hi this is dr carrie hemelgarn i want to introduce you to module 2 of our toxicology
course it's going to be on triaging and decontamination of our veterinary patient
once a patient has been assessed as cardiovascularly stable or you have stabilized
the patient decontamination should be considered each patient is unique and each toxin is unique
emissive should be considered if the toxin was ingested within two hours of presentation or if
it's a toxin with a high level of toxicity up to a few hours past ingestion emesis is induced in
these patients that aided a few hours ago and hope to remove that they may remove anything that might
still be in their system because of how toxic this substance is mss should not be induced in patients
who have consumed a strong alkali or acid due to the concern of corrosive injury when they're
bringing it back up on their esophagus a patient also needs to be neurologically appropriate
with a gag reflex to induce vomiting the concern if we induce vomiting in a patient that's not
neurologically appropriate or doesn't have a gag reflex is that there is a high risk that
they could aspirate their vomit into their lungs which we want to avoid at all costs
if a patient is at all neurologically impaired emphasis should not be an attempted in them if
a patient has consumed zinc or aluminum phosphide redenticide ms's should be done
in a well-ventilated area and caution needs to be taken with the care staff that's taking care of
them for the concern that this rodenticide creates phosphine gas in the stomach which can cause human
injury if an inhaled and so there is a concern that if we induce vomiting in these patients in
a closed area with not good ventilation that us as veterinary professionals could inhale
phosphine gas and cause injury to ourselves recently there was a fda approved ophthalmic
drop that can be used it's called propinerol it's a dopamine agonist and it's been able to
show that it is reliable in inducing emesis in dogs and so if it is a difficulty getting
april morphine or you want to use something that doesn't involve injectable medications to induce
vomiting in dogs rapinroll is a very good option to potentially look into putting into your clinic
in which you can use eye drops put into their eyes to induce vomiting in dogs
the effectiveness of clevver was demonstrated in a clinical field study in which it was administered
to a hundred client-owned dogs to invite induce vomiting of the last meal the dogs ate
no harmful objects or toxins were given to the dogs the study demonstrated that clever
is effective for the induction of vomiting in dogs as 95 percent of dogs treated with cover
vomited within 30 minutes 86 percent of the dogs in the clever group vomited
after the first dose and 14 needed a second dose 20 minutes after the first dose was administered
half of the dogs vomited within the study within 10 minutes with three minutes being the fastest
you can get this compounded to whatever concentration you want from some of the more
common compounding pharmacies the dose is 0.02 megs per keg up to 0.04 mgs per gig iv and the
mss should occur within 15 minutes of ingestion and you can repeat the dose up to once there's
also apomorphine tablets that can be dissolved in saline and then given in their subconjunctival
sac in their eye but it's easier if you give them injectable medications hydrogen peroxide
can also induce vomiting in dogs but carries higher risks giving hydrogen peroxide there's
a risk of aspiration as well as dogs not willingly wanting tin just hydrogen peroxide and potentially
them fighting that and increasing the risk of aspiration
hydrogen peroxide has also been shown to cause gastroduodenal ulcerations after administration
there was recently a study that compared gastroenterons in a study population of dogs
all dogs that were administered hydrogen peroxide had evidence of gastric ulcerative lesions and
some had duodenal lesions whereas all of the dogs that were given apomorphine in the study
population of dogs did not have any ulcerative lesions another study we can talk about is one
that compared apomorphine compared to hydrogen peroxide which showed a higher success rate with
apomorphine of 94 compared with hydrogen peroxide which only had a 90 success rate due to the risk
of aspiration pneumonia with hydrogen peroxide and the risk of gastric duodenal ulcerations inducing
emesis with hydrogen peroxide is not readily recommended if there's other options available
that would be using something like apomorphine the next thing we're going to talk about is a
little bit more difficult which is the safest way to induce emesis in cats the safest way is
through injectable medications we'll discuss what three options there are available in cats which
are all injectable medications cats should not be given hydrogen peroxide to induce vomiting due to
their risk of aspiration but also unfortunately cats can develop necro-alternative gastritis
as a sequela post-administration of hydrogen peroxide so cats should not be given hydrogen
peroxide to induce vomiting our three options for injectable medications to induce vomiting in cats
is dexmedetomidine xylazine and hydromorphine we're going to talk about all three of those
and break down pros and cons dexmeditomazine is consistently known to induce vomiting in cats in
about 81 percent of time compared with xylazine xylazine was not as successful in cats in which
they only produced the cats vomiting in about 40 to 60 percent in a steady population of cats
the median dose in this study of dexmodatormidine that was used in cats
that was successful in getting them to vomit is about seven milligrams per kilogram and that dose
could be given either im or iv the most common adverse side effects noted with dexmeditomidine
with sedation there's another study that compared hydromorphine with dexmetatomidine
so we're going to talk about whether you would use one versus the other one in that one and that's
what this study was designed for so in that study they found that there was a higher percentage cats
that vomited with hydromorphine at 75 percent compared with dexmedetomidine which was only about
58 percent in cats less sedation was noted with hydromorphine compared to dexmeditomidine and less
bradycardia was noted when using hydromorphine so in those cases that's something that hydromorphine
if available in your clinic would be a good alternative to dex metatomine and cats and
if you don't have dexmenodomatine or hydromorphine then xylazine may be something to consider in cats
hyperthermia was one noted side effect with cats that were given hydromorphine but that
it was self-limiting and did not need further care after that once emesis has been induced in
cases where it's recommended and safe further decontamination method mechanisms should be
discussed so we're going to talk about ways to further decontaminate your patient activated
charcoal is commonly recommended based off of the toxins ability to absorb the toxin in their
gi tract so what activated charcoal does is that the goal for it is to absorb toxins so they can be
moved through the gi tract without being absorbed and therefore they're more safely eliminated
sorbitol in charcoal formulations acts as a cathartic to speed up gi transit
and with multiple doses can cause diarrhea and electrolyte arrangements cathartics containing
activated charcoal should only be given once and then subsequent doses of activated charcoal
if recommended should not have sorbitol activated charcoal can be mixed with a small volume of food
and fed to the patient if it will eat it readily such as our labrador retrievers if they won't
eat the charcoal readily they can be syringe fed their dose but extreme caution must be observed
to prevent aspiration of activated charcoal unfortunately activated charcoal aspiration
ammonia is very difficult to recover from and can be fatal we want to avoid it at all options
another option would be to induce anesthesia secure their airway with a cuffed endotracheal
tube passing a gastric tube and then putting the charcoal directly into their gastric lumen
this is not commonly performed but it is something that's recommended
in cases of toxins that are very very toxic and a high dose has been received
and that oral administration of activated charcoal is not something that can be happening
activated charcoal can cause hypernatremia and electrolyte abnormalities so we should always
recheck electrolytes before subsequent doses and skip the next dose if hypernatremia is noted
also if at any point a patient showing neurologic signs unexpectedly electrolytes should be checked
to make sure their sodium is not high and could be contributing to their neurologic signs
repeat doses of non-sorbitol containing charcoal are often needed in toxins that undergo
enterohepatic recirculation so again that's a toxin that's excreted through the bile and then
reabsorbed through their gi tract with some toxins gastric lavage is indicated and the one particular
substance in which gastric lavage is one of the main ways we recommend decontamination is when a
particular dog cats don't tend to do this but if they eat uncooked bread dough or yeast containing
products these products ferment in their stomach and then cause marked gastric distension
which can lead to gdv or gastric distension in valvulus also the fermentation creates ethanol in
their stomach which can cause neurologic signs and hypoglycemia in these cases in dogs that ingest
these large amounts of uncooked dough or yeast containing products gastrocle rivage
is recommended to remove the dough from their stomach but also we do that gastric lavage with
ice water and it stops the fermentation process because they like nice warm environments and when
you put ice water it stops the fermentation so gastric or lavage again includes general
anesthesia a protected airway with a cuffed endotracheal tube and the gastric tube is passed
into the stomach the stomach is then lavaged with water or in the cases of dough ingestion ice water
using a siphon technique of being able to remove that dough out of their stomach the procedure
can be stopped when minimal material is being returned and the lavage fluid is relatively clear
the next decontamination we're going to talk about is with ingestions of acid or alkali this
is something that's commonly recommended by poison control to dilute the toxin with water or milk
again we don't want to induce vomiting in these patients occasionally an anti-inflammatory dose
of corticosteroids may be recommended by poison control depending on what toxin they got into
when a pet gets into dermal toxins or something that is contaminating
on their skin the decontamination should focus on early removal of the substance from the skin
by bathing them with a mild soap such as dawn dish soap is the most common way that we remove any
dermal contaminants if the toxin is caustic owners and veterinary staff should take precautions
to prevent their own dermal exposure so if it's something that could burn your skin and is on a
pet it's something that you need to make sure that you're wearing gloves or appropriate ppe
when you're bathing these pets because it could then cause toxicity in our veterinary staff
bathing can be repeated until residue or odor is reduced or eliminated and take caution
bathing neurologic patients and monitor for hypothermia if it's a sticky substance using oil
peanut butter or vegetable oil are all things that can help to reduce that residue so if
it's something that's not coming off with dawn soap or if it's something that has like a very
sticky substance doing something like butter or vegetable oil can sometimes help to break
down that residue and then bathing afterwards is recommended to get that residue off the pets
powders or dust should be brushed off or vacuumed off before bathing to prevent them from getting
wet and then soaking into the skin or fur if you have something that gets into a pet's eye or an
ocular toxin any possible ocular exposure the eye should be flushed for 20 to 30 minutes with tepid
water or sterile saline sedation may be needed for this process as many cats or dogs are not
going to let you flush their eyes for 20 to 30 minutes without giving a little bit of a fight
so in these cases potentially sedation may be needed to really thoroughly flush their eyes
and you want to soak up any toxin to prevent dermal exposure under their eyes with a towel
or gauze so you don't flush it from their eyes and then burn the skin under their eyes
we want to avoid high pressure eye flushing just gentle flushing to prevent further injury
to their eyes and after flushing you want to look for any evidence of corneal abrasions
or ulcerations if ocular chemical burns are noted then lubricating eye ointments
should be started and corticosteroid eye drops should be avoided at all cost
you