11/17/2015. Tox Tips: How to Easily Improve Your Management of Small Animal Poisoning Cases. November 17, The best pet insurance plan ever!

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1 Tox Tips: How to Easily Improve Your Management of Small Animal Poisoning Cases November 17, 2015 Ahna Brutlag, DVM, MS, DABT, DABVT Associate Director of Veterinary Services Pet Poison Helpline & Adjunct Assistant Professor Dept. Veterinary Biomedical Sciences College of Vet. Med., University of Minnesota American Blvd. W., #725 Bloomington, MN Pet Poison Helpline 2015 Whole Pet from Nationwide Carol McConnell, DVM, MBA Chief Veterinary Officer November 2015 The best pet insurance plan ever! Two great options! 90% reimbursement with $100 annual deductible 90% reimbursement with $250 annual deductible It s a new day for pet insurance. Whole Pet with Wellness is a true industry game-changer: If you examine it, prescribe it, treat it or administer it, we ll cover it. Clients get back 90% on everything from Bordetella to bilateral ACL surgeries; from dental cleanings to dysplasias. It s serious coverage which means serious business for you. Quite frankly, it s the best pet insurance plan ever made. And it s only from Nationwide. 3 1

2 Introducing Whole Pet with Wellness! Coverage Highlights: One annual deductible not per incident 90% reimbursement on veterinary expenses All veterinary exams including specialty and emergency visits All hospitalization and surgeries including preventive and elective procedures All injuries, illnesses, and cancer including hereditary and congenital conditions All diagnostic testing including xrays, MRIs, CAT scans and ultrasounds All prescribed medications, nutritional supplements and therapeutic diets All preventive care including vaccinations, teeth cleaning and spay/neuter 4 Introducing Whole Pet with Wellness! It s easier to tell you what we don t cover: Pre-existing conditions Boarding Grooming Tax Waste 5 Speaker Introduction Ahna G. Brutlag, DVM, MS, DABT, DABVT Associate Director of Veterinary Services Pet Poison Helpline Minneapolis, Minnesota 2

3 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 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 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 3

4 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: atipamezoleequal volume in mls How not to induce emesis in cats H 2 O 2 Not very effective Hemorrhagic gastritis Apomorphine Not effective dopamine 2 receptors in CRTZ CNS stimulation Courtesy of Patricia A. Talcott, MS, DVM, PhD, DABVT WIMU Regional Program in Veterinary Medicine 4

5 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 5

6 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?! 6

7 Case 1: Phenylpropanolamine (PPA) Hx: Ate 50, 75 mg PPA = 125 mg/kg Vomited 3 x, hair standing on end, nervous PE: T 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! Chet, 2 yo, MN, 65 lbs (30 kgs) 210/130 mmhg Case 1: Phenylpropanolamine (PPA) Now what? Check blood pressure! Chet, 2 yo, MN, 65 lbs (30 kgs) 210/130 mmhg First line treatment? 7

8 Case 1: Phenylpropanolamine (PPA) BP 210/130 mmhg Atropine? IV fluids? Beta blocker? Acepromazine? Non specific alpha blocker Antiemetic Sedation Hypotension Dose = 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 D Video 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 8

9 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 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 Tips Agitation: Acepromazine mg/kg IV, IM, or SQ, titrated to effect Do not exceed 3 mg total Chlorpromazine mg/kg IV, IM, or SQ, titrated to effect Monitoring: Monitor ECG and blood pressure TPR 9

10 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 mg/kg IV) Seizures: Diazepam mg/kg IV PRN, titrated to effect Phenobarbital 4 16 mg/kg IV or PO PRN, titrated to effect Treatment Tips Cat vs pyrethrin Tremors: Methocarbamol Plumb: 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 1⁰ goal: renal vasodilation & perfusion Ibuprofen NSAIDS Anti hypertensives ACE inhibitors B blockers 2⁰ goal: renal excretion 3⁰ goal: replace dehydration 30 10

11 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 F Methocarbamol OK to exceed 330 mg/kg/day Diuretic guide: PCV/TS = 35%/5 6 USG < PET POISON HELPLINE When in doubt, call Something you re not familiar or comfortable with Odd clinical signs Animals with preexisting disease PET POISON HELPLINE Introducing Pet Poison Helpline s new video series: More information coming in tomorrow s follow up ! In the meantime 1. Subscribe to our YouTube Channel (petpoisonhelpline) 2. Follow the blog on our website for updates 3. Sign up for our program or contact us for more info: info@petpoisonhelpline.com 11

12 Tox goodies! Our iphone app Details 200+ toxins $1.99 Free for clinics! Request one/clinic via chapters for general and ER practices. Practical and clinical! Thank you for attending! CE credit FAQs 1. When will I get my CE certificate? We ll 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 address to info@petpoisonhelpline.com 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 noninteractive CE credit. Go to the For Vets page on our website, for more info. Comments? Questions? us! info@petpoisonhelpline.com 12