Perfect, thank you. Good morning all. My name is Josh Rayner, and I'd like to introduce you to JHP Recruitment.

JHP Recruitment are a specialist recruitment company within the veterinary industry, and then we are able to supply both locum and permanent candidates on all levels. Our team has many years' experience within the sector, and we pride ourselves on providing a professional and friendly service. So if you're looking, for, sorry, if you're a veterinary surgeon or a veterinary nurse or a veterinary care assistant, practise manager or receptionist, seeking work within the industry, please feel free to contact us via email or telephone.

For those of you who aren't aware, the GHP team is currently made up of 15 consultants, two of which have worked within the veterinary industry in a nursing capacity. So we are well placed to assist you with any recruitment requirements. Last year in 2018, it was a pretty big year for us.

We're fortunate enough to, to win 4 awards. First of all, in May, we won, Best Veterinary recruitment Specialist at the Lux Pet Products and Services. We also won the Best New Startup Business at the Express and Echo Business Award.

And then a little bit later on in the year in November, we won most trusted veterinary recruitment company at the Vet Trust Awards. And I was, fortunate enough to win favourite speaker at the Vet Trust Awards as well. So, whilst I've got this opportunity, I'd like to thank all of you that have supported us over the last few years.

It really is appreciated. Also like to welcome everyone to, this webinar, especially to all of those who have received the free tickets through JHP recruitment. Thank you all for your continued support and loyalty and hard work for our agency.

We hope you enjoy the webinar. Thanks for your time. Oh, hello, morning everybody.

Thank you so much for getting up so early to come and listen to our stream. Hopefully I'll go through some common, sort of beline poisons with you today. And obviously we'll have a little Q&A session at the end, so if you've got any questions, obviously it's quite nice, you can write them down and then ask me at the end.

Obviously this is my first webinar, so please bear with me for any technical problems, but I'm sure it will go nice and smooth, so. We'll start off with our first slide. So really any sort of toxicity or patient that we have suspected that has ingested a toxin or come into contact with one, we get a phone call from the client owner on the into our veterinary practise.

And most important thing that we all know is really just to Make sure, identify the packaging, ask the owner to bring it in, identify what kind of toxin they've ingested or come into contact with if known, just helps us obviously add our whole, our history for our patient and again come up with any antidotes or therapies that help aid with this toxin ingestion or what they come into contact with and link those clinical signs that they're presenting with together. And obviously we do this without thinking really sort of the basics of sort of very nursing about sort of telephone triaging of our patients and making sure that they pay the owners if they're obviously really worried if that cat's sort of seizuring over the phone, we sort of give them some advice, making sure that, you know, if the cat is seizuring to make sure that they're not gonna get harmed or bitten. Probably so it's quite different to our canine patients where you sort of would sort of back off and leave them, you probably would.

If they were harming themselves, a small cat if they were se, you probably get a towel wrap them in it, and making sure that if the owners can make sure they, they, they're aware of their mentation, making sure they're not really turned. It just gives you an idea of what to expect and so you can prepare yourself at the practise of their arrival and making sure you've got an estimated time of arrival as well. So they're really far away, just gives you an idea of if it's some sort of .

You know, what to expect, whether they're could be critical at the point when they arrive to you. And also, when you're on the phone, it could be helpful just to look at a recent body weight if they are actually already logged in on your system, and they're an existing client of yours. And again, this is a, sort of, once you've sort of come off the phone and you've got the idea of what they've ingested sort of toxin wise, we all have got, most of us have got a sort of the veterinary poisons information service to hand, and they're such a help, they're so helpful.

So if you have got the packaging or you know what the patients ingested, you know, give these guys a call and they shall help you. . Obviously, once you have an idea or perhaps you don't have an idea of what the animals ingested, but you have an idea of the clinical signs, you can get your triage area ready.

So this obviously requirement of your IV access is really important depending if they're sort of, you know, tuned, the sort ofmentation is not, sort of alert. We want to get IV access as soon as possible. And obviously with IV access, we can then get a minimum database.

So for us at sort of Langford where I work we, that includes not just a PCV total solids, that includes it getting a sort of blood gas and maybe if we're You know, concerned we can draw some more blood, to send to the lab for later on. It's better to try and get those blood before we administer any sort of fluid therapies and things like that as well, just so we have a baseline to go from. And again, if you've sort of spoke to on the phone, you may have a treatment or your antidote ready to hand to go through, especially if you've already spoken to the veteran poisons Information Service, .

Depending what the patients come into contact with, it's really important to make sure you've got some protection, so like sort of protection equipment, so gloves, aprons, just in case if you get it into your, onto your hands, you know, you still want to be affected by whatever the patients come to contact with as well. So triage, obviously, if we've spoken to them on the phone, we've got an idea of what the patient's gonna look like when they come to us. Obviously, you may have, you know, they're obviously really in respiratory distress, you may have some therapy and things like that to get ready to administer.

We've got our IV access, but Sort of triage sort of happens very quickly, but, you know, we'll go through it day by day sort of slowly here. I initially we can see the cats brought into us in its basket. We can see straight away if it's mentation normal, not normal, if we're sort of comatose or sort of look at the levels of consciousness.

That's probably one of the first things we'll see when we look at it sort of breathing, respiratory rate and effort, . And then we'll probably, once we've taken the cat from the owner, we'll probably pop it onto the table and try and get some sort of idea of perfusion whether we've got, you know, what's our pulse quality like, what's our heart rate doing, if we've got any murmurs, we ask to take those lung fields. And again, if we're coming into.

Thinking about what a toxin or poison they come into contact with. We want to check, you know, their mouth and things like that. We're wearing our gloves, just making sure we're not gonna harm ourselves while doing that, but making sure we're checking for the mixed membrane because also while you're in there, check for ulcers in the mouth and things like that and check, making sure the airway and everything's clear, .

Sort of, as I sort of spoke about check auscultating those lung fields is really important just in case they've aspirated anything as well. You know, getting a good idea of your patients, if they've got any sort of pulse deficits as well as checking pulse rate and heart rate, and if their pulse quality, good or poor, obviously we'll check, blood pressure. So I, anything that comes into, the ICU at Langford, we tend to do the same things regardless of what type of patients come in, but sometimes it can be difficult depending what sort of equipment you have at your practise, but we tend to, as they come in, heart rate, pulse rate, check the pulse deficits, breast rate, rest effort, auscultation, and we maybe place an ECG in our patient and take your blood pressure and obviously, checking temperature and things like that as well.

So it's just obviously to get a good idea of the baseline of your patient, exactly how they've come in and what they're presenting with you. So obviously you've got more information of your patient as well. And if they admit to you and they're seizuring, obviously it's really scary.

It's more, I think the owners, they find it really difficult when patients, their own pets are seizuring, . The first things sort of don't panic, even though it's, you know, maybe it might be your first time seeing an animal seizure and all animals sees you differently and sometimes it can look really sort of dramatic and horrible. It's really important just try and stay calm, especially if the owner is there with you, you may have to just sort of, you know, the animals come and see you and just keep calm and take the, pet away from the owner into the prep room or wherever you need to do your triage of your patient.

It's really important. So upon arrival, maybe they might have seizured whilst they're in the journey on the car here. If they've happened to just start it sort of seizure with you, taking note of the time is really important.

Also, if you can, administer some oxygen therapy to those seizure in patients, and again, it's really important just to make sure you don't get bitten, sort of by this patient, obviously cat bites are quite nasty. And maybe you've got it maybe out of hours you may not have a veterinary surgeon there, so obviously you would give them a call, let them know, you've got the patient here. Once you're, you've spoken to your veterinary surgeon, if you are like a nurse by yourself doing that night shift, it's really important to get a seizure plan or plan of what drug therapies you can get from the veterinary surgeon.

We, routinely have, a blanket policy of having seizure plans for every patient that's had a seizure in our hospital. So if we are a nurse and we're working in our ward and a patient's seizure, we've got a plan that is, it's been prescribed by the veterinary surgeon. It's signed by them.

They've got drug therapies they want us to give. So therefore, we can carry out that plan without any repercussions of giving those drugs. So it's quite important, you know, this cat's coming down, you could probably give your veterinary surgeon a heads up.

If you're out of hours and just try and get a plan of action of what they would like you to administer, or they might be on their way anyway. And again, it's really important, obviously, in this day and age, to make sure we record everything on the clinical notes just to the legalities of the situation and make sure that we know what's happened and when. Sort of, post seizure, so sometimes, you know, once you've timed it, if it's a obviously it may be in status, but It may have just lasted, say 2 minutes or so.

We like to try and check your temperature. So obviously, if there's still seizuring, we're gonna try and check, check your temperature. It's really important, obviously the risk of going hypothermic really quickly.

Normally if you say if you're checking the temperature and you find it's normal, but there's still seizuring, we tend to check it sort of every 2 minutes to 1 minute because obviously it can escalate quite quickly all these muscle tremors of the tonic clonic, . And again, if it's not tolerated, the oxygen therapy, you know, don't worry about it, but obviously it just helps obviously with the body with those sort of all those muscles and those sort of tissues as the seizuring using up all those sort of oxygen. So giving them oxygen therapy just sort of helps and sometimes the mammals can become quite sort of hypoxic during their seizure.

I would sort of say if your patient is, the temperature is quite high, it comes sort of around about 40 going over to 41 degrees, sort of making sure that we do actually cool them, just to prevent any sort of hypothermic injuries that may occur. We stop at 39.9.

It still sounds quite high, but your patient will drop quite sort of slowly, in their temperature, and we don't want our patients to become hypothermic, . It's really important to say, obviously, most toxins that make cat seizures, obviously, we talk about, I'll talk about promethane toxicities in a second, but it's really important again, if they are have come into contact with permethamine to you suspect methamine toxicity not to overexacerbate obviously or make those sort of tremors worse, as well. So.

We'll sort of think about drug therapies to try and control those seizures rather and then bringing the temperature down. Maybe you have to anaesthetize or give a heavy sedation to those patients rather than actively cool them just because it can exacerbate those tremor signs as well. And again, obviously once you've come to 39.9, you want to try and thoroughly dry your patient with towels, so as I said, the temperature will drop down even though you've dried them, so don't.

We keep sort of wetting them, just dry with a towel, put them in a nice dry bed, and if they are obtunded post seizure, we want to elevate their head and body and see, just to prevent any aspiration that in case they've got a reduced gag reflex as well. So sort of as we discussed the methin, so, we normally see it, as, you know, those sort of spot ons we get in the supermarkets, and, you know, maybe, you know, the owners accidentally picked up the wrong one or put a small dog spot on onto their large cat thinking it's OK. So unfortunately these, still easily accessed over the counter and, I mean, they still happen, I think.

They were quite common, a few years ago, but it's, yeah, it's still, still the, odd case happens, and obviously cats, don't really, cope with the high thyroids and the methins, and I've got a little video here of a methamin poisoning. So, you know, if they're, they'll usually present like this sort of tremoring and maybe exacerbate . The sort of seizures and stuff if you're trying to overly handle them.

So less is more with these cases, and again, if you're really worried about them going hypothermic, we just have to think about maybe drug therapies as a first line instead of sort of putting water on them just in case they, you know, exacerbate them makes it a lot worse. So this poor cat, you know, lots of things will obviously be hypothermic and salivation. You know, they sort of maybe feel a bit or the tingling limbs and really sensitive and feel, sort of maybe they'll feel like they are being like painful upon handling because if they're sort of reacting to the non-n just stimuli just because of, the effects on their nervous system.

. Stop that. Get to the next one. Absorbed really sort of quicklymethrins and usually, once the spot on's placed, our cats, they like to groom themselves obviously when we put you know a spot on a cat, if they've accidentally licked themselves, they sometimes froth at the mouth anyway, but obviously with a, you know, maybe a, a dog, small dog spot on that they've had put on them by accident.

And they normally they sort of cream themselves and add sort of orally absorb that of them. And brains as well. And again, hi there, it's Vicky just speaking here.

We're just struggling with Holly's audio, just bear with us a moment, and then we'll, we'll catch up with Holly and see if we can get her back online. OK, can you, great, sorry about that guys. So.

I don't know how much you got of that, but we, obviously with the spot on we, we have if we have, small dog spot onto our patient. Normally it's our patients sort of grooming themselves and absorbing it through their mucous membranes that affects, that sort of, obviously, when we put normal spot-ons on cats, obviously they'll groom themselves, maybe get a bit sort of upset or have froy mouths, but obviously they've been given a sort of spot on, meant for dogs, they could absorb that through the mucous membranes more so than they would generally. And again, this, this affects our nervous system, sort of, and our sodium channels, and that's what causes our sort of tremoring signs in our muscles as well.

The importance of making sure our patients don't go hypothermic is obviously. The effects it has on our muscles. So obviously our patients tremoring anyway and they've got really hot sort of temperature.

This causes a rhabdomyolysis unless there's a breakdown of our muscle fibres, and this therefore sort of produces myoglobin and this is obviously our kidneys don't like myoglobin, it causes acute kidney injury. So initially, obviously it's really important to try and control these clinical signs as soon as they happen. So we can prevent any further damage that may happen down the line.

Obviously, we're not gonna know about any sort of acute kidney injuries, probably, you know, maybe sort of say you are like say about the next day or something like that after we've had the methamine spot on put on us. So it's really important these patients, that we do think about the sort of future effects of the clinical signs from the permethrin that the toxicity this patients had. Right.

So for treatment of our sort of tremors and seizures that are sort of patients presenting with, we can give a muscle relaxant, that's probably the best, thing we can give obviously the other drugs are popped on there and all these doses are like out of the formulary and things like that. So they may vary practise practise, but sort of just the marks or dose range on there popped on for you, but . Methocarbonals of your will help stop those muscle tremors and normally obviously the patient that's either tremoring or seizuring you're worried about sort of mentation and maybe they've got a reduced gag, thinking about sort of giving those drugs orally is probably not the best thing.

So we, give those sort of as a pessary rectally, sort of similar how you would give a lactulose enema. So we would probably, just use a Foley catheter. And sort of crush up methocarboy tablet into some saline and put the Foley catheter directly into our patient, and inflate the balloon.

So obviously nothing can backflow and there's sort of holes in the end of the foley catheter since we sort of start injecting our sort of crushed up methocarol, we can then Brush a little bit of saline with it and just keep put a bung in the end of the Foley catheter and actually just gives a nice sort of retention and enema and make sure that we know the metacarbomol is being absorbed by the patient as well. So those are quite useful as well. And again, you mean if you don't have any metarbool, maybe it's like you just have to give some propofolfaxolone just to make sure that your patient just stops those tremors and the risk of hypothermic injury.

Goes down. Again, it's just one of those things challenging obviously trying to get an IV catheter. We may end up giving something else like diazepam rectally and just to be able to get a catheter into your patient, get some IV access.

So, one of the sort of therapy, we're using more and more nowadays. We use a lot at Langford, for to sort of different toxins that we have, is intralipid therapy, and this is, obviously because use for nutritional therapy, but, we've come to really use it as to help us treat sort of lipophilic sort of toxins, so. The sort of fear of people are not really sure how intralipid sort of works, or the ins and outs, but the basics really sort of acts like a sink, putting those toxins towards the, or the lipid trapped into the lipids and they're not then attaching themselves to the receptors and all the tissues and things and preventing those neurological signs that you sort of see with those types of toxins and those are sort of excreted out the body.

And they used obviously and so the only attracted by this lipophilic, molecules. But, we find it really effective. We have really good, outcomes with using intralipid therapy.

And I've obviously, you've got the notes, you've got I put all the, sort of doses and treatment plans in your notes you have there, but The nice thing about obviously having webinars and things, you get time to either take a photo or write those notes down, but I have put a lot on this slide, but we normally start off with a 1.5 mL per kg bolus over 30 minutes of the intralipid therapy, and then we start back on like a CRI of 0.25 mL per kg per minute over sort of 30 to 60 minutes.

And there are some studies to show it just may aid in sort of faster recovery time, but you know, again, it's just really important with any sort of lipophilic sort of substance, . You know, just to make sure we're giving it quite, aseptically, the intralipid just because it's obviously a big growth medium for bacteria as well. So just make sure that, you know, any sort of phlebitis and things in the IV catheter, you're just keeping a BDI on.

. And With these patients have popped in here sort of care with handling of just preventing exacerbation of those sort of tremors and seizures and things like that. Obviously, once your patient, those sort of tremor signs have subsided with drug therapies that you've given, we're gonna start trying to get off any sort of residual, sort of in dermal contamination of that product. And again, things like washing up liquid, shampoo just to get rid of that, that substance.

And again, just making sure we're not having, our patients not being hypothermic. So bear in mind if we are bathing them, just make sure we make them sure they're dry and we're making sure that, we either put them on a heat mat or a bear hooker again, making sure we're not, they are either responding to the drug therapies, therefore not going to react to say something like a bear, the noise of a bear hooker or something like that. If you You know, buster cos obviously a really good idea for you and make sure you haven't got all of the contaminant off the coat.

O cats are gonna try and groom themselves and it just reduces the risk of further contamination of of any sort of products that have been left on the patient. So these sort of patients, obviously this picture is quite dramatic here, just sort of gives an example of the type of patients we have at Langford, but, making sure that our patients quite obtunded post, seizure or maybe it is on a CRI of propofol or something like that just to help while we give intralipid therapy to prevent those tremors and make sure a patient isn't hypothermic. We want to make sure that our patient is elevated, prevent, obviously you could have a reduced gag and making sure we don't have aspiration pneumonia.

We're gonna maintain that airway so if we need to have some suction, just to sort of suction any sort of sloth away from the mouth, and excess saliva. Eye care is really, really important. Any sort of, optimed patient has got any neurological deficits or is on sort of long term, not long term, but say you run a CRI or you've had a, you know, a propofol bolus or infusion, making sure we are lubricating those eyes.

Obvious, if our patients come for one thing that we can treat and help, then we don't want to obviously go home with, you know, really sort of a poorly eye, as well, so it's just really important. And again, making sure our patients. Isn't going hypothermic if we had drug therapies and we've bathed them, and again, bladder care sort of we had sort of talked about the risk of acute kidney injury or AKI.

We want to make sure that our patient is urinating. So obviously, in the first instance, we may have started a patient on fluid therapy. Make sure if you have got an ultrasound scanner, you can just scan that bladder and just to check that it's going larger in size if you're worried they haven't passed any urine.

So if you know it's increasing in size, like sort of. Rest assured that they are producing some urine, but it's good just to obviously monitor urine output, making sure it's matching your ins and outs, what you're putting into your patient as well. And again, if they've had muscle relaxants that may, may help.

And again, making sure our patients in sort of quiet, maybe not dark, but as in like a dimmed room if you have got a dimmer, in your sort of area, they're going to house them in and making sure our patients are either turned frequently, so every 4 hours, or they're internal recumbency and we're just sort of shifting their joints every 4 hours so. Obviously sternal cumbers you just to make sure if they have aspirated anything whilst they were seizuring or any of their saliva, that they've got the best chance of ventilating properly. And again, as I said about fluid therapy, one sort of diaries, any myoglobin that may have occurred if they've had a severe sort of hypothermia.

You want to reduce that AKI but obviously we're not gonna know until sort of, you know, sort of 7 hours plus onwards for that. So that's back on going to Baclofen. So we've had a few cases of these.

These aren't common, but it sort of highlights sort of human drugs that our patients can get hold of and it's very rare for I say a cat to don't want to go and eat a tablet, but these things do happen, or maybe they have got a patient, they've got their own pet that's on medication, they've got mixed up with theirs and they've accidentally given it a tablet of their own. These things do happen. So, we just had a few of these cases in, but it's just important really just a highlight of the, you know, animals and ingesting which of these sort of human drugs that we're on, but, back of sort of our, a muscle relaxants and The sort of list of the clinical signs that can be presented again, obviously they relaxed.

They're not gonna, they may not sort of be ventilating, breathing as as much as we would, so it's really important that we make sure that if they have come in, they're really sort of reduced mentation they're sort of really obtunded we need to sort of maybe. And check that they are the best rate, make sure they're ventilating well. We may have to ventilate for them, but, it's just obviously being aware of those clinical signs.

There's lots of things we can do beforehand, obviously check if we need to ventilate them, we can check, make sure that entidal CO2 is not building up. Obviously, it's very high, we can then start to intubate and ventilate those patients. And we've got a sort of rapid onset of those clinical signs as well.

So, Baclofen responds again very well to intralipid therapy. So if we have had a case and we know the owner is like, oh I've given my tablet by accident or my cat's, you know, eating this packet for some reason, we can then obviously get our treatment therapies ready upon their arrival. We can think about decontamination of decontamination wise I mean.

We can induce the mucus, but it depends on how long if it's rapid onset of absorption. So it depends how long ago this cat ate or ingested the baclofen. So sometimes that's not always possible.

Obviously we can think about, activated charcoal, which depends on how, What our level of mentation and consciousness is like. Obvious, if our patients got reduced mentation, we're not gonna sort of pass a nasal gastric tube and give them activated charcoal and things like that. So, it's really nice that obviously intralipid therapy, this is a treatment therapy for black and ingestion.

And again, we just want to Give them intravenous fluid therapy just to make sure we we've got perfusion through our kidneys and make sure we're monitoring urine output and things like that. As I said about ventilation, it's really important, you know, this is a muscle relaxant we have reduced sort of our respiratory muscle intercostal muscles and things like that have to think about where it's gonna go. Our entire CT is gonna go sort of quite high if you've got, the, a blood gas machine in your practise, you can check a, just a venous blood gas just to check what the venous CO2 is doing or if you've got .

You know, if you're worried about that airway, you can just intubate your patient and start ventilating for them and maybe monitor your entire CO2 through Kay as well. We want to see once we're sort of monitoring our patient, we want to make sure they're not getting too cold, just because they're not moving if they're really relaxed on the Baclofen, and again think about eye care and elevating our patient again, it's really important, obviously any sort of reduced mentation and things like that, we want to make sure our patients. Head and body elevated just to prevent any aspiration as well.

And We've had quite good outcomes what they've had in lipid therapy usually, we've got sort of 2 to 4 day resolves with sort of fast therapies as well. And another sort of classic, one, ethylene glycol. Really sad, doesn't always, usually doesn't end that we that great, and again it's be sad, obviously this time of year, obviously we've got frostiness going, obviously the snow season, February is around the corner, .

NRD ices, breakthroughs, screen wash our little cats hiding underneath the car. Maybe they've been locked out, maybe they're lost or they're having need to drink some water and they end up drinking some ethne glycol. It can be accidentally drank or I know, and forbid, sort of no one adds it to their water source, but most of the time we see patients that have accidentally ingested ethne glycol.

And again, if they've got some on their coat, bring into cars and stuff like that, they can sort of ingest it by grooming. So treatment therapies for these, again, it's really sort of I think glycol. There's a a long sort of stage it's like 3 stages of the clinical signs that goes over, and the therapies that we have to sort of have to be quite doing quite quickly.

And unfortunately this usually the signs that they present with, it's usually too late to give any therapies that are going to rectify the damage that's already been done. So, you know, all the sort of different clinical signs are put on here sort of. Present on different stages about sort of when sort of from the point of when e glycol was ingested.

So the development of our clinical signs, so they have they put me in stages 12 or 3, people may call them different things like the neuro neurological stage and stuff like that, but, we just give an example of really when those clinical signs start to happen. We, sort of the first stages, and this is sort of from ingestion, up to about 12 hours, they'll have sort of some signs, maybe to be a bit depressed, bit of ataxia, maybe vomiting. And usually this sort of resolves and the patient, or the pet starts to look better.

And the owners are then like, Oh, my cat seems all right now. And unfortunately, at this stage one, if this is sort of seen, this is the point where we should sort of bring up cat, you know, if they've been outside for a long time into the car or whatever, bring them into the vets. But obviously, if they look perkier, and they seem to recover.

This is sort of overlooked by owners sometimes and again those those sort of toxic metabolites that are building up within our patients, as well. So, just important to be aware of this initial signs. And again, you know, it's a longest and easy in your notes as well.

It's quite a long list of clinical signs that happen at each stage. But again, it's that sort of initial stage and then the break and they obviously have a period where they look well and then it's not until sort of stage 2 or unfortunately stage 3 that we maybe see our patients as well. So probably just be aware of patients having a sort of severe sort of metabolic acidosis, they may present, you know, a bit of pulmonary edoema, seizures, obtundation, and again, the later stages sort of showing classic signs of azotemia.

Having calcium oxalate crystals and maybe comatose as well and again signs of this classic signs of aura, allegura, and elevated, renal parameters as well. So Those nasty metabolites that are causing sort of all these clinical signs, so for examples of our, oxalic acid, which is sort of binding, sort of to our calcium, which also causes the hypocalcemia and the formation of those crystals as well. So it's quite nice to know like why the oxalate crystals come about.

And those crystals sort of quite pesky and they sort of cause some renal tubular obstruction. So that's what we sort of worry about our damage to our renal tubules and sort of sort of kidneys and things like that. If you have, I put on, I put on there about an iron gap and metabolic acidosis, but, .

Gap is just a way of measuring sort of measured anions and obviously if you're worried about this patient, you don't know what it's ingested, having a elevated and an iron gap may give you a clue to that it's ingested as inclineco it as it's an extra metabolite that's not accounted for and therefore it's sort of pushing an iron gap higher. If you do have blood gas facilities. If you suspect, you know, it's really good to think, oh, you know, should wear a blood gas on this patient, just check it on and gap if we suspect it's got these weird clinical signs.

We're not sure. We suspect it may have a glycol toxicity. So, obviously, if we know it's ingested it, we can try and, you know, get in there quickly and then do some mess.

Again, I've put xylazine on there, but I know we tend to sort of not use that as much anymore if you guys use that out there, or dexametomidine sort of works as well. And again, it can be re reversed by amazole. .

You can obviously sort of think about gastric lavage. Again, gastric lavage is really risky. The risk of aspiration is very high.

So it's just obviously if they've got any reduced mentation, you want to make sure that you don't want to use any mess. The risk of aspiration is really high again if they are sort of depressed, in any way. .

It's, it's really absorbed quite rapidly through the GI tract as well, and activate charcoal won't help with ethylene glycol either. So, or treatments, we sort of think of, vodka, as the sort of first line to go to, really, and I've put obviously I slide with lots of information on it. So, it's only gonna sort of work if our patient is presenting to us and azotemia isn't already, you know, if it's, if the aotemia is already there, it's, this therapy is obviously it's too late, it's not going to work.

We have to be aware of if we're giving vodka. It can worsen sort of our body obtundation of our patient and it can sort of worsen the metabolic, you know, thinking about the metabolic acidosis, things like that, so, . We have put some sort of doses on if you wanted to give it, you know, via NO2, but again, you just have to be aware if your patient looks bright and breezy, it may be in stage one of its clinical signs, we've maybe done blood gas and it's got an elevated NAN gap.

We suspect we know it's ingested it, we can pass that tube if they're looking quite perky and alert. But again, if they're not, we're gonna think about doing it as an IV solution, and those all doses are popped on there for you and giving them it's quite intense, these patients, their treatments and looking after them as well and when we give those doses. Other treatments are obviously in people, they'll give, it's called it's M4 MP sort of therapy.

It's really expensive and it's sort of, not widely used in veterinary, but This, didn't have any sort of obtundation effects, on our patients. It's probably the better one to use for therapies like this, but it is sort of, you know, use it in people and things like that NHS, but it's very expensive, so it's not used, sort of in veterinary medicine really. Other things to consider are dialysis.

Ob we're worried about our, kidneys, our kidneys are damaged, we can do personal dialysis. But again, we've got a high risk of peritonitis with these patients, so we'd have to be obviously strict asepsis when doing this. Again, you can refer these patients for hemodialysis.

Again, it depends on how much of the poor prognosis of this patient and how far the owners want to go with this. But again, it's very expensive and again doesn't guarantee that you're gonna come out with a fixed patient, but nice to know the options there. So these patients, again, much of the same want to make sure, our patients have got a, if we have diars and we're not di, we're sort of diariesing them trying to help their kidneys, .

If we're worried about patients maybe about fluid overload, we can place an tube to pass water through to give them their sort of water requirement by that. But again, we should be aware if they're not haven't got a reduced gag. Monitoring your urine output is really important in these patients, make sure we're matching those in and out.

So if we, a urine catheter is a must in these, and again making sure we're not overloading these patients, and monitoring those lung sounds, making sure there's no puledema. Again, if they have risk of aspiration, if they have got reduced mentation as well, reduced gag, and there's classic things we keep an eye on our blood pressure, heart rate, respirate, and make sure, a best BO2 as well, and all those sort of bloods as well to make sure those, renal values either stay the same or if they're getting worse, we'll know about it by taking regular bloods and electrolytes and obviously making sure that their temperature stays within normal range. So on to lilies, so I think most felines are quite aware of this sort of toxins, lilies sort of can sort of present to our feline friends.

And again, it's the whole plant, it's not just, you know, stem, so, clinical signs sort of come on within about 2 hours post-ingesting signs of vomiting, of atax and depression. And again, we're gonna get within those sort of, post 12 hour window we can get elevated, renal values as well and possibly sort of potassium as well. And post 24 hour period, you may see some protein in the urine as well.

So usually owners are quite saving, they're like either they know they've got, lilies in the house, but it's maybe quite hard for cats that like to go to other people's houses. May not know what they've ingested. So that's when it comes tricky if they've gone to another person's house for a meal, secret meal, and they've maybe come into contact with a lily, or something like that or maybe they've just been roaming, roaming around, but, yeah, it's just sort of being aware of those, early clinical signs, but again, it's, it's easier when we know what the patients come into contact with.

So I mean, again we talked about sort of inducing sort of ais in these sort of type of patients, but if we have get there quickly, we and the patient obviously won't have reduced mentation in this case, and they sort of maybe I suppose have a little bit of depression, but maybe they are quite sprightly after they've eaten it, so we can induce a sort of. Cytosine or dexamomidine. Again, we can think about gastric lavage.

Gastric lava, you know, if we're really worried, has its place, but it's just really important to be aware of this of high risk of aspiration pneumonia with gastric lava to require a GA and things like that. Activated charcoal. So if, you know, it's been post 2 hours or something like that and you can't do that to reduce mess, you can think about activated charcoal, we can pass an tube.

We've got sort of nicer, sort of thinner, products out there now that we can pass down an NO tube into our feline friends and that might bind the toxin nicely and prevent any further reabsorption into our patient as well. And again, we want to make sure that we worried about our renal values. We've already started fluid therapy and sort of diing those kidneys, make sure again matching those in and outs, keep an eye on those bloods, as creatinine and BUN and electrolytes.

And again, it can be quite absolutely fine if it's treated quite quickly, but it's just those cases where we don't know what they've ingested, and that's where the risk of acute sort of further sort of damage to our kidneys long term may occur. So a little bit on activated charcoal. So normally, obviously we've got the classic activated charcoal, we've got the carbo dough, which is quite handy because it's sort of a thinner solution we can get down as NO tubes and it's roughly, it really depends on the packaging, but always check on your packet and the manufacturer, but roughly between 1 to 5 grammes per kilo.

For us, and yeah, this is, again, doesn't work on alcohols or metals or anything like that, but anything else, it sort of binds to the substance with our GI tract, and sort of prevents that rheopathic, enteropathic circulation, which is really important, obviously, as your toxins sitting in your So make it, it sort of can be sort of reabsorbed, sort of put into your body multiple times as it's been digested. So once you activate charcoal's gone in there, and binded to it, it sort of reduces the risk of that and therefore our toxins or signs of toxicity are reduced and any further damage and it's sort of excreted sort of quite quickly as well if it's got cathartic as well, and within it. .

And some people feel like they can just give one dose or you can give multiple doses. Any sort of care with giving multiple doses is if it has got a cathartic in it, you don't want to sort of dehydrate your patient as it's sort of moving that sort of the stools out faster, and giving it earlier on, fativated charcoal is better. And again, as I've said about being careful with our obtundation and any sort of reduced gags with activated charcoal as well.

And I said, sort of I mentioned about cathartics and stuff like that. So if we have got a cathartic within our activated charcoal, just again, making sure that we're not sort of losing too much sort of free water with that and make sure we monitoring those electrolytes. Again, sort of examples of what small molecules that activate charcoal won't bind to.

And again, you can give in food or via a nasogastric tube is quite, nice and easy to give. So on to some other plants. So we sort of know about foxgloves and the association with things like the, digoxin and the cardiac signs of foxgloves and the glycosides.

Again, you know, also it's really helpful if we know what the patients ingested, but sometimes we don't see our patients are presenting with It's been outside when we go around, maybe the owner has got foxgloves in their garden or some sort of lilies out there. We can look for our clinical signs again, it's all about putting the puzzle piece together, but it can be quite hard sometimes with some toxins that patients come into contact with, you know, to match those clinical signs. But, again, if we know they presented with cardiac arrhythmias or they risk of cardiac arrest, obviously to do with that like potassium and sort of affecting our.

Iron channels within our cell walls of our heart and things like that. So we just have to be, careful and monitor those patients quite closely if we're not sure what they've ingested if we haven't already decontaminated them. So, again, if we know they've ingested, sort of foxgloves, we can think about decontamination.

So this is thinking about inducing a mess or activated charcoal, that's the AC I put on there. And if we're thinking about fluid therapies, maybe we just think about, sort of. And nothing was without the calcium in it, just obviously again thinking about the heart and those heart cells are sort of quite upset.

So we're gonna sort of maybe think about antiarrhythmics or therapies as well if we are worried about some cardiac arrhythmias on our patient. I'd say with these patients, you know, if you have got the sort of, ways to monitor an ECG on your patient, that'd be great. It's quite hard to keep an ECG on a cat sometimes, but sometimes you can put them over the apex of the hearts on their chest as well if cats don't tolerate the ECG pads on their feet, just so you can keep a BTI on them, just it's quite important just to keep an eye on those, any of those arrhythmias.

Paracetamol toxicity. So we all like, obviously we've got IV paracetamol all over like sort of in our practises now, and really unusual for a cat to want to eat a paracetamol's bitter and horrible. But again, you know, we have those episodes where maybe it's been given by accident by an owner or we've given it maybe out by accident in hospital.

Again, this is pesky metabolites again upsetting our feline friends, so it's not metabolised very well by cats, . And sort of causing an oxative damage to our red blood cells and our sort of liver cells, and causing meta hemoglobinemia. So, you know, our classic signs of patients having sort of brown mucous membranes.

There is no safe dose in cats. I've put, some doses of what sort of toxic and fatal doses on there as well. And this is just because cats don't have the process the sort of.

Make up to try and metabolise the paracetamol in like dogs. So our clinical signs, again, because of the meta hemoglobinemia, our sort of oxygen has can't really bind to our red blood cells as well. Now it's got this sort of, sort of paracetamol metabolite in there, so we may have signs of cyanosis, dark brownous membranes and dyspnea.

Again, we know that cats eating it, we can give sort of trying to decontaminate our patient with gastric lavage inducing ausis. Thinking about things that activated charcoal. Obviously it's not always a time and place for, you know, gastric lava, if we're worried about the risk of aspiration of these patients, they've had paracetamol, they're not usually obtundation like them to or anything, so you probably can use the meys quite easily if we can't or if we want to make sure we've got the sort of belts and braces, we've induced a mess, probably gonna start some IV therapy.

So, acetylcysteine. Is a way of helping, activate those, metabolites and making it safe that it's excreted throughout the body. Making sure if you are giving activated charcoal at the same time as your acetylcysteine, is not given at the same time because you activated charcoal will absorb the drug therapy.

So making sure you just spread those, those out. And again, I put those like sort of semi. The sort of, liver, sort of, drugs like Demain and things like that to help out, .

Therapies for our liver and sort of fluid therapy as well as just to keep a BDI on our feline friends. And, and the cheeky one, I know sort of isn't happen very often, but I think it's just sometimes, you know, someone who just want to use, herbal therapies for worming or not worming, but like beef, like flea treatment and things like that in their patients. Sort of onion and garlic are found in, you know, sort of, homemade remedies or just mainly garlic for like flea treatments.

Obviously, if you're cat grooming and they've got garlic on them and things like that, and again, it, I think it'd have to be over a long period of time. That they've ingested it, so they may, again, it can cause injury to our patients and maybe possibly Heinz body anaemia again and sort of me sort of with haemoglobin, as well. It's just to be aware, you know, if that's your cat's presenting anaemic, and, you know, we've got Heinz bodies on there, you know, have they ingested sort of garlic or onion or they been given a garlic therapy of flea treatment.

It's probably just good, that's what it's quite good to get a full on history from your owners of finding out the puzzle piece and putting it together. So that's nice short. Short one there, but, you know, clinical signs, as I said, that come with being anaemic with our patients, again, they're gonna maybe be a bit sort of lethargic.

They've obviously got maybe they're quite anaemic, again, maybe tachycardic, making up, they've only got a little bit of dyspnea, maybe it's sort of not dys it's more tachyia rather than dyspnea. Obviously it's quite severe, they're severely anaemic. They're not gonna have as many red blood cells around their body so they become dyne but usually present with maybe some more mild like kidney and be sort of slightly tachycardic as well.

And again, it's the same thing again, sort of repeat myself here with the sort of decontamination, thinking about activated charcoal. Again, we wanna look at our haematology and probably check that over the next few days to see if our red blood cells are increasing as they've sort of recovering from this ingestion or toxicity as well. They may require some oxygen therapy, but again, if you, your patient's anaemic, there's any similar red blood cells that the oxygen can bind to, but again, oxygen therapy is not contraindicated and just make sure monitoring that heart rate and breast rate as well.

So a little bit on inducing images, and I'm coming close to my end time, but, this is already in your notes as well, so please don't worry. So obviously, you know, up to sort of 75% of toxin. Can be brought up, vomited up within sort of 30 minutes.

So obviously, as we know, as the longer you leave it, the less is gonna come out of reducing reiss. So those sort of 4 hours, we're gonna think about other ways of having to decontaminate our patient either by activated charcoal or thinking about what we can do to alleviate those. The clinical signs that they are giving us.

And, again, sort of basics of corstic or corrosive we know we're not gonna, if they've eaten something or ingest them in something caustic, we're not gonna try and get to induce me and re-expose those tissues to that corrosive substance. Again, obtundation and risk of aspiration, I said that quite a lot through this talk, but, you know, always be aware of that. There are little crosses next to those.

And again, inducing a mess, soappomorphine can work in some cats, doesn't always work. Ob we know it works better in dogs. And again, you know, one dose is only needed.

We don't want to repeat doses with the risk of CNS depression like overdose, but we can reverse with naloxone if needed as well. Thinking about dexametomidine, this is sort of quite useful in cats and again can be reversed with apamazole, obviously thylazine, you know, you can use that if you do have it in practise. But again, inducing me in cats is really hard, doesn't always work.

So sometimes you do have to think about whether it means like gastric lavage or activated charcoal. But again, as I said, the risk of gastric lava is quite risky with some aspiration pneumonia. And introducing cats, I've never seen a cat reeat its vomit, but, you know, there may be one out there, so making sure if they are vomiting the substance, I'm going to try and re-eat it.

It's mainly a dog thing, so I don't expect a cat to do that, but just be aware once they vomit it up, get rid of it as soon as possible. And you may find that giving them a small meal if they want to eat, before we're inducing a mess helps bulk it out and bring up the bulk of the whatever they've ingested as well. Again, I put things like brackets of eyes, so we think about our Persian breeds and things like that.

So making sure, you know, you're aware of any current, sort of diseases or illnesses this cat has priorfa or got a history with you at your vets, just to make sure, you know, if they've got cardiac disease that you're aware of of how they may affect or react to inducing a mess to them. So cats sometimes have vasovagal responses and things like that. They may sort of go.

Sort of bradycardia and things like that. So it's just making sure that we're aware of any sort of, any other illnesses and things they have going on. And they put a bit of antiemetic therapies on there.

You may want to think about antiemetics after you've given something to reduce the mucus, obviously, you know, animals are very sad once they've had to be sick, but sometimes the side effects do last longer than we want them to. So thinking about antiemetics is quite nice for a patient as well. And that's it.

Thank you so much for listening to me this morning and I hope, yeah, giving you some ideas. Thank you so much, Holly. That was really, really interesting.

I really enjoyed and certainly learned a lot there. I'd encourage any of you to type in the Q&A if you've got any questions for Holly now. Holly, I had a question for you.

With the vodka, do you, do you have to sterilise that then, or do you just put it in the drip bag then? No, I think you, cause it's already so, cause it's vodka, you could just give it. I think that people, some people think about a philtre, but You can put it through a philtre if you'd like, but you can just give it off the needle.

It's OK. Oh wow. OK, lovely.

I think everyone will agree. Thank you very much Holly. That was a really interesting and detailed talk and really we, we all learned a lot there.

So thank you, thanks. Thank you. Oh, Holly, we've got a question from Sarah.

Yes, I see, great talk. What activated charcoal do you use? So we have, oh, we have the like, I can't know what it's called now, that big bottle.

I think I had a picture on my slide. I activate Charcoal, that's from Cruise, that's the brand, isn't it? The Crew, they make activated charcoal, and that's a massive bottle, but in small patients, we use the carbado, and I find that's much, if you want to put it down like a nasogastric tube or something like that, that's much easier to use.

I think the cruise activated child doesn't actually have a cathartic in it, and I think the carbado doesn't have a cathartic. If you wanted to add a cathartic and you find that your activated charcoal hasn't got a cathartic in it, things like, Oh, it's like milk of magnesia and like lactulose will do fine as cathartics, but again, if you just be aware that, you know, obviously the cons of cathartics passing things through quite quickly may dehydrate your patient and electrolyte disturbances, but those are the two we normally use the crew activated charcoal and the carbodo. Great.

Thank you very much.