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Pet Poison Helpline ©20153600 Amer i can B l vd . W. , #725 B loom in g ton , MN 55431www.pe tpo i sonhe lp l i n e . com
ToxTips: How to Easily Improve Your Management of
Small Animal Poisoning Cases
Ahna Brutlag, DVM, MS, DABT, DABVTAssociate Director of Veterinary ServicesPet Poison [email protected]&Adjunct Assistant ProfessorDept. Veterinary Biomedical SciencesCollege of Vet. Med., University of Minnesota
November 17, 2015
Whole Pet from NationwideCarol McConnell, DVM, MBA
Chief Veterinary Officer
November 2015
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Coverage Highlights:
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Introducing Whole Pet with Wellness!
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It’s easier to tell you what we don’t cover:
• Pre-existing conditions• Boarding• Grooming• Tax• Waste
Speaker Introduction
Ahna G. Brutlag, DVM,
MS, DABT, DABVT
Associate Director of Veterinary Services
Pet Poison Helpline
Minneapolis, Minnesota
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What is Pet Poison Helpline?• 24/7 animal poison control
center– Affiliated with University of
Minnesota
• Veterinary & human expertise– 19 DVMs, 35 CVTs
• DABVT, DABT
• DACVECC
• DACVIM
– 7 PharmDs
• Case fee of $49 includes – Unlimited consultation
– Fax or email 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
Email us for info!
Today’s Tox Tips
• Emesis induction in cats
• Sympathomimetic case management
• Pharm tips
• Demystify diuresis
• Magic of methocarbamol
Tox Tip #1: Cats are Not Small Dogs
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Tox Tip #2: How to induce emesis in cats
How we induce emesis: cats
• Xylazine
– a‐2 adrenergic agonist
– Dose: 0.44 mg/kg, IM
– Reversal:
• yohimbine (0.1mg/kg IM or IV)
• atipamezole (0.2 mg/kg IM or IV)
• Dexmedetomidine
– a‐2 adrenergic agonist
– 5‐10 mcg/kg IM
– ~0.1 mL/cat
– Reversal: atipamezole‐equal volume in mLs
How not to induce emesis in cats
• H2O2
– Not very effective
– Hemorrhagic gastritis
• Apomorphine
– Not effective
• ↓dopamine2receptors in CRTZ
– CNS stimulation
Courtesy of Patricia A. Talcott, MS, DVM, PhD, DABVTWIMU Regional Program in Veterinary Medicine
11/17/2015
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http://www.giovannasdogtraining.com/
What is a sympathomimetic drug?
• Engages sympathetic (adrenergic) nervous system
– Epinephrine, norepinephrine, dopamine
• Directly or indirectly stimulate alpha and beta adrenergic receptors
Examples: • Amphetamines (Vyvanse)• Cocaine• Ecstasy (MDMA)• Methamphetamine• Epinephrine
Examples: • Methylphenidate (Ritalin, Concerta,
Focalin)• Phenylpropanolamine (Proin)• Pseudoephedrine (Sudafed, Benadryl‐D,
Claritin‐D)• Albuterol & isoproterenol
Sympathomimetic: Clinical Signs• CNS:
– Mydriasis– Agitation– Hyperactivity/over‐stimulated– Head bobbing (poor prognosis)– Tremors– Seizures
• Cardiovascular: – Tachycardia– Hypertension
• Respiratory:– Hyperventilating
http://blogs.families.com/media/hyperactive1.jpg
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Worrisome parameters
• Tachycardia– >180 bpm (dogs), >240 bpm (cats)
– Decreased cardiac output
– Decreased myocardial perfusion
• Hypertension– Systolic >180 mmHg
– MAP >140 mmHg
– Risk of end organ damage (eye, brain, kidney, heart and vessels)
Decontamination• Rapid onset of clinical signs
• Emesis best done in the clinic (not by owner!)
• Emesis only if asymptomatic
• Emesis only if early!
• Activated charcoal with a cathartic X1
• If “XR” “LA” “SR” multiple doses
of activated charcoal• No repeated doses of cathartic
Sympathomimetic treatment• Treatment tool box
– IV fluids– Beta‐blockers– Sedatives– Cooling measures– Muscle relaxants– ACE inhibitors– Calcium channel blockers– Vasodilators
Where to start?!
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Case 1: Phenylpropanolamine (PPA)
• Hx:– Ate 50, 75 mg PPA = 125
mg/kg– Vomited 3 x, “hair standing
on end”, nervous
• PE:– T 103.4 F– HR 60 bpm– R = panting– BAR, agitated– Mydriasis OU– Erythema on
pinna/chest/abdomen
• “Chet,” 2 yo, MN, 65 lbs(30 kgs)
Case 1: Phenylpropanolamine (PPA)
• Now what?
• Check blood pressure!
• 210/130 mmHg
• “Chet,” 2 yo, MN, 65 lbs(30 kgs)
Case 1: Phenylpropanolamine (PPA)
• Now what?
• Check blood pressure!
• 210/130 mmHg
• First line treatment?
• “Chet,” 2 yo, MN, 65 lbs(30 kgs)
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Case 1: Phenylpropanolamine (PPA)
• BP 210/130 mmHg
• Atropine?
• IV fluids?
• Beta‐blocker?
• Acepromazine?– Non‐specific alpha blocker
– Antiemetic
– Sedation
– Hypotension
– Dose = 0.05‐0.1 mg/kg IV PRN
• “Chet,” 2 yo, MN, 65 lbs(30 kgs)
Case 1: Phenylpropanolamine (PPA)
• Dose 0.1 mg/kg Ace x 2• BP drops to 150/90
mmHg• Adequately seated• HR = 140 bpm• Cerenia given• IVF started at 1.5 x maint.• Re‐dose ace when systolic
= 165 mmHg• 18 hrs later = calm, BP
and HR WNL, discharged
• “Chet,” 2 yo, MN, 65 lbs(30 kgs)
Case 2 – Benadryl‐DVideo link:
Video caption: A 3 year old, 28 kg, male, neutered, Border Collie suffering from pseudoephedrine poisoning. The dog was administered two doses of 24 Hour Claritin‐D (loratadine, 10 mg; pseudoephedrine, 240 mg each) one day apart and began exhibiting agitation approximately 36 hours after the first dose. No other medications were administered during that same time frame. This video was taken 48 hours after first dose (24 hours after second dose). The dog’s total dose of pseudoephedrine was approximately 17 mg/kg. The predominant and continuous head‐bobbing are consistent with severe intoxication and a poor prognosis. The pet owner stated she was advised by a pharmacist that this drug would be appropriate for dogs.
Video courtesy of Dr. Virginia (Gini) Frauenthal
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Case 2 – Benadryl‐D
• PE:
– T 106.4F
– HR = 220 bpm
– RR = 36 rpm
– BP 180/100 mmHg
Where to start?
Case 2 – Benadryl‐D• PE:
– T 106.4F
– HR = 220 bpm
– RR = 36 rpm
– BP 180/100 mmHg
• Hyperthermia: – Cooling measures (to 103.5
F or 39.7 C)
– IV fluids
– Stop the agitation/tremoring
– Evaporative methods
• Reduce HR and BP:– Acepromazine!
• Sedation = BP 140/80 mmHg– HR = 220 bpm
• Beta‐blocker!– Propranolol or esmolol
Treatment TipsAgitation:
– Acepromazine
• 0.05‐0.1 mg/kg IV, IM, or SQ, titrated to effect
• Do not “exceed 3 mg total”
– Chlorpromazine
• 0.1‐0.5 mg/kg IV, IM, or SQ, titrated to effect
Monitoring:– Monitor ECG and blood pressure
– TPR
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Treatment Tips
• Tachycardia (HR > 180 bpm):
– Blood pressure measurement?
• If hypotensive IV fluids
• If hypertensive (>180 mmHg)/agitated – Sedation first! (acepromazine)
– Beta‐blocker (e.g., propranolol 0.02‐0.06 mg/kg IV)
• Seizures:
– Diazepam 0.25‐0.5 mg/kg IV PRN, titrated to effect
– Phenobarbital 4‐16 mg/kg IV or PO PRN, titrated to effect
Treatment Tips• Cat vs pyrethrin
• https://www.youtube.com/watch?v=I5YJm7IvPNM
• Tremors:– Methocarbamol
– Plumb: 55‐220 mg/kg IV. “Do not exceed 330 mg/k/day.”
– Tip: Dose slow, IV, to effect. – Severe cases may require very high doses! OK to exceed 330 mg/kg/day when necessary.
Fluid therapy in the poisoned patient
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• 1⁰ goal: renal vasodilation & perfusion– Ibuprofen
– NSAIDS
– Anti‐hypertensives
– ACE inhibitors
– B‐blockers
• 2⁰ goal: renal excretion
• 3⁰ goal: replace dehydration
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Tox Tips Review
• Emesis induction in cats: xylazine or dexmeditomodine
• HR > 180 bpm = poor ventricular filling (dog)
• BP > 180 mmHg = organ damage
• Always check BP if HR is abnormal
• Sedate, then control heart rate
• Stop cooling at 103.5 F
• Methocarbamol— OK to exceed 330 mg/kg/day
• Diuretic guide:
– PCV/TS = 35%/5‐6
– USG < 1.020
PET POISON HELPLINE
When in doubt, call 800‐213‐6680
• Something you’re not familiar or comfortable with
• Odd clinical signs
• Animals with preexisting disease
PET POISON HELPLINE
Introducing…
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In the meantime…1. Subscribe to our YouTube Channel (petpoisonhelpline)2. Follow the blog on our website for updates3. Sign up for our program or contact us for more info:
11/17/2015
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Tox goodies!
Free for clinics!Request one/clinic via [email protected]
Our iPhone appDetails 200+ toxins
$1.99
100+ chapters for general and ER practices.
Practical and clinical!
Thank you for attending!
CE credit FAQs1. When will I get my CE certificate? We’ll email it to you within 24 hrs.
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 email address to [email protected] by 1pm central time on November 18, 2015 (strict deadline).
3. Can I watch the recorded webinar online for CE credit? Yes. You can receive non-interactive CE credit. Go to the “For Vets” page on our website, www.petpoisonhelpline.comfor more info.
Comments? Questions? Email us! [email protected]
