Great. Well, thank you so much for the introduction and yeah, welcome to this second webinar in this series where we're carrying on covering everything that we need to know about what to do with the intoxicated patient and We saw this, this figure last week. Hopefully if I can get that to advance.
We saw this figure last week covering a sort of general clinical approach to these patients as to kind of where do we start, where does everything fit in. And we talked about the sort of the initial patient assessment, making sure the patient's stable, getting that initial history to find out exactly what we're, we're dealing with these, with these patients. And the next thing that we're gonna focus on it in detail is how we decontaminate patients as best we can to try and minimise any sort of toxin, morbidity or mortality potentially.
And we're probably all aware that patients can be exposed to a toxin by lots of different routes. So, you know, there's the, the eye, the skin, the GI tract, but we'll start talking about the GI tract first because certainly in, in my experience, that's probably one of the most common ways that our, our pets get access to all of the things that they do. But we will, towards the end of this, webinar today talk about the other routes as well, just to make sure we've covered everything.
So starting with gastric decontamination, as we said, we've got lots of things that we can do, which is good news for how we can address these patients. I guess with choice comes that responsibility as to what should we pick when, what's the best thing for, for each of these individual scenarios and based on the number of possible agents and toxins that our pets can get into. And it makes sense that there's gonna be some decision making as to what's, what's best to use.
So over the course of today's webinar, we'll talk about each of these options and covering how to do these various things, and the decision making that goes into choosing what would be best for a sort of given, patient population. So to kind of get everybody, everybody's attention kind of early on in the webinar today, we've got a little bit of a poll coming up, so. We're gonna start with talking about how we induce emesis, and a question that is often asked by owners is whether they can or whether they should give something of themselves at home to, to make their, their own pet sick.
So there's a clinical scenario here, and puppy eating quite a lot potentially of ibuprofen about an hour ago. And the owner asking should they administer table salt to induce emesis. So we've got three options here, and I'm interested to see what, what everybody thinks about this.
So I'll give you a second to read through the options and then place your vote. Oh folks, it's quite easy once you've read the question and you've read the answers, pick the best one that suits you. Remember that it is completely anonymous.
So don't sit on the fence, make a decision, make a choice, and then simply just click on the answer that you feel best suits, what you believe or what you would tell the owner and those answers will come through and we will be able to share them, once we've all finished voting. So click on the answer that best suits what you feel. We'll give you another 10 seconds or so, and then we will share those answers.
Right. Right, let's end that poll quickly and share those results. Can you see those, Lindsay?
I can see those. That's great. Thanks everybody for, for voting there.
So, yeah, it's interesting, it seems like nobody really went for, for option B, which is, is interesting, kind of smaller proportion going for option C saying about the I guess the issue with that part is the the timing of the ingestion and most people going for for option A. So that's that's really interesting and I think what I would say, and we'll talk about timing the ingestion as as a sort of really, really good thing to discuss because there's lots of different opinions and lots of different things written out there. So we'll cover that as we go throughout the webinar, but for me, I would probably say the most reasonable answer here is option A.
So if you voted for that, you're, you're in the, the, the majority, but we'll cover kind of the, the issues surrounding option C as we go through the webinar today. So, My kind of take on this case will be that this is a dog whose access to drug that we know could have toxic effects. If we're thinking our worst case scenario an entire packet, that's if we were to work out the approximate milligrammes per kilo exposure, that would definitely, definitely be within a toxic dose.
So induction of MS is appropriate, but the issue I have is whether or not table salt and given orally is the right thing to do. So. It's something that does come up from, from time to time, and I think I would always say to owners this this is something to to avoid And the reason for this is several fold.
I'll get on my soapbox about this now. I think one of the, the, one of the issues I have is that it's just not that reliable as an emetic agent, so it's not like we can guarantee that this emesis will be successful and, and this puppy will be safe from the potential toxic effects of the ibuprofen. So that's kind of one issue that is it doing what we actually intended it to do.
The potential bigger issue is that we just don't have control as to how much of this salt is going to be given to, to this, this particular patient. And, the issue with that is we are, we are literally giving them salt. And as such, a quite likely side effect from giving too much of that is that we can get, hyponatremia or potentially a crazy high blood sodium level with, really severe consequences.
And I remember a few, a few years back I read a, a really quite a sad case report of a dog that was given salted water at home by its owner to induce MSS after it ate some chocolate. They were obviously concerned about the potential toxic effects and gave the salted water. In hindsight, it turns out this wasn't a toxic dose of chocolate, so no action was needed.
But this poor dog ended up having a blood sodium level of over 200, whereas normally we consider up to sort of 150, maybe a little higher is sort of what we'd consider acceptable. And this dog was severely hyponatraemic, with seizuring and, and had, had a really life-threatening, occurrence after a non-toxic exposure. So it's very hard to control how much is too much to a, to an owner.
And as such, the safest thing to do is to say it doesn't work that well, it's not that safe. Let's just avoid it. So discussing alternatives, and saying if for a puppy like this to say we're really worried about this dog, the best thing to do would be to come into the practise.
If we've gotten into this situation 5 minutes after that advice that we would have given, it turns out the owner's already given this, as sometimes happen as well, then the advice to come down to the clinic straight away absolutely still stands, but in the meantime, they should, assuming the dog has an appropriate mentation, hasn't developed any neurologic signs and certainly no depress mentation, seizure activity, etc. That patient should be given ad lib access to as much water as they possibly want, just to try and minimise any sort of sodium disturbances they might have. So in summary, use of table salt to induce emesis, a big no no.
Something else that has been used quite widely as a at-home induction of MSI agent and also in some practises as well is hydrogen peroxide and so it's quite widely written about in lots of textbooks, you'll kind of see this sort of mentioned. And the theory behind giving this, this is a a substance that's given orally to induce emesis and the mechanism how this actually, actually can work is that it's, it really irritates the gastric mucosa directly as it's ingested orally. And then that triggers the variant afferent nerves that stimulate the vomiting centre in the brain, and then, and then you get emesis in the, in the patient.
So in, in dogs, there's recommended doses quite widely published, so approximately 1 to 2 mL per kilo, notably of the 3% solution, and nothing more concentrated. And that can be given one time and repeated once in dogs if it's unsuccessful. The potential issue with this is that although it's cheap and it's readily available, maybe more so in the United States potentially than in the UK, is that not all dogs will vomit with this, and if you give too much, if you give too much of a concentrated solution, You can actually get really quite severe hyper salivation and hemorrhagic gastritis, which is kind of not really something that we're, we're shooting for with this.
And it's using cats just as a, as a big no, no full stop because you get those side effects without any benefit of, of inducing emesis as well. So, Potentially in dogs is a kind of a once one time dose and appropriate amount potentially something that somebody could do. But again, for me, this would be sort of second choice to to having the pet come in.
I thought I'd include this study from, it's a couple of years ago now, which looked at what this product was actually doing to the mucosa of, of healthy dogs because we kind of, you know, potentially give this advice and say you can give this and it, you know, make them vomit and it sounds like it's something fairly innocuous, but It was actually an interesting, an interesting read of this study. So this, was a prospective study whereby they gave various emmetic agents to a total of 7 adult healthy dogs, and 6 of those dogs got this standard dose of hydrogen peroxide, so what we would be sort of recommending, and 1 dog get given apomorphine, instead. And what they did was it's quite an involved study, given this was sort of healthy, healthy staff owned dogs.
Is that they'd randomise these dogs to give these different agents and then the dogs were anaesthetized for endoscopy and for gross inspection of the mucosa and they had biopsies at various time points that sort of exact details of the study if you're interested, and it's worth having a look, but they, they really kind of interrogated these dogs visually and, and histopathologically to see what was happening. And they saw quite a lot of stuff for, for something that sounds fairly benign. They saw various grades of, esophagitis in the hydrogen peroxide group.
So quite a few dogs with, sort of grade, grade 1 esophagitis, within 4 hours, but that persisted for up to a couple of weeks. And in one dog, they saw a grade 3 esophagitis that, was still there a week later after administration. And so it was actually quite, quite a lot of damage was done, with these, and these were, were healthy dogs that didn't have a toxin that may well sort of cause GI compromise, down the line anyway.
So. I guess it's one of those risk benefit things like the puppy case that we just mentioned. So we, we know that having that much ibuprofen is, is going to be bad.
So this is hydrogen peroxide probably not as bad. But if we have a better agent than this, then that's maybe something we could use. And in contrast, the, the apomorphine, single dog, didn't have any abnormalities and had normal histopath scene.
So it seems like of the, the kind of two things included in this study, the apomorphine was the better option. The other thing to consider is that induction of memesis at home can go really badly wrong at times as well beyond some esophagitis and, and some sort of general irritation. And something again that's, that's out there that people will do is to give soda crystals, so this sort of washing soda or active ingredients, sodium carbonate, as again, as a sort of direct gastric irritant to, to induce emesis directly, much as we talked about with the hydrogen peroxide.
But the image here was a, a case of a, of a sad dog who'd eaten something that, would subsequently have been non-toxic, and the decision was made to try and induce emesis with some soda crystals. But there was a, a terrible mistake made whereby instead of washing soda, caustic soda was administered, which is sodium hydroxide, and a really alkaline solution. And I think you can probably appreciate images here.
We've just got really severe mucosal injuries to the edge of the tongue here, to the commissures of the lips, and to kind of the, the gingiva up here. And this is pretty, pretty extensive injury as we can see, but this wasn't limited just to the oral cavity. This extended down to the oesophagus as well.
And this poor dog ended up, having, an esophageal stricture that just was refractory to, to management and actually ended up, the, the dog ended up getting put to sleep later. And so you can see if, if this sort of thing goes wrong, then it can go really quite wrong. And on the same vein, lots of other agents have been reportedly used in a home environment to induce MSs, so dry mustard powder, .
Pharyngeal stimulation, which is, is basically sort of, or otherwise, you know, if you want to be fancy digital induction of, of emesis, whereby not entirely reliable but may well reliably injure the the owner depending on the, the patient involved. Other things that have been used before have now sort of fallen out of Bali. This, syrup of Epica has, historically been recommended to induce MSI, in fact, but isn't really considered standard of care anymore because of the fact it's got really quite a delayed, onset of action, can have some cardiotoxic effects and the tendency to result in really quite prolonged vomiting and lethargy that could cause some quite significant dehydration and, and sort of downstream effects of that.
So, None of these things are really recommended for MSS given that there's the safer and the more reliable things available. So if we are gonna say, well, let's, let's get these patients into the veterinary clinic, I probably, probably kind of made the point about the MSI induction, at home not being the best idea unless there's no other alternatives available. If we're gonna get the patient in, then what's the, what's the appropriate timing?
And this is a useful thing to pick up on after, our poll. Regardless of the exact number that we're gonna put on the appropriate timing, it's really important to say that this is only appropriate if the patient's asymptomatic. And the reason for that being that if the patient presents with clinical signs of the, the toxin that's been ingested, then we've kind of missed our window.
It's been absorbed, it's got to target tissues, and it's not really gonna do anything. And inducing emesis may well just cause more harm than good. Especially, let's say if this is, a dog who's ingested, xylitol gum, and is now presented with, mental sort of depression, maybe some kind of early seizure activity, inducing MSS in that patient is, is a bit of a recipe for disaster.
So, the patient has to be asymptomatic regardless of the, the time window that we're gonna put on this. In terms of the exact timing, we do know that the sooner we induce emesis or attempt to, after the ingestion of a toxic substance, the more effective it is. So the sooner the better, hence the kind of the, the hurry to get these patients in and, and, and get sorted.
And, the sooner we, we get there, just the, the more we get out. And there's various kind of percentages, on there. But really, it's the longer the time elapses, the less the stuff that we get out, which makes sense because things have started to kind of move on and through the GI tract and.
If you do want to put a number on this, what is the appropriate timing? You could line up a bunch of emergency practitioners, you could bunch line up a bunch of people and sort of dealing in toxicology and fields most of their time and say, what, what's your cut off? And I, my suspicion is you get different numbers, but a consensus is probably around the 4 hours post ingestion mark that.
If you have an asymptomatic patient up to that point, for me, it's worth a try to kind of see if we can get something out. And beyond that, then that, that may be a sort of a, a different issue. But again, it's in this asymptomatic patient we're kind of talking about.
And in terms of appropriate timing, again, although, you know, we're going to talk through tonight indications and various contraindications to inducing emesis, some of the art in dealing with these patients, knows in, it lies in kind of knowing when we can bend the rules a little bit, for want of a better expression. And sometimes we might push out that that appropriate window a little bit longer and say that we might try for delayed induction of emesis that's sort of between up to 4 and 6 hours post toxin ingestion in some specific circumstances where there's something about the toxin specifically that means that we might still get yield and even sort of 6 hours out. And these aren't necessarily things that we'd see super commonly up at the top here, but some toxins that might delay gastric emptying, such as opioids or anticholinergics or some antidepressants.
If they've delayed gastric emptying, by definition, they're likely sticking around for longer and therefore might be available to be removed by vomiting. So specific agents might say that delayed emesis is, is appropriate. Or it might be that there's something about the toxin that makes it physically stay in the stomach for a longer period of time, that kind of forms this kind of concretion or, or lump, for want of a better word.
And therefore, it's kind of available for, for us to, to get vomited up as well. So things that we might think about are, are sticky kind of toxins, things you might think about for this. So things like chocolate or, or gum, which can kind of form these sort of large sticky mounds that might stick around for a bit longer.
Things like, things that are eaten in large quantities, so certainly grapes and, and raisins is, is a, example of this. And a few years back we had, a little Chihuahua dog that was owned by, a couple of the interns at the time at the RBC that got into, quite a significant amount of, of grapes, accidentally. And a few hours later it was realised and we said, you know, let's, let's give this a go.
Let's see if we can get something out. And this was beyond that 4 hour window, but we got a lot of grapes out of this dog and it's probably again by that physical bulk. It's just harder to clear fully within that 4 hours, so you might get something out.
And again, if it, there's kind of various things, and this is hard to kind of include everything on a on a slide like this. But then if there's something specific about the toxin that makes us think it's sticking around for longer and the patient is asymptomatic, quite importantly, then we might go with sort of more of an extended protocol. So how should you actually go about inducing emesis, firstly in the dog?
Well, it's pretty easy. I, I think everybody's gonna know the answer to this. This appomorphine is the drug of choice in dogs.
And, now that we have our, our licenced, form of this, it's, it's very, very easy. So in all of the, the kind of the promotional stuff that, that TVVM have that we'll mention at the start of the webinar last time. All of the dosing and stuff is on there, with kind of really nice guidelines as to how to go about giving this.
It is a one-time dose, that, that shouldn't be repeated, for the reason that if you give it more than once, then it's not likely to be effective, but you may well start getting, adverse clinical effects of, of too much apomorphine. So it's typically a one-time, one-time agent. Possible side effects you might see are, are more vomiting than we expected, and potentially some of the, the side effects related to the fact it's an opioid, but in terms of frequency, they're, they're really pretty rare.
And if we do get into a bind and we're really unhappy with how that patient is handling this from a major body systems perspective, then we can reverse those effects without them doing the, the MSI intent. So. In terms of agents, it's the drug of choice because it, it works, works nicely, works rapidly, and, and thankfully it's easy to get hold of again.
Once we've given it, we need to make sure that our correct time point has been achieved and basically the goal for inducing emesis is to make sure that we've emptied out the stomach as much as possible and This guilty looking dog here, like it's produced quite a significant pile of vomit. It's looking, you know, we think this might be it. This was the tip of the iceberg and this dog.
This dog had actually eaten several large chocolate containers, and there was probably 3 or 4 times as much vomit came out of this dog. And we really want to observe these patients to make sure that we're getting to the point that they, they've vomited to the point where they're not bringing anything up. It's sort of that dry heave and we know that there's hopefully emptied out as, as much as we can.
And for patients who have just ingested an awful lot, sometimes some gentle abdominal palpation may aid some kind of clearance in some of those cases, . A lot of them obviously just kind of managed really quite well just with the appomorphine and no further assistance needed. And a question that often comes up is, is there a role for giving antiemetic therapy to these, these dogs following induction of emesis?
And I would say for me, most of the time, I, I don't feel like I, it's, it's needed or, or, sort of makes a difference. But there are specific populations of patients where I think it, it, it is a good idea and essentially it's those that have any sort of protracted vomiting or the ones that just look really drooling and nauseous, for longer than. Then we think is is reasonable or or or normal.
And the benefit of giving the antiemetic is, it makes them feel better, which is kind of what we're all about. But, from a toxicology standpoint, hopefully lets us give the any activated charcoal earlier if, if that's what we're going to do. And so plenty of options out there.
If you want to think about the underlying mechanisms of things, then given we know that apomorphine works through sort of dopaminergic effects, then metoclopramide might be a good choice, but I've definitely used Moropotent and had good, good effect with that. So we have have options if we have a selected case where we think it's going to be helpful. And then there's the cat.
And we all know that cats aren't small dogs, but I feel it's never really been truer than when we're talking about inducing emesis and we try and compare them to dogs. And I would rather make a dog vomit any day of the week compared to a cat. It just seems like it's a trickier, a bigger challenge, just a trickier event in general.
And it's just not a straightforward from a picking a drug perspective. So there's many drugs been tried, and it's reported and that in itself tells me that there isn't this one kind of good choice, like we have for the dog. And xylozine is often written in the, the textbooks as sort of reported as the agent of choice, but we do know we can see adverse side effects from that, and it tends the issue for me tends to be availability, that it's just, we just don't have that on our shelves, whereas you might have something like meatomidine or dex meatomidine.
So you might well pick an alpha 2 agent of our choosing or, or the one that we have exposure to and monitor these patients for any sort of adverse effects of that. It's disappointing we can't use apomorphine in, in cats, but the truth of the matter is that it's just not effective or licenced and the reason for that, just out of interest, is that we know apomorphine works on the dopamine receptors in the brain to induce vomiting and whilst the vomiting centre in the, in the dog brain has lots and lots of dopamine receptors. The vomiting centre in, in the average cat has more alpha receptors and as such, cats just don't usually vomit with apomorphine, but you can get some really quite impressive agitation.
So, to cut a long story short, just best not to even sort of bother trying. My impression on using these sort of various agents, these alpha 2 agents to induce MSS in cats is that it's quite hit or miss, frankly. And it's interesting to kind of read this study by one of my old resident mates, Jenny Sinnott who just reported what happened when you gave Xylazine to induce MSI in cats.
. And they've got a 60% success rate, which I, I feel is about right. A lot of them do, some of them do vomit, but it's nowhere near as many as we would like. And in terms of side effects, they were saying about just under a third of those cats, had some sedations.
But I think that sort of fits with our, our clinical experience looking at just thylazine. I said, what about drugs that we might have access to in sort of the majority of our practises. And this was a more extensive study and out of the University of Pennsylvania, where, again, retrospectively, they looked at a bunch of cats that had had MSS induced because of a known or suspected toxic and ingestion or a recent ingestion of a string foreign body.
And they recorded what agent had been used to induce MSIS and, and basically what happened. And They, to kind of look at the, the data in, in a slightly more readable format. They had a few cats that had hydrogen peroxide, which is interesting given that's something that we, we're not really recommending in cats at all.
Some had had xylazine and, some had had dexameddoomidine. And if you kind of pull the data and look at effectiveness, then none of the hydrogen peroxide cats vomited. 44% of the xylazine cats did, so a bit less than the, the previous retrospective we just mentioned.
But it seems like Dexedatomidine was for the wind that 81% of the cats receiving that had successful MSI in G so. They had some suggested doses for that, depending on if you're going IM or IV but it seems like that's a sort of, seemed like in this study that was the, the agent of choice. Something for me that was, was really interesting, this is just the results section of this study blown up for, for slightly easier reading, is that, I guess, I guess I'm, to be honest, a little bit impatient by nature.
And I was really interested to read the, how long it took from giving the emetic agent to the induction of emesis in these cats. And it was much longer than I would have been prepared for, to be perfectly honest. So in the Xylazine treaty cats, the median was, was 10 minutes, so reasonable, but the range was from 5 to 175 minutes.
I think I'd have probably given up a long time before then. But a shorter kind of window within the dexamedotomidine treated cats. So again, medium of 5 minutes up to about 12 minutes.
So probably a good learning point for me to say that maybe I need to be a bit more patient, but it can take a while to kind of get there. And as such, these cats given sedation is, is an adverse effect, are gonna need sort of direct monitoring during this sort of period of waiting for these drugs to work. When we're deciding whether induction of emesis is appropriate, we do need to think about it a few different factors and things that we might think about the health of the patient, the type of ingestion as we talked about, and the specifics of the, the toxin that's been ingested.
And for me, one of the biggest concerns is to, that we need to kind of think about as to if there's a contraindication is whether that patients at an increased risk of aspiration pneumonia and In general terms, patients with issues with the, the airways that make them more predisposed or ones that already have aspiration pneumonia where we just don't want to give them a second dose on top. Patients when neurologically, I just don't feel like they're in a good spot to protect their airway are all kind of groups of patients that I have to be very, very convinced that MSI induction is in that patient's best interest, and there's nothing else as an alternative that would be better before we go ahead. But I would be, I would need some serious persuading to, to go ahead with a patient like this and probably couldn't be persuaded for most of those instances.
Brachycephalic patients have made it on the list. It's not to say that we can't induce MSIS in them as a, as a population as a whole. It's more just to say that they, they are at an increased risk of aspiration pneumonia.
I think we've probably all had the, the brachycephalic, either vomit or regurgitate and then aspirate somewhat more readily than the average patient would. So again, it's that sort of risk benefit assessment. And again, other risks of increased aspiration pneumonia or specific agents that might be particularly volatile that are just sort of the very low viscosity fluids and, and really are associated with a high risk of aspiration.
So probably all contraindications on the the list for emesis for that reason. But there might be other things too, if this is a, a patient who's at risk of having seizure activity, that's the last thing we want to happen after we've given them an agent that's gonna induce some emesis, recent abdominal surgery for kind of obvious reasons or if they're just not stable enough for some of these drugs that we want to give. Previous vomiting is an interesting one, because a lot of the texts will report that having a patient be vomiting already is a contraindication for induction of emesis presumably because the patient's kind of already doing that job for us, but Emoys that's induced is often more forceful than natural vomiting.
And so there's a chance that induction of emesiss might result in better retrieval of ingested objects, but again, it's sort of a patient by patient assessment. And again, if they're symptomatic for the toxin, it's a no go, as we talked about before. The other kind of contraindications you might think about are related to the, the substance itself.
So if there's something particularly caustic or corrosive, that's potentially injured, mucosal surfaces already, the last thing we want to do is to expose those injured surfaces to kind of round 2. Sharp objects kind of makes sense. We don't want to kind of forcibly, eject that from the, the GI tract with any kind of unknown, injury that might occur.
And also, if we just think that the specifics of the ingested thing, if, if by inducing MSI we can make the whole clinical situation worse, and then that's a, a bit of a, bit of a no go. And we've kind of mentioned about the, the timing of ingestion, saying that for some toxins, we might be able to push that out longer. We do know some toxins such as those in sort of like gel capsule formulations, they're typically absorbed pretty quickly.
So depending on the exact formulation, it might be that even if we're in a 4 hour window, it's it's just not gonna work. So again, the sort of specifics of the toxin is, is quite relevant. I have done a couple of slides coming up covering sort of specific intoxications where there's some additional considerations and again, these, these might be quite rare we may never see these certainly mulate or zinc phosphide is is one of those things whereby I saw a few cases when I, I worked in the States and although this product is available in the UK, I, I, I personally, thankfully haven't seen any of these in, in a long while, but is, is out there and obviously is kind of agents used for pest control change we might well see more of.
And if you've got a a young healthy dog comes in an hour after ingesting a packet of mulate containing the zinc phosphide, should we induce emesis in that dog? Well, it's a probably yes, but this has some extra considerations and. One of the kind of the really important things about toxicology, is that you don't want to kind of contaminate the decontaminator.
And the problem with zinc phosphide is that once it's ingested and it combines with, our, our stomach acid, is that it releases quite a, quite a nasty gas, this phosphene gas, which is both corrosive and cytotoxic, and As such, has the capability to cause toxicosis in in people. And again, kind of case reports out the states, the centre for Disease Control has documented several incidences of affected veterinary staff after MSS induction has occurred where they've been exposed to this gas and and had a problem. So, It's a bit of a tricky one.
We've got a dog who's eating something that's, that's highly toxic, but we don't want to make the situation worse for ourselves and those we're working with. So they kind of probably yes and goes with the territory of we probably need to handle these patients a bit differently. So consider inducing emesis either outside or certainly in a well ventilated area.
And then after vomiting has occurred to make sure rather than sort of the, the normal kind of cleaning up that we would sort of the handling that we would do to clean up that we're hosing away any kind of vomitter that's occurred just to kind of minimise exposure. And just, yeah, getting sort of advice from the kind of sources we talked about last week, but not using smell as a guide to evaluate whether there's the risk of exposure because it's known that you can have significant levels of this gas being produced, that could be, risky to staff handling these patients without there being a smell. So, a few kind of specifics about that one, but thought it was worth, worth mentioning just to have in the back of the old memory bank.
And the other one that people may well have seen in, in, in the UK, is this sort of wood glue ingestion or gorilla glue, is something that's sort of, seen in kind of various craft shops and, and things. Again, a young otherwise healthy dog presents even a quarter of an hour, after ingesting a sort of half of a bottle or so of this wood glue. Should we induce emesis in that dog.
This is an absolute no. And the kind of the reason behind this, it's kind of an interesting, interesting little thing if you haven't seen this before. Is that although the active ingredient in this is in itself not particularly toxic, when it gets inside the, the body, it's got this amazing capacity to sort of expand and foam and, and cure basically and and produce this almost rock-like mould that, that kind of expands to fill the space that it's in.
So it will fill up the stomach. It might attach itself to various sort of portions of the, the GI tract as well, and basically causes an obstruction. And it's interesting, this sort of thing that's created and takes up much more space than the amount of glue that was ingested.
And it happens incredibly rapidly. So even in a case like this, 15 minutes after ingestion, emesis, it, it's too late, and we're looking at radiographing to kind of confirm that's what's happened, and then we're looking at sort of surgical removal for, for sort of, I'd say decontamination, but more like treatment a little bit later on. Another tool that we've got in our armoury again for sort of decontamination, the GI tract is gastric lavage and times I think about doing this would be if I've got a patient who's now symptomatic, where we're saying actually that window for induction of MSIS is closed.
And specifically, patients who've ingested large amounts of, of things that are really concerning. So, certainly drugs where we're approaching 50% of the lethal dose, like that's a pretty scary position to be in. But there's recent ingestion, so I know it's whatever's in there is probably still in the stomach and, and therefore going to be removed.
In terms of contraindications for, for doing this, then we're thinking about, again, we don't wanna cause extra damage. So if something's particularly caustic, then we don't want to sort of cause more injury by trying to get that up. And if there's issues in terms of, already previous gastric pathology or or surgery, then that's again something that wouldn't really be considered a safe procedure.
This is some complications in here that that can and do happen from this procedure. But in, in general terms with sort of good technique as we'll talk about that, they're pretty rare. And again, as, as with any of the things we're talking about tonight, it's that risk benefit assessment to say, well, it's a small chance of some minor electrolyte disturbances?
Is that better or worse than the sort of toxic effect from the thing that's been ingested. So sort of clinical judgement as to, whether we should do it or not. And this is how it kind of looks, so we can kind of automatically see that this is a much bigger undertaking than your average induction of emesis approaches.
And again, it's, it's deciding what's sort of right for that patient at that point in time. If you are going to go ahead, it's really important we've got good techniques. So for me, having these patients under general anaesthesia is, is just mandatory.
It's just something that they, they have to be with a cuffed endotracheal tube that's, that's snug fitting. I'm basically doing everything I can to try and reduce that aspiration risk if I'm about to lavage them with sort of large amounts of fluids. And I also want to make sure that that stomach tube is, is in the stomach.
So like you would before passing a stomach tube for any other reason will typically pre-measure, marking with a sharpie or or tape or whatever from the muzzle to the last rib, and hopefully that will get us our landmark to say that we're in the stomach there. Having their patients sort of positioned correctly is helpful, so having them in lateral recumbency with the head lower than the body again helps sort of drain things out, tries to minimise that aspiration risk. And once we've landmarked our our tube to know how far we're gonna advance this then lubricating it and, and passing it with a sort of gentle twisting motion just like you would for doing a decompression in GDB but much, much easier hopefully.
. And the getting the tube in is, is usually pretty straightforward in these patients since they're intubated, there's no other place that it can go. So we kind of confirmed our correct tube placement already, but we can Help out kind of convince ourselves a bit more by palpating the neck for sort of two tube-like structures, so the trachea and then the oesophagus with the tube placed in it. It's just a sort of nice reassurance to have.
And then we can basically go ahead with the, the actual lavage procedure. And the basic principle behind this is that we're just using warm water, warm to try and reduce that potential complication of hypothermia, and especially in small patients. And we're basically instilling the kind of the text will say between 10 and 20 mL per kilo.
I can honestly say I don't think I've ever measured this out in, in my life of doing these. I'm sort of eyeballing it for an amount that we're putting in. And bearing in mind the average stomach will typically hold between sort of 60 and 90 mL per kilo, sort of a small fraction of that is is basically what we're aiming for.
And we'll ideally use a funnel or something to try and minimise the mess, getting this watered down into the stomach. And then it's not a particularly a technical term, but sort of allowing that to slosh around to sort of distribute to help sort of pick up the various toxins that we, we need to get out of there. And then to empty the contents, we're just simply using gravity flow so we're placing the end of that stomach tube below the patient into a bucket that hopefully somebody's remember to get because that's the bit I always forget to to get until it's it's a little bit too late.
And literally emptying that out again, . If we're not measuring amounts of sort of aquats of fluid, it's, it's useful to be able to palpate that stomach just to make sure we're not over extending them and during the procedure, but it's unlikely that we're gonna be super aggressive with the amount of fluid we're putting into to achieve that. And it may well be that as we're sort of repeating this, up to 10 times or, or maybe, until we've gotten to the point that there's no more content retrieved, maybe the the blue stuff's kind of stopped coming out and we're we're saying we're all done.
If there's large amounts, we may need to do a little bit of sort of gentle manipulation and externally to sort of break up any sort of lumps or, or kind of groups of things stuck in there. But most of the time, the kind of lavage will help break stuff up itself. And if we're having trouble, you can do this sort of in, in three sides, the sort of left lateral recumbency, right lateral recumbency internal, just to try and get all of those various sort of crevices, and get it as empty as we possibly can.
It's helpful to kind of look at this fluid that we get out to see if the toxicant that we thought was in there is coming out. So whether that be tablets or plant material or whatever and In patients whereby, maybe the toxin exposure is, is malicious or unknown, potentially, we can save samples for considering whether or not we want to submit that to one of the, the labs that we have available, we talked about last time. We want to make sure we've emptied out all of that lavage fluid before we kind of move on and typically after I've done that, this is the point that I'll install some activated charcoal before I remove that tube and removing the tube again, we've got a chance to try and decrease the risk of aspiration pneumonia by Kinking the end of it just as, just before that last little bit is sort of pulled out of the oral cavity just to keep that last bit of sort of lavage fluid within the tube itself rather than having it leak into the oesophagus and at the back of the pharynx.
Just like you would for sort of a, a, a GDV stomach tubing. And again, thinking about the, the patient reducing aspiration risk and extubating them only when that sort of gag reflex has returned. So a procedure that is much more involved, clearly, but one that's actually quite technically, technically easy to do.
And there are some specific indications for that where it's a really good choice to decontaminate these patients effectively. Another important part of gastrointestinal decontamination is the use of, of activated charcoal and actually in, in human medicine, it's, it forms the mainstay of decontamination in those patients whereby if, you know, you ingest something that you shouldn't, emesis is only only fairly rarely induced in the sort of, human emergency setting, since they worry so much about it delaying the administration of charcoal. So, this is a, a really, really, really big thing in, in human medicine and I'm sure we're familiar with the kind of the premise behind this, is that it's this carbonaceous compound that we give orally and it, it basically binds any toxins and, and minimises their sort of subsequent systemic absorption and Various formulations out there, they all have in common the carbidos, you know, has this as well whereby there's a really large surface area, that creates this huge binding service for toxins and so there's much less of it can be systemically absorbed as well.
We typically give this after we've done gastric emptying, whether that be induction of MSS or or lava as we've talked about. And again, if, if we're kind of thinking that there's something delaying us giving activated charcoal, then we might consider antiemetic therapy and specifically to, to give that since in, in human medicine again, there's, there's, It's known that the sooner you give charcoal, the, the sort of more an effect, more of an opportunity it's gonna have an effect as well. The kind of dosage of, the sort of carbodo formulation that we're, we're sort of now using more commonly is, is pretty simple.
It's one bottle per per 20 kg, and it's, I, I personally find it much easier than trying to work out various grammes contained within a mL of some solution that's been under the, the sink in the cupboard under the sink for a long time. So dosing is, is now pretty straightforward. And the nice thing about it is that certainly in in dogs, those patients who present for ingesting a toxin are by definition fairly indiscriminate with what they eat.
So I find most of them will ingest that really quite nicely with food. It can be mixed with dog food to try and sort of enhance the palatability, although, a lot of them will just eat it plain, which is, telling in itself. And there is a question, you know, does that impair the kind of the binding effect of the, the charcoal?
Does that kind of stop it working and There was a nice in vitro study where somebody looked at Acetaminophen, or paracetamol or they actually used Calpol, sort of in vitro mixing that with with food and charcoal and look to see how much binding happened and Although there was a little bit of binding, it didn't reduce the overall kind of effect of what the charcoal was going to achieve in those patients. So yeah, happy to give that in food, just trivia fact of the day, just not ice cream. Apparently that does affect the, the binding capacity.
I'm not sure I've read the original study to confirm that, but it's an interesting, interesting thing to pass along anyway, not that many of us would be doing that. If the patient's unwilling to eat the charcoal, either by itself or in food, we can syringe feed that. But again, this is where we're sort of being extra careful for that dreaded aspiration pneumonia, thinking about do we need to place this via a tube, but 100% being happy with our tube placement before we go ahead and give that.
But whatever it takes to kind of get this charcoal as, as quickly as we can. In terms of contraindications kind of makes sense that if it's not gonna stay down, if it's if there's a patient who were worried about their aspiration again, it's, it's not something that's in their best interests. If there's a possibility, a strong possibility of a GI perforation, then we kind of worry about this sort of stuff leaking into the abdomen.
But at the same time, if, if we give this and that transpires to have happened, then the solution to pollution is dilution, as they say, so lavaging that out in a timely fashion is is going to sort that out, hopefully. For me, one of the other big contraindications is if it's just not going to do anything effective and it's a few toxins whereby there's just going to be no minimal minimal absorption onto, onto charcoal and, again, there's kind of lots of information sheets out there as to kind of, which, which, compounds activated charcoal can be used against. Sometimes we think that most of the time, I should say, we'll just give a single dose of charcoal and that will do the job and, and we'll consider it done.
But there are some specific instances where repeated doses might be, might be needed and that's for toxins undergoing this so-called enterohepatic recirculation whereby There's sort of reuptake from the intestines into the liver, secretion out into the bile duct and kind of reuptake again, so kind of lots of potential opportunity for the body to be exposed to the toxin. By giving repeat doses, we can capture those bits as they, those toxin metabolites as they get out into the GI tract without, before they get an opportunity to be reabsorbed again. So.
In those cases, we'll give that every sort of 4 to 6 hours, but around the sort of 24 hour mark with the hope that we'll hopefully catch all of the various cycles of, of toxin within that time. And there's lots of these compounds that do undergo this recirculation. Some of the more common ones we talked about as being the sort of non-steroidals and chocolate toxicity will do that, but some mushrooms and marijuana and various other things will do it too.
Again, this sort of information is really out there, with these sort of charcoal compounds as well. So, useful thing to kind of think about is do I, do I need to give charcoal? Do I need to give it, more than once?
And we might also think about giving it in repeated doses in some specific instances as well. So if there's an extended release product where we're worried that this kind of the hit from this toxin is gonna be ongoing, we might choose to give repeated doses of charcoal. And for cases of grape and raisin toxicity, it's something that we can consider doing is giving repeated doses of charcoal for at least 24 hours if we're still getting passage of, of grapes and raisins in, in the faeces.
So saying that there's still exposure of the patient to this particular toxin. And the reason for that is that We know that this kind of toxic toxin can be really quite severe and we don't know the exact cause. So maybe it might help.
Maybe it's doing nothing. It's, it's hard to say. Hopefully we'll get a bit more information on that at some point to be able to give a stronger recommendation, but it's something to, to consider, for those patients is something that we can do.
We might also consider giving so-called cathartics as a sort of decontamination strategy. So these are various substances that will decrease the absorption of toxic substances from the GI tract by accelerating their expulsion from the body. So they basically decrease GI transit time, they speed up elimination and so we just shorten the window of when toxins could be absorbed.
And there's a few different ones out there, sorbitol being one of the sort of the, the common ones is sort of non-absorbable sugar that's metabolised to fructose once it's given orally and then that acts as an osmotic agent to basically draw stuff out of, out of the body as quickly as it can, but various, various other kind of, more electrolyte-based, substances can do that as well. One of the things about this is that they can be given, but they don't need to be given. So again, it probably depends on, may depend on stocking, to be perfectly honest, if you have some in, it may depend on how worried you are about a given toxin.
Previously they, they did come, some of them came already combined with the various charcoal products, notably not with the carbodo formulation. I think most of us are kind of using at the moment. And that's quite a nice thing because Whilst they can be, can potentially be useful, they should only be given once and that usually with that first dose of charcoal, if you are going to use them because of the risk of really quite severe side effects if they are given repeatedly.
So it's quite nice to have a formulation of activated charcoal where we don't have to worry about giving too much cathartic. So, You might think about using these. I don't know if many people are using them.
It's one of those things I'm a bit plus or minus on. I don't feel super strongly. I've got a really bad toxin, I'll, I'll consider it, but for the average toxicology patient, it's not necessarily something I would leap to do per se.
And so what I've kind of just presented is, is sort of current standard of care for how we sort of approach these toxicology cases. But it's always worth taking a step back and saying, is this actually, we've been doing it for a while, maybe, maybe there's some kind of additional tweaks and, and more information, but is it actually the, the right thing to do? And I thought I mentioned this was an interesting study that was published in, in 2015.
Now, and they basically looked, it's quite interesting. It's a really interesting question to ask, is they looked at single versus multiple dose activated charcoal in experimental Carprofen and toxicity. .
With sorbitol as a sort of cathartic, and they, they looked, they looked to kind of see what, what happened, basically. And this carprofan is a drug that does undergo enterohepatic recirculation. So conventional wisdom would say repeated doses will be the right thing to do.
But they thought, OK, let's, let's look at this in an experimental, sort of situation and, and see if that actually, actually the case or not. And I put the kind of the, the, the detail of the abstract up here for, for people to kind of read the specifics of doses and and protocols and what they actually did if, if you're super interested in this, but This study actually found that a single dose of activated charcoal was as effective as 4 doses of activated charcoal in preventing carpafen absorption after ingestion. And so it raises the question is, is, is multiple dosing, is that the right thing to do?
Are we wasting our time? And, you know, what, what should we be doing? And For me, this was an interesting study because I think it's, it's nice to kind of question what we're doing to say is this still the right thing, you know, things have moved on in human medicine, should we be doing something different as well?
But I think for me it's, it's safe to say these were, were healthy beagles. They, you know, they, they always are. This isn't your, you know, geriatric Labrador.
This, this is a standard dose of Carrofen to a healthy dog. This isn't an extended release product that we're worried about sort of additional hits from. It's just one toxin at one dose.
Can we really apply this information to all of the sort of, what did we say last week, sort of 16,000 potential toxin, ingestions sort of reported annually to the VPIS. For me, this is, this is really interesting and makes me kind of think about what we're doing, but doesn't, isn't enough, isn't general enough for me to kind of change that sort of general approach as to what we should do with these patients. We might think about minimising systemic effects of, of toxins, a sort of decontamination if you like, with, with diuresis and we saw this slide last week thinking about is, is fluid therapy helpful to kind of help flush out toxins that are really excreted, or the kind of the, the chocolate toxicity thing that we talked about last week as well.
And something we'll talk about in the next webinar in the series and in more detail, is using a sort of a lipid emulsion to help sort of again decontaminate these patients. Whether or not you want to call it decontamination or or antidote is, you know, is, is, is up to you really. But we will talk about this, in a lot more detail, next week as well.
There's a sort of final decontamination strategy for things sort of ingested orally, but may be applicable for other routes as well, is whether or not there's sort of new things on the horizon, whether or not these sort of dialysis or therapeutic plasma exchange or sort of charcoal hema perfusion where you can actually run blood through a sort of charcoal philtre to kind of get rid of stuff that's already been taken on is, is, is an interesting area that's really getting a lot more data and stuff published, especially from, groups within the United States where dialysis centres are sort of set up, a lot kind of have been a lot more established before us. And there's actually lots of toxins where this, this could be a consideration. So clearly at the moment, not necessarily that practical, that available, but, again, in the future, this is, is something that may well be of interest to kind of watch out for.
Just to use the last kind of couple of minutes just to kind of finish up the, the other routes. We don't tend to see that much ocular exposure from intoxication, but it can result in really quite severe clinical signs, . Our kind of goals of decontaminating the eye to kind of remove the substance and try and reduce any damage that's occurred, whether that be irritation at one end of the, the scale through to some kind of corneal injury or ulceration due to possible blindness.
And that's especially irrelevant if we have an injury from alkaline agents because we know that that can cause really quite deep corneal ulcerations there kind of your, your, your bad guys of, of ocular intoxication because it can be really quite a severe problem. We do know that ocular exposure needs to be managed promptly to try and avoid this kind of progression of, of, of eye injury as well. And so we know that we need to treat that promptly when they arrive at the clinic, but there's potentially a nice window for owner first aid to be provided if this is sort of a, an initial phone triage that happens to, to try and try and do something to reduce that sort of, toxic outcome, just before the the pet's presented to the hospital.
And the sort of basically the basic premise is that that contaminated eye should be flushed with really copious amounts of either tepid water or, or isotonic saline, for at least 10 to 15 minutes, which sounds great in principle, but trying to restrain the average cap to to do this well may may be easier said than done. So it might be feasible for some owners to do this at home. It might be better for them just to head down to the clinic and we'll sort of do what we need to to sort that out.
But in terms of how that's done, we want to make sure that we, we have flushing occur without too much high pressure that might worsen ocular injury. So, Putting the, the fluid into a syringe without a needle or an eyedropper just to have a sort of steady stream of lavage fluid and trying to lavage out the eye rather than using a shower hose or kind of other more high pressure system and that we might otherwise use in other kind of flushing scenarios is as important to not sort of make things worse. Recommendation is 10 to 15 minutes of flushing time, but I, I, it may well be that we sort of break that up into we'll do a bit, have a break, do a bit, have a break.
And certainly for these really nasty alkaline solutions, it might well be that we need to kind of keep going back to that to sort of do what we need to to get that IPH back to as, as where it can be. I can think of patients where we could attempt this conscious, but I can think of plenty more where we might need to do a little sedation or anaesthesia to make this happen. And in terms of when, when we have them, then the recommendation is to use a sort of water or isotonic saline rather than any sort of neutralising solution that may make things worse.
Afterwards, after we've sort of done the, the decontamination strategy, then we're really wanting to sort of examine the eyes, stay in the eye, and, and treat as necessary. So hopefully we're dealing with irritation or just mild corneal damage that we can treat with sort of routine treatments listed here. Preventing the patient from making things worse by putting on buster collars, but thinking about whether or not we need to consult an ophthalmologist if there's any sort of severe corneal injury, especially if there's been exposure to these alkaline substances that can be really quite nasty.
Lindsey, I'm sorry to interrupt you, but we're getting that crackle back that we had before. We went live. I switched to my speaker on my laptop.
Does that, can you hear me OK? OK, great, no worries. So yeah, so just to finish up, if we've got dermal exposure, then how do we decontaminate that specifically and This is something whereby the owner again can play a really useful role to to try and get that sorted sooner rather than later and do what they can at home before they present to the clinic.
And again, it, it's nothing fancy. It's sort of washing that patient specifically to minimise any irritation to the skin, but more to stop any absorption by the skin and get the, get the stuff off the pets so they're not sort of ingesting it by grooming and having a sort of, GI exposure as well. So that's kind of the basic principle behind it.
Again, trying to stop things getting worse by, if there's going to be any delay in this sort of washing procedure, placing a buster collar, so at least we lessen that sort of grooming exposure, keeping the pet away from other animals, he may well get in on the action and any children, especially that we don't want to come into contact with these various things, considering clipping sort of long-haired patients just to try and, and have less of stuff to kind of wash out and think about. Could this be a toxin that's been absorbed systemically? Do we need to do something else, especially for really lipophilic agents that might well have been absorbed across the skin, and maybe there's other kind of routes to decontamination for us to think about as well.
And so Most of these sort of patients will just use a mild soap or a detergent, so good old sort of fairy liquid or or similar, something quite mild is is usually enough. If something is particularly more greasy, then you might need a sort of a specific decreasing agent like sulfi or something similar, but whichever is kind of used based on what's been exposed to, then rinsing them, the patients thoroughly to kind of make sure everything's off them and they're not gonna get any irritation from the sort of decontamination substance, is really important as well. And then just finally, we just want to make sure that we don't make the problem worse.
These patients can really have been bathed, so making sure we're drying them off thoroughly. Making sure if there is any sort of powder toxin that we try and, and get that off, before we, we wash them so we don't end up with sort of lumps of this sort of toxin now stuck to the fur harder to get off than it would have been to start with. And avoiding anything that might make things worse, so avoiding any solvents like alcohol or white spirits as it might spread the contaminant even further and irritate the skin, similarly with sort of pH neutralising solutions, as we talked about before, best avoided.
And again, a kind of final note, avoiding contaminating the decontaminator, making sure we're kind of protecting ourselves from this stuff with our sort of clothing, but also in terms of how the, the patient's kind of restrained to kind of stop, stop any kind of leaping off the table kind of attempts and and people getting covered in in this stuff as well. So kind of restraining patients as necessary. That's a bit of a whistle stop tour through sort of the general approach to how we decontaminate these patients.
So hopefully you picked up kind of a thing or two you can apply to your patients there, but I'm happy to to take any questions you've got. Lindsey, thank you very much and I'm sorry I interrupted you. No.
It's it's always fascinating to, to have owners calling in with all these old fashioned remedies for either, you know, degreasing or decontaminating outside or dosing internally to make animals sick and everything else. It was quite funny though your presentation was perfect because we got a whole lot of questions coming through. And as they came through, it was like you were reading them and answering them.
So that was great. Great, I'm glad to hear it. Yeah.
You, you really have answered all the questions that had come through there. So, folks, just to let you know that it's not next week. A couple of you have been asking.
The next one in the series is a fortnight's time because next Monday is Easter Monday. So, part 3 of the the series of 4 in toxicology with Lindsay will be in a fortnight's time. Lindsay, thank you so much for your time tonight.
We really do appreciate it. No worries. Thank you so much for for listening and yeah, we'll yeah, regroup in a couple of weeks.
And to our sponsors, TBM thank you so much for your generous sponsorship. Really without you, we wouldn't be able to have these webinars. So guys remember support those that support us.
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Remember, this is your channel, so feedback to us so that we know what it is that you are looking for. To Lewis, my controller in the background, thank you for your time. Thank you everybody for attending and once again, Lindsey, thank you so much for a brilliant presentation.
