7/1/15 Introduc4on Summer toxicants affec4ng small animals Jus4ne 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 Introduc4on Garret Pach4nger, VMD, DACVECC COO, VETgirl VETgirl…on the RUN! VETgirl ELITE • The tech-savvy way to get CE credit! • A subscrip4on-based podcast and webinar service offering veterinary RACE-approved CE 50-60 podcasts/year plus 24+ hours of webinars! – $199/year – 30+ hours of RACE-CE 1 7/1/15 New and improved video! Members: iTunes Download! Easier playback, less buffering – be`er! Find us on social media and our blog! Logiscs: CE Cerficates ! No need to raise your hand! ! Type in ques4ons ! Emailed to you 48 hours aer the webinar ! Ac4ve par4cipaon = no quiz ! Watching video later, must complete quiz ! ELITE members only ! Email / contact with ANY ques4ons ! [email protected] ! 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Summer toxicants • Insec4cides • Compost • Mushrooms • Blue-green algae • Fer4lizers • Bone meal • Organophosphates 2 7/1/15 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) Insec4cides Insec4cides: 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/4ck treatment (40-50% concentraon) – Bi`er 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 – Bi`er taste " severe hypersalivaon – Save your $$$ – Gets on paws (“unable to walk!”) Insec4cide: Treatment Insect bait stations • Cats: • Abamectin – If presen4ng tremoring/twitching, sedate first with 40-50 mg/kg of methocarbamol IV • Hydramethylon • Fipronil – Once sedate, bath with liquid dish soap 3X (full body) – IV access • Treatment: typically not necessary – Thermoregulaon – IV fluids + IV methobarbamol • Plastic + peanut butter • IV diazepam doesn’t work as well • Plastic foreign body obstruction (FBO) risk • Save your $$$ 18 3 7/1/15 Compost toxicity Compost toxicity • Due to tremorgenic mycotoxins – Penitrem A and roquefor4ne – 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) • Vomi4ng • Pasta • Agitaon • • Stored grains Hyperresponsive to smuli • Abdominal distension • Pan4ng • 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 4 7/1/15 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 absorp4on " 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! – h`p://www.namyco.org/toxicology/iden4fiers.html – Save your $$$ • Not all deadly mushrooms look deadly – White bu`on cap Death Cap (Amanita phalloides) 5 7/1/15 Types of mushrooms Types of mushrooms • Muscarine • Amani4ns – liver failure: – CS: SLUDGE signs – Develop GI signs (6-24 hours) – Tx: Decontaminaon, atropine, – “False recovery” period suppor4ve 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 suppor4ve 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: vomi4ng, diarrhea, seizures (rare) – CS: ataxia, howling, aggression, nystagmus, hyperthermia – Tx: Decontaminaon, symptomac suppor4ve care – Treatment not generally necessary – Types of mushroom: Gyromitra spp. – Type: Psilocybe, Conocybe, Gymnopilus spp. • Gastrointes4nal irritaon – CS: vomi4ng, diarrhea – Tx: Decontaminaon, symptomac suppor4ve care, an4-eme4cs, 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 • An4-emecs – Emesis inducon – Maropitant 1 mg/kg IV q 24 – Mul4ple-doses of charcoal • SAMe X 2 weeks • Baseline CBC & chemistry – Repeat chemistry in 24 hours 6 7/1/15 Cyanobacteria: Blue-green algae • Algae blooms – Most non-toxic, but hard to iden4fy with naked eye – Toxic to everything! • Stagnant, hot, humid condi4ons – Brackish water – Freshwater BLUE-GREEN ALGAE • Wind blows the algae to one side of the lake • MOA: – Neurotoxins: Anabeana, Aphanizomenon,etc. – Hepatotoxins: MicrocysBs, Nodularia Cyanobacteria: Blue-green algae Blue-green algae • Microcys4ns 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 nico4nic acetylcholine hours to days (hepatotoxin) receptors " con4nuous electrical s4mulaon 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 • Microcys4ns: – GI: vomi4ng, diarrhea • Decontaminaon: ofen too late – Weakness, collapse – Emesis? – CARDIAC: pallor, tachycardia, shock – Gastric lavage + ac4vated charcoal – Bathe (using protec4ve gear) • Anatoxin-a: – CNS: paralysis, cyanosis, death • Clinicopathologic tes4ng: • Anatoxin-as: s = salivaon – PCV/TS/BG – SLUDGE like signs – Baseline CBC, chemistry, PT/PTT – Tremors, ataxia, seizures, respiratory arrest 7 7/1/15 General Treatment Treatment: Gastrointes4nal support • An4-emecs • Fluid therapy – Maropitant – Balanced crystalloid – Ondansetron, dolasetron – Fluid closest to paent’s sodium – Avoid LRS • An4convulsants – 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 – An4-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 – Ki`y li`er remnants – Corn cob industry 8 7/1/15 Organic fer4lizers Bone meal/blood meal: “ ” • Organic but s4ll 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