenng tremoring/twitching, sedate first with 40-50 mg/kg of methocarbamol IV • Hydramethylon • Fipronil – Once sedate, bath with liquid dish soap 3X (full body) – IV access • Treatment: typically not necessary – Thermoregulaon – IV fluids + IV methobarbamol • Plastic + peanut butter • IV diazepam doesn’t work as well • Plastic foreign body obstruction (FBO) risk

• Save your $$$

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Compost toxicity Compost toxicity

• Due to tremorgenic mycotoxins – Penitrem A and roqueforne – Act as a glycine antagonist in the brain tremors

• What’s it found in? – Moldy food – Compost – Garbage

Most common sources? Compost toxicity: Clinical signs

• Dairy products • Hypersalivaon • Nuts (e.g., peanuts, walnuts) • Voming • Pasta • Agitaon • • Stored grains Hyperresponsive to smuli • Abdominal distension • Panng • Tremors • Secondary hyperthermia • Seizures • Rhabdomyolysis (rare)

Stabilizaon! Consider gastric lavage + charcoal!

• Already symptomac NO emesis!

• IV catheter, TPR

• Bolus of methocarbamol IV slow – No methocarbamol? Diazepam IV slow

• Oxygen therapy

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Treatment Treatment • • Tremors: Hyperthermia: – Stop the tremoring! – Methocarbamol 44-220 mg/kg IV or PO q. 6-8 – Ideally IV • Sedatives/methobarbamol – “Do not exceed 330 mg/kg/day” ☺ – Provide cooling measures if > 105ºF/40.5ºC – Rectal absorpon prefer not to give oral – REMOVE cooling measures if 103.5ºF/39.7ºC

• Seizures: • IV fluids: – Stop the seizure! – 2-3.5X maintenance • Phenobarbital 4-16 mg/kg IV or PO PRN, titrated to effect • Cools your patient • Diazepam 0.25-0.5 mg/kg IV PRN, titrated to effect • Minimizes AKI injury from myobloginuria (from tremoring)

Treatment • Anti-emetics: – Maropitant 1 mg/kg IV or SQ q 24

• Preventative care: – Fencing off compost/garbage

MUSHROOMS

Mushrooms Mushrooms

• Several thousand species in North America • Unless you’re a mycologist or experienced mushroom hunter… – • < 100 toxic Never trust a mushroom unless it’s Fly Amanita (Amanita muscaria) – Most are Amanita from the grocery store! – Deadly mushrooms exist everywhere! • No simple test, hard to ID • Amanitas – North American Mycology Associaon – Worst case scenario! – hp://www.namyco.org/toxicology/idenfiers.html – Save your $$$ • Not all deadly mushrooms look deadly – White buon cap Death Cap (Amanita phalloides)

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Types of mushrooms Types of mushrooms

• Muscarine • Amanins – liver failure: – CS: SLUDGE signs – Develop GI signs (6-24 hours) – Tx: Decontaminaon, atropine, – “False recovery” period supporve care – Fulminant liver failure (36-48 hours) – Types of mushroom: – Possible AKI too Inocybe, Clitocybe dealbata – Amainta ocreata – Tx: decontaminaon, IVF, hepatoprotectants, Destroying angel “Sweang mushroom” symptomac supporve care, monitoring Clitocybe dealbata • Muscimol and ibotenic acid “Sweang mushroom” • Types: Amanita, Galerina, Lepiota, A. phalloids – CS: ataxia, sedaon, muscle spasms, (death cap, death angel), A. ocreata seizures – Types: Amanita muscaria, A.pantherina

Types of mushrooms Types of mushrooms

• False morel • Hallucinogenic mushrooms – CS: voming, diarrhea, seizures (rare) – CS: ataxia, howling, aggression, nystagmus, hyperthermia – Tx: Decontaminaon, symptomac supporve care – Treatment not generally necessary – Types of mushroom: Gyromitra spp. – Type: Psilocybe, Conocybe, Gymnopilus spp.

• Gastrointesnal irritaon – CS: voming, diarrhea – Tx: Decontaminaon, symptomac supporve care, an-emecs, IVF – Seen in 1-6 hours; last 1-2 days – Types: Agaricus, Boletus, Entoloma

Agaricus spp. Gymnophilus spp. “Big Laughing Jim”

Treatment for the unknown mushroom Treatment for the unknown mushroom

• Treat as worst-case scenario • IV fluids X 24 hours

• Decontaminaon • An-emecs – Emesis inducon – Maropitant 1 mg/kg IV q 24 – Mulple-doses of charcoal • SAMe X 2 weeks • Baseline CBC & chemistry – Repeat chemistry in 24 hours

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Cyanobacteria: Blue-green algae

• Algae blooms – Most non-toxic, but hard to idenfy with naked eye – Toxic to everything!

• Stagnant, hot, humid condions – Brackish water – Freshwater

BLUE-GREEN ALGAE • Wind blows the algae to one side of the lake

• MOA: – Neurotoxins: Anabeana, Aphanizomenon,etc. – Hepatotoxins: Microcyss, Nodularia

Cyanobacteria: Blue-green algae Blue-green algae

• Microcysns inhibit protein phosphatases 1 and 2A sevre liver • Can see very acute clinical signs damage and acute centrilobular necrosis • Death can occur within minutes to hours (neurotoxin) or • Anatoxin-a potent cholingeric agonist at niconic acetylcholine hours to days (hepatotoxin) receptors connuous electrical smulaon at NMJ • Dermal irritaon • Anatoxin-as irreversible acetylcholinesterase inhibitor (OP like); doesn’t cross BBB • Grave prognosis

• Toxic dose? 50-11,000 mcg/kg!

Blue-green algae: Clinical signs Blue-green algae: Treatment • Microcysns: – GI: voming, diarrhea • Decontaminaon: oen too late – Weakness, collapse – Emesis? – CARDIAC: pallor, tachycardia, shock – Gastric lavage + acvated charcoal – Bathe (using protecve gear) • Anatoxin-a: – CNS: paralysis, cyanosis, death • Clinicopathologic tesng:

• Anatoxin-as: s = salivaon – PCV/TS/BG – SLUDGE like signs – Baseline CBC, chemistry, PT/PTT – Tremors, ataxia, seizures, respiratory arrest

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General Treatment Treatment: Gastrointesnal support • An-emecs • Fluid therapy – Maropitant – Balanced crystalloid – Ondansetron, dolasetron – Fluid closest to paent’s sodium – Avoid LRS • Anconvulsants – Phenobarbital 4-20 mg/kg, IV PRN – Diazepam 0.25-0.5 mg/kg, IV PRN • Colloidal support? – Keppra 20-60 mg/kg, IV PRN – If TS < 5 mg/dL, consider Hetastarch – 1 ml/kg/hour • Atropine

– 0.02-0.04 mg/kg, IV, IM if anatoxin-as – SLUDGE signs

If evidence of liver failure with blue-green algae If evidence of liver failure with blue-green algae

• SAMe • N-acetylcysteine (NAC) – Increases glutathione – Increases glutathione – Improves membrane stability – An-inflammatory – Cytokine modulator – Improve microcirculaon – Dose: 20 mg/kg PO X 30 days – Improve oxygen delivery? – Dose: 280 mg/kg IV, then 70 mg/kg q 6 hrs X 2 days

Fertilizers/Soil amendments • Primarily made of elements (e.g., 40:10:10) – Nitrogen – Phosphate – Potassium

• Commonly implicated, rarely toxic

• Wide margin of safety – Directly ingested from bag? – Some pyrethrins more dangerous?

• Washes off with rain FERTILIZERS – Kiy lier remnants – Corn cob industry

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Organic ferlizers Bone meal/blood meal: “ ” • Organic but sll dangerous! • Clinical signs: • Treatment: – Hypersalivation – Palpate abdomen • Palatable! – Bloat – Radiographs to r/o bezoar bone – Vomiting – Emesis induction gastric lavage to break up • Crushed up dead things – Pancreatitis – Foreign body – Anti-emetics obstruction (FBO) – Fluid therapy • Mixed in with ??? • IV fluids – Organophosphate granules? • SQ fluids – Spring bulbs? – Supportive care

Organophosphates and Carbamates

• Less commonly seen anymore due to EPA – Seizuring cat? no atropine! – Call ASPCA Animal Poison Control Center for these!

• Most common, dangerous types: – Disulfoton – TEPP – Parathion – Malathion – Terbufos ORGANOPHOSPHATES & – Aldicarb – Methomyl (carbamate) CARBAMATES • 1% Golden Malrin

Organophosphates Carbamates

• acephate (Orthene) • fensulfothion (Dasanit) • Aspon • fenthion (Baytex, Tiguvon) • aldicarb (Temik) • methiocarb (Mesurol) • azinphos-methyl (Guthion) • fonofos (Dyfonate) • carbofuran (Furadan, F formulaon) • isofenfos (Oanol, Amaze) • • • carbophenothion (Trithion) • malathion (Cythion) bendiocarb (Ficam) methomyl (Lannate, • chlorfenvinphos (Birlane) • methamidophos (Monitor) Nudrin) • chlorpyrifos (Dursban, Lorsban) • methidathion (Supracide) • bufencarb • coumaphos (Co-Ral) • methyl parathion • crotoxyphos (Ciodrin, Ciovap) • mevinphos (Phosdrin) • carbaryl (Sevin) • oxamyl (Vydate) • crufomate (Ruelene) • monocrotophos • demeton (Systox) • naled (Dibrom) • • pinmicarb (Pirimor) • diazinon (Spectracide) • oxydemeton-methyl(Meta systox-R) carbofuran (Furadan) • dichlorvos (DDVP, Vapona) • parathion (Niran, Phoskil) • propoxur (Baygon) • dicrotophos (Bidrin) • phorate (Thimet) • formetanate (Carzol) • dimethoate (Cygon, De-Fend) • phosalone (Zolonc) • dioxathion (Delnav) • phosmet (Irnidan, Prolate) • disulfoton (Di-Syston) • phosphamidon (Dimecron) • EPN • temephos (Abate) • ethion • TEPP • ethoprop (Mocap) • terbufos (Counter) • famphur • tetrachlorvinphos (Rabon, Ravap) • fenamiphos (Nemacur) • trichlorfon (Dylox, Neguvon) • fenitrothion (Sumithion)

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MOA

• Acetylcholinesterase inhibitor • Cholinesterase inhibion (enzyme necessary to • Compevely inhibit pseudocholinesterase and break down AcH) acetylcholinesterase prevent breakdown of acetylcholine (AcH) • acetylcholine (AcH)

• Too much AcH!

• Smulaon of sympathec, parasympathec, and peripheral nervous systems • Constant smulaon or “firing” of electrical messages • Cholingeric excess

Clinical signs How does it kill pets?

• SLUDGE – Salivaon • Leaking from all orifices – Lacrimaon – Urinaon – Defecaon/Diarrhea • Fluid within the bronchi – Gastrointesnal (leakage)

• Seen within 30-60 minutes; definitely by 6 hours; rarely aer 12 hours • Tremors/seizures hyperthermia DIC

• Intermediate syndrome signs seen > 24-72 hours aer onset of acute signs; last 7-14 days + – Neuromuscular weakness, ventroflexion – Cranial nerve deficits – Death from hypovenlaon/respiratory depression

Treatment for OP/carbamates Treatment for OP/carbamates

• Atropine, atropine, atropine! ancholingergic • Fluid therapy – Blocks the neurotransmier acetylcholine in the central • Neurologic support: and the peripheral nervous system – An-convulsants – For SLUDGE signs – Muscle relaxants – Used to treat bronchial secreons • Gastrointesnal support – Dose: 0.1-0.5 mg/kg, up to 2 mg/kg! – An-emecs – Use frequently unl stable bronchial secreons • Cardiovascular support – Blood pressure and ECG monitoring • Miscellaneous • 2-PAM: Reverses binding with acetylcholinesterase – Atropine!

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Summary Questions?

• Treat summer toxins aggressively! @VetGirlOnTheRun

• The answer to all of toxicology: symptomac VetGirlOnTheRun

supporve care and the BIG 4 treatments [email protected]

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Check out our 2015 upcoming VETgirl appearances!

Dr. Jusne Lee • Merck, Tampa, Chicago, July 2015 • IVS, Amelia Island, July 2015 • IVECCS, DC, September 2015

Dr. Garret Pachnger • NCASAM, October 2015 • GVMA, November 2015 • CVC, San Diego, Dec 2015

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