Hi there, my name's Natasha Summerfield, and I'm a registered vet nurse in the UK and also a vet tech specialist in emergency critical care. And I am currently working in a busy emergency department in Switzerland and I'd like to talk to you today about toxicosis in practise. So our learning objectives for today will be to navigate the initial client contact, list some of the common intoxications in small animal practise, identify the current treatment options for those toxicities, and understand the nursing consideration for these patients and recognise complications that may occur.

So navigating the initial client contacts, this is where we kind of first get in touch with the owners and kind of where our job begins when it comes to these intox cases. So what we need to be asking is pretty direct, but compassionate questions because the owner may be quite upset and concerned about what's gone on and just kind of wanna come straight back straight down. But getting a little bit of information from them first will be really useful for us and and potentially kind of useful for them because, you know, maybe they don't need to come down straight away or they can kind of monitor at home.

So firstly we need to find out what the animal has been ingested or what they've been exposed to. If the owner kind of is aware, there are situations where maybe the owner's not not aware, you know, the, the animals, the dog's been on a walk, . And and they've managed to get into something and the owners kind of just come and saw what's what's kind of, you know, the, the dregs of of what might have been eaten.

So those cases are a bit difficult, but if possible, we, you know, should try and find out what kind of the active ingredient was, that the animal has been eating. So, you know, if they've gone into a medication or whatnot that they, they have a look at the active ingredient on that packet. We need to know how much roughly at least.

So we need to ask the owner if they knew, for example, if they've got into like a packet of paracetamol or ibuprofen, how much was in the packet beforehand, how much they think, you know, the animal has ingested, how much is, you know, kind of gone into them. This can be also quite difficult when it's a multi-pet household, so there's, you know, kind of a few animals there and they're not sure which one has eaten it or both of them, or, you know, just one of them, so this can be quite difficult in those sorts of situations, but just to kind of try and get a rough gauge, a rough estimate. I want to know how long ago, if possible, especially if you know this has been kind of, not, you know, watched obviously the owner is not going to stand by and watch them whilst this is happening, but you know, kind of, they've gone in out of the room and they've come back 10 minutes later, then they can sort of say it's gonna happen around this, this time frame.

And sometimes this is really difficult if the owners just come home and they've found loads of things that have just been kind of sprawled out across the kitchen floor. But again, try to kind of roughly figure out how long ago this could have been. Is it, you know, 20 minutes ago or are we looking at potentially 6 hours ago, that will kind of make quite a big difference to us and our treatment plan.

And we also of course want to know if the animal is showing any clinical signs. So, you know, are they lethargic, are they kind of a bit, hyper excitable? Are they showing neurological signs already?

So these are really, really important for us to questions for us to be asking. What we can also kind of figure out by how much roughly is kind of what is the maximum amount that this animal could have been exposed to. And something that's also really important with that initial client contact is, is really not recommended anymore to induce some mes at home.

So previously there was kind of these at home remedies that people could try, well I'm, you know, even when I started nursing, we would sometimes kind of recommend or say that owners could try certain things at home. But now it's, it's really not recommended, so they should really try and get that animal into us, as soon as possible. And so they should really try and bring in the packet as well so that we can kind of figure out whether say if it's been chocolate, you know, what the cocoa content of that chocolate is and whether it's got any extra ingredients that have been hidden in there as well.

So routes of admission administration that we have or administration of kind of being exposed to, we have pero, so by mouth, we have by dermal, we have skin, and we have ocular, so kind of things that get into their eyes. So decontamination wise, I'll go through one by each kind of bit by bit, so the ocular one. What's the most important is really flushing it.

So ideally you want to flush this with saline and for 10 to 15 minutes. But what's really important is just getting it done as soon as possible. So if they, if the owner is able to try this at home to make an attempt to flush this their eyes at home, then tap water is totally acceptable, and to try and do it for as long as possible, so as I say, the sooner the better.

But often the patients will need like a slight sedation to tolerate this, especially if it's a cat. So, you know, you can kind of recommend that the owners start flushing at home and see how they get on and then that they should also come in to be, to be seen, as soon as soon after they've flushed as much as they can at home. So dern or decontamination, so we need to make sure we're bathing these animals as soon as possible with soapy water.

Now there is a concern about bathing these animals if they are showing neurological signs. So if they're showing neurological signs. You know, kind of starting to be pre-act or or having seizures, then we need to make sure those animals get into us straight away, so we're not gonna be recommending for these owners to be bathing these patients at home.

So just that's a question for sure that you need to be asking. Are they showing clinical signs before we start giving advice. Cause we definitely do not want an owner, trying to bathe a, a seizure in cat after, you know, a spot on treatment, for example.

So, we want to bathe these animals with soapy water, so dish soap, fairy liquid is absolutely fine, so kind of a degreaser is what we're looking for. The caregivers or the person bathing, they should be wearing gloves, that's really important to be protecting themselves as well. And just to note that long-haired animals may need to be clipped as well around that site of the spot on site.

And It's really important that we avoid hypo excuse me, that we avoid hypothermia in these animals, and that can really easily occur with small dogs and cats. We just had a case actually yesterday that one of my colleagues was telling me about with a seizure in cat after a spot on treatment. And it went into extreme hypothermia even though they were, you know, keeping it warm as much as they could, getting it dry and using bear huggers and and whatnot.

So that's definitely something to consideration to consider, especially if the owner's doing it at home. Now with this patient that we had, she was also obtunded, so there was kind of multiple factors in there. I'm sure if the patient is able to get themselves up and moving about, then it's a bit of a different story, but it's just definitely something to kind of to keep in mind.

Ideally just kind of lukewarm water should be used. If we're using kind of hot water that could, increase absorption rate and the kind of the, how quickly that is absorbed. So, just really lukewarm water and making sure that it's obviously not cold either.

So further talking about decontamination, so pero decontamination, we've got a few options here, so we can induce a mess, we can do some gastric lavage or we could potentially do an enema as well. I have to say personally, I've not been involved in in in doing a performing an enema for a contamination, for decontamination of intoxication. Intoxications but inducing induction of emesis and gastric lavage, that's something that's kind of done on a on a regular basis in in our practise for sure, especially the induction of emesis.

So what we need to be kind of careful with with these patients with even with just the induction of aiseis is that if there is any risk of a laryngeal paralysis, so these kind of older large breed dogs that we're just aware of that. I mean that may not, that may mean that we still go ahead with it. Kind of weighing up the risks and the pros and the cons, but they just may need a bit more nursing care and someone kind of, you know, really sitting next to them the whole time.

And, kind of, they may also get sleepy whilst we've given these drugs, so given an apomorphine, for example, they may get a bit sleepy, which could, you know, affect them aspirating even more. So that's just something to kind of be aware of. So just a bit more info going into the induction of a mess.

So I just kind of wanna be aware of time, so I'm not trying not to go too deep so that we kind of get everything covered. But of course this should be avoided in sedated and seizuring animals. It definitely needs to be avoided in corrosive or or sharp substances.

So those sorts of situations with sharp substances, for example, then we may need to go for a scope to get those bits out, . And ideally we want to induce a mess within 4 hours of ingestion, kind of depending on the toxin that they've eaten. The vet may decide to induce a mess up to 6 hours later, if it's kind of quite a fatty, you know, material that's been, you know, food that's been kind of, eaten.

And they think it's not been, you know, it's not gone through the system so quickly, it may still be in the stomach, but really we say, you know, within 4 hours of ingestion. So as I said before, in hospital induction of a mess is really recommended rather than trying to do anything at home. And just to be careful because those patients may become, sedated on administration, especially if we're giving it to, if we're giving cats some dex meatomidine or meatomidine or some xylazine, it's very likely that they're gonna get a little bit sedated.

So, we need to really keep a close eye on those, on those animals and make sure that we're getting someone to sit with them. So, you know, either. Really getting kind of the nurse to, to sit with them whilst they're until all of those stomach contents are up rather than.

You know, I'm sure no one would do this, but, you know, in inducing a mess and then kind of leaving them and then cracking on with another job, it's really, really important that actually someone is, is with that patient the whole time. So, afterwards, once the stomach contents are up, then we should be giving those patients an antiemetic. So you could look at giving some Mirroperin or some metoclopramide, after giving apomorphine, and that's just kind of, not only a nice thing to do, but that will stop the, hopefully kind of reduce the risk of any aspiration pneumonia of them kind of keep on bringing up, vomit whilst they are a little bit sedated.

So then the kind of I think this is the last bit on decontamination. So, gastric lavage. So this is gonna be useful in your patients that are already drowsy, seizuring and otherwise neurological.

So, in those patients we definitely don't want to be inducing any emesis. We have got a really high chance of having some aspiration pneumonia, otherwise if, if, if we are inducing aesis in those patients. Now, gastric lavage itself, it does come with its risks for sure.

So those patients need to be fully anaesthetized, and they must be intubated really well and really well intubated. They must be intubated and the cuff must be inflated very well to try and avoid any aspiration of that going into vomit is going into the lungs. So of course this comes with a risk of aspiration pneumonia itself.

And the normal risks of a patient going under general anaesthesia as well. These patients it's really, really important that a nurse, an experienced nurse stays with this patient on recovery until they are awake and up and aware so that we kind of, there's no more vomiters coming up and then just being aspirated back down, so that's really really important by these patients. With these patients.

And what it involves is basically passing a gastric tube into the stomach and kind of performing several rounds of gastric lavage, so kind of pouring in lukewarm water, and emptying the contents, using gravity, so using kind of a jug to put this. Water into the tube that's gonna go through to the stomach. You give that a little bit of a jiggle and then you let that content come out via gravity via the tube.

So you need to have a bucket on the floor ready for you. It's quite a mucky procedure. It's not, it's not everyone's favourite, but, it can be quite rewarding.

So last bit on decontamination, so we have a couple of options of rather kind of other ways of decontaminating our patients. So, we don't have loads of antidotes, so to say, but we have things like, you know, kind of medication that can help us once we've had an an intoxication in these patients. So those two things that are commonly used.

Active charcoal and also intralipid therapy. So active charcoal, how to use it, when to use it. So this is an absorbent, so this is given peros, pretty simple.

It's normally given with food, and that's why it's also important. That we make sure that we're giving these patients some anti-emetics after we have induced the emesis in them because there's no way they're gonna eat anything, especially this kind of black food slurry, if we haven't given them an anti-emetic. So, we need to kind of make sure we're giving them antiemetic, give them a bit of time, and then ideally give them this active charcoal in with some food.

Otherwise you could give it with a syringe, but just to be kind of careful in case of any aspiration, of course, as, as always. And it's given either in single or multiple doses. So whoever it's given in a multiple dose depends on the toxin itself and also the clinician because there are different studies that say, potentially that a single dose is as efficacious as given multiple doses.

So that really will depend on your clinician as to whether they decide to go for a single or multiple doses. So examples of toxins that we would give this for the paracetamol. Would be our, rodenticide, poisonings, the bromine, so that would be our chocolate, toxicity, diazepam, barbiturates, for example, as well, so kind of maybe overdoses of those sorts of medication.

And then we have our intralipids, so this may not be used as much in general practise, this is something that we use actually quite a lot in in our university. How to use it, when to use it. So, we give it over, an IV bolus over kind of 30 to 60 minutes.

Now this is like a fat solution. It's a lipid solution, so we need to make sure that we're being really aseptic when we're given it so we have good aseptic techniques. So, as always, we should be really wearing gloves and making sure that everything is clean as we are drawing up this drug and that our surface is clean.

And that we give this drug over 30 to 60 minutes and then we remove that CRI from those patients rather than kind of keeping it on in case they need it for later or whatnot. And it should then be thrown away. So this is useful with lipophylic drug overdose, for example.

So this would be your local anaesthetics, this is kind of what it's been used for a lot in human medicine. It's been shown to be useful in permephrin intoxications, ivermectin intoxication and also marijuana as well. So this is quite an interesting drug in that we're not sure of the exact mechanism of action as yet and there's quite a few theories, but the latest is that it manages to kind of take the the the toxin.

Away from where it's kind of wanting to bind to and and it's sort of target place and then gets it to places like the liver where it can be metabolised out of the system or kind of go into the muscle adipose tissue where it can be stored. So it's really trying to stop this from, you know, kind of causing the maximum effect that it that the drugs trying or the toxins trying to cause. And then last bit of decontamination, so if it is possible for you, if it's kind of something that you may have in your, in your university or practise, you may have seen that hemodialysis or dialysis is being used to kind of philtre out these toxins.

So I've got a few cases here that I've found, so, you know, kind of a cannabiid, toxicity, . It's also been found to be useful in metaldehydes, so these kind of snail bait, toxicities and also a phenobarbital overdose, so toxicity as well. And we've actually used it quite a lot in our university.

Last one I think was snail bait, so this metaldehyde poisoning. And the patient wasn't yet seizuring but was a bit neurological and they decided to go for dialysis rather than gastric lavage so. In this patient, we wouldn't have induced a meis, but we would have maybe gone for gastric lavage in the past, but instead we managed to kind of keep the patient calm and quiet on some muscle relaxants and get them undergoing the hemodialysis and it worked pretty nicely and they had a good recovery.

And I think all in all, the cost wise of getting that patient under anaesthesia and doing the gastric diva and all of the recovery time that they would have had to spend in ICU versus having the dialysis treatment. And then actually being able to go home a bit sooner, it worked out cost wise, actually not, you know, quite effective. So I was quite surprised at that.

I thought that it would be a much more expensive procedure, but after speaking to one of the clinicians, it's kind of interesting that that this could be a way forward as well. So let's get onto the toxins that we'll discuss today. So we'll go through chocolate intoxication, rodenticide, permierri, and grapes and raisins and paracetamol, hopefully if we have time to go through all of those things.

So chocolate, how does it work? So, this contains Theo Broman and Theo Broman is a, I always have trouble saying this word, so please excuse me, a methylazant theme. And that's important to know because this methylazanthe, this inhibits certain enzymes that antagonise receptor mediated actions of adenosine, and adenosine is an important neurotransmitter which acts in many places in the body, and some of those places include the Heart and the brain and the blood vessels.

So this is why we have a combination of the clinical signs that result in restlessness, excitability, neurological signs. We can have some tachycardia, we can even have some arrhythmias as well. Definitely some incontinence because we're having a lot of diuresis.

As it's kind of making its way through the system, with the excitability, we can have some hypothermia as well and we can even see some seizures in these patients. So the signs tend to occur typically kind of 2 to 4 hours post ingestion, and it's definitely dose dependent. So this is really, really dependent on how much.

Cocoa is in these products. And there's lots of chocolate calculators out there nowadays, so this is something that's really kind of quite nice in to so to say, because if you have an owner on the phone, you can sort of go on to, you know, Google and type in chocolate, you know, calculator, veterinarian. And it comes up with a few different options.

I, I'm not affiliated with any of the things, so I won't say any of the names. And it kind of tells you whether you should be concerned, or whether they should come in or whether they can could be monitored at home, whether they would start, you know, whether they would recommend treatment. So it really really depends on how much they've eaten, the size of the animal, whether it's milk chocolate, whether it's dark chocolate, whether it's kaka powder, so whether there's kind of pure kaka powder that's been put into a cake, for example.

If it's kind of white chocolate for, you know, then we're not normally so concerned, but. It really depends on kind of the dose per, of like the gramage per kilogramme. And so that's really, really important to try and distinguish from the owner how much has actually been eaten.

If it's like a big Labrador who's eaten kind of some milk chocolate, maybe we're not too concerned, but if it is a little Chihuahua who's gone in for some dark chocolate, then yes, we'll be definitely very concerned. And so we'll kind of be needing to get those patients. If you're concerned, if you're worried, if you're not sure, I mean, first of all, you should be speaking to your vets after you've spoken to those owners and asking them whether they think that they, these kind of, this patient needs to come in or not, because maybe what you've read, online from the chocolate calculator is that it's borderline or actually they wouldn't need treatment.

So firstly, you should be asking your vet who you're, you know, on call with or you're working on the emergency shift with, and then otherwise if you know, if you're a bit, you know, unsure of whether they should come in or not, then better to err on the side of caution and get those patients to come in, because we don't want those patients kind of getting worse for wear at home and, you know, you know, worst case scenario having a seizure. So treatment for these cases and nursing care, what's important to us, so when they come in, we need to decontaminate them and give them some supportive care. So that would include inducing of amesis, potentially gastric lava.

I personally haven't seen any gastric lavage cases with a chocolate intox case, . But definitely a mess, depending on when the chocolate was ingested, we would be giving these patients some activated charcoal after all of those stomach contents are up and then we've given an antiemetic. We would typically keep these patients in.

And increase in the excretion of of urine. So we need to, we'd be giving these patients some fluids and making sure that they are going out every kind of 2 hours at least, so 1 to 2 hours. So these are patients that are really important for us as nurses that we are making sure that they are going outside or they are excreting that they are, you know, urinating often.

Because, some of the metabolites in the the mephhiloanthes in the the brine, they can be reabsorbed in the bladder wall. So it's really, really important that we get that urine out and that's why we'd also be giving them kind of increased fluids as well to, you know, induce diuresis a little bit. But as I say, really, really important to make sure that these patients are getting outside, urinating, or that you're seeing on the kind of nap you've had that they are urinating hourly or two hourly, to, to make sure that, you know, that they're not holding on to their, to their urine in their bladder.

You know, those are things that is definitely, I think the responsibility of the nurse and if you are noticing that. That animal hasn't urinated in 3 hours, then you need to be, or 2 hours, then you need to be checking their bladder and kind of seeing, OK, is it, is it a bit big, is it quite small, OK, is it small? Maybe I'll speak to the vet and potentially we need to up their fluid rates.

If they've got a big bladder, then we need to talk to the vet about potentially expressing their bladder, if it's safe to do so, or kind of thinking about other options, maybe if you're in a cat or whatnot. Personally, luckily, I've never had that situation. The dogs have always gone to the toilet eventually or I've just given it a little express and then they've kind of gone by themselves, so.

But that's definitely something that I think is our responsibility to be monitoring that they are urinating often. So other symptomatic support for these patients, so really depending on your practise and your clinician and how symptomatic the patient is as to kind of what you'd be putting on these, these animals, but an ECG potentially they may need some antiarrhythmics if they are showing some arrhythmias, and to kind of seizure watch and sedatives, so you may want to have a seizure plan for these patients if they're already a little bit neurological. Showing kind of ticks and whatnot, then you may want to speak to your doctor and say, look, if he does seizure, can I have the dose of, you know, whatever you used as pamidazolam to give to him in an emergency situation.

So if you're kind of on your own in the prep room whilst. Stuff's going out on out the front and you can't get hold of the vet that you know that you have the you're allowed to give these patients a certain, you know, kind of millilitre of a certain drug. So I think that's really important that we speak to those, speak to the vets and get a plan for these patients.

So next we're flying through these anticoagulant rodenticide. So this is what I find a really interesting one, but I'm a bit of a geek when it comes to this sort of stuff. So this inhibits the recycling of vitamin K, and vitamin K, has dependent coagulation factors that is 27, 9.

And 10 and basically vitamin K goes through a cycle from vitamin K oxide, quinone and hydroquinone, which is its reduced form and to change between these stages it needs to have an enzyme called this K epoxide reductide a enzyme which is this thing here. And that needs to be, activated. And so what we have, the problem we have with anticoagulant rodenticide is that it stops this, this enzyme from working.

And so this cycle can't take place and so the recycling of vitamin K can't take place. And then what we have is coagulation factors that aren't active because this section here, if we can't can't have the whole recycling section, then this section here, this oxidisation can't take place. And so this carbox lays can't take place and then we don't have active forms of these coagulation factors to 79 and 10.

So here you can kind of see it a little bit better. So this is where our anticoagulant rodenticides work. So here and here.

And so it just stops this recycling process. So what we have is we still have some vitamin K that is is working for a period of time and so these patients don't come in symptomatic, potentially straight away. And so that's just kind of something to note as well.

We'll go into that a little bit on the next slide. But, just so you're aware that Factor 7 has the shortest half-life, so that's over here. And both the extrinsic and intrinsic pathways are involved.

And so when we're doing our tests, when we're doing our, coagulation tests, the clinician or the doctor, the vet made us decide to go for a PT because really that should come up first, and show a prolonged, time, a prolonged coagulation time, because of this factor 7 being the one that's got the shortest half-life, so the one that's gonna run out of the, the, the soonest. So dose dose dependent, excuse me, not COVID, just a regular cold and flu unfortunately. Well, fortunately not COVID.

So this is dose dependent, but it's really, really difficult to estimate. I mean, normally these are patients, these are animals who are out on a walk and or they, you know, farm animals and they've gone out and they've got into something. So even if the owner has potentially witnessed it.

It's very difficult to know what dose they've kind of got into unless they, they know exactly how much was in the trap. And coagulation tests are gonna be necessary for these patients even if it's been if it's been witnessed. And then signs that we have for these patients.

So generally speaking, unless they're coming in straight away, their owners witnessed it and they're bringing them in to induce a mesis so those patients generally won't come in with signs, but. If they do come in with signs, you know, potentially a few days later, so 3 days later, for example, then our signs are gonna be bleeding. So we're gonna have, you know, bleeding.

We may have some tea or whatnot, but normally it's intra cavity bleeding, so in the thorax or in the abdomen. So these patients are gonna be lethargic, they're gonna have some pale mucous membranes, and they may be tachycardic, they may be hypotensive from this blood loss, and they may have some lameness if they've bled into their joints, for example, they may have seizures if they've ble bled intracranally, dysnea if they're bleeding in their thorax region, and abdominal pain, of course, if they are bleeding into abdominally. So lots of different signs for these patients, but generally they're not doing very well.

So treatment for these patients. So decontamination, yeah, directly if we've witnessed it, and I've had one case in, you know, the over 10 years that I've been nursing, that I've seen where the owners actually witnessed it, and their, their two little Jack Russells came in and we induced a mess. All the rest of them, they've come in a few days later.

And this should then be followed by some activated charcoal. Even for those patients, we would want to be doing some coagulation panels as well, just to see what's going on, and vitamin K therapy as well, and then potentially that may need to be prolonged based on their coagulation panels that we would do a few days later. If these patients coming in already symptomatic, we would have been wanting to get coagulation panels on them for sure.

We would want to be giving them some vitamin K therapy either per also subcutaneously, depending on kind of how well those patients are and how much they're able to tolerate. We'd need to get some diagnostics on those patients, so ultrasound, some x-rays, definitely some blood work, like our coagulation panels, our PCV blood gas analysis, and then we would want to be treating them symptomatically as well. So we need to give them potentially some fluid therapy if it's necessary, some oxygen therapy if they're having trouble breathing.

We wanna give them potentially some blood products, so we give them some fresh frozen plasma to. Kind of replace some of those coagulation factors, we may want to give them some hole blood instead if they, if their PCV is, is kind of dropping and they are showing clinical signs for, for, for, for, for bleeding. Or if you don't have whole blood available, then It may be decided by a clinician that you kind of give them some fresh frozen plasma.

Sorry, I've just seen here that it says FFB rather than FFP, so FFP fresh frozen plasma, and some packed red blood cells kind of together, if that whole blood isn't available to you. They may need some pain relief if they are, painful, especially if they're kind of painful in their abdomen, for example, and we need to be monitoring these patients, vital parameters. So monitoring their blood pressure, their SPO2, potentially putting an ECG on these guys as well, and, and, and really keeping an eye on them.

So just to note that if we're giving them the vitamin K therapy, it's not a quick fix. So this, this that would take kind of 6 to 12 hours to have some effect. And it's, it's not kind of, it's something that we would give, but it's not going to be a quick fix in emergency situations.

So in those emergency situations where they're really haemorrhaging and need those blood products, then we're gonna need to be given those blood products straight away rather than kind of waiting for the vitamin K to set in. . Yeah, and so that's kind of just definitely something to, to know.

And as I say, these patients tend to come in about 3 days or so after ingestion, so kind of it's the, the, it starts kind of having an effect, you know, kind of after I think 48 hours to 72 hours, you may have some lingering vitamin K or it's still in the system, so we may not see the signs straight away, but yeah, kind of around the 35 day mark, we're gonna get these patients coming in. So next will be permiferin. So this is a commonly used insecticide, which cats are definitely much more sensitive to.

I have not seen a perfrin in toxin a dog. I've only seen ones in in cats and young and otherwise debilitated animals can also be sensitive to this, this toxin as well. So the toxicity usually occurs because of consumer confusion, so that would be inappropriate application, too much being kind of given to you know, the wrong animal, the wrong pet, or if a, if it's been applied to a dog, for example, in a, in a dog cat household and those animals share beds or groom each other, for example.

So the mechanism of action of action with permiferin is it causes hyper excitability by slowing and and opening these so slowing and the opening and closing of sodium channels. And this is why we can sometimes see these neurological signs that we would see in these patients. So signs, symptoms, we can have kind of, you know, minor symptoms like hyper salivation and agitation, weakness that move on to tremors and even seizures.

And this normally can take this normally has effect a few hours after there's been application or you know, kind of they've had been exposed to this this toxin. So what we need to be doing is a treatment wise for these patients, so decontamination, and this would include bathing the patient, so bathing bathing the cat with this lukewarm water and some kind of decreasing, you know, kind of dish soap. Now, as I say, one thing that we need to definitely take into consideration if those patients are already.

symptomatic, so if they're already showing tremors or neurological signs, then just, I'm sure it kind of goes without saying, but these patients were not gonna be bathing first and then, you know, sorting out their, their, their seizures afterwards. So we need to make sure that we getting these patients under control, getting their seizures under control, getting their tremors under control. And then doing that as quickly as possible and then we want to be bathing these patients and potentially clipping the area where the application was, the area of application.

Now with that, we need to be really, really aware of hypothermia and that it can occur. So we need to be, you know, keeping these patients warm. So bathing them firstly with some kind of lukewarm water and then drying them as quickly as possible and keeping them warm with you know bear huggers or lots of towels.

Blankets, keeping an eye on their temperature and really closely monitoring their temperature, especially until kind of they're really up and moving and and awake, you know, especially if these patients are a little bit neurological, and showing, I'm quite lethargic, then I, you know, I'd really recommend taking a temperature every 15 minutes at least so that we just stop it plummeting before it does. So supportive care, we'd be looking at kind of making sure that we've got IV access and IV fluids, neurological stabilisation. So this will be given our anti-convulsants if necessary, and really that kind of comes up the top.

So if those patients are neurological, when they come in, then we wanna be, you know, that's gonna be the the top thing that we're gonna be looking for, and, and treating for. So we wanna be given, as I say, our, our anti-convulsants, so our benzodiazepines, potentially our phenobarbital or whatnot for these patients, and maybe some muscle relaxants as well, so maybe some methocarbool, but again that's gonna really depend on on your vet and your clinician and their and their choices, their preferences. So symptomatic treatment, so we may need to be monitoring their glucose, especially if they've been seizuring a lot and kind of warming and cooling these patients, .

Warming and cool so warming these patients if they've been bathed and they're growing a bit hypothermic and calling them if they are really seizuring a lot. So obviously that's the other end of the spectrum if they come in and they're having loads of seizures and they've got 40 degrees, then we need to be calling these patients, you know, first as well. So that's just kind of something to to bear in mind.

We want to monitor, and nurse the kind of the seizureing patients and seizing patients and recumbent patients, and essentially giving some intralipid administration to these patients as well, so given the IV, if your clinician is happy with administering that, and you have that on hand. So we'll go into grapes and raisins and then hopefully have a quick moment for paracetamol and then before we finish up. So grapes, raisins, this is quicker one, mechanism of action, unknown.

So we those unknown. Basically, the toxic mechanism and dose has not been established. There are cases where a very small amount of raisins have been ingested and they've had clinical signs.

so at the moment it is unknown exactly how much. So we have kind of an idiosyncratic effect that that happens. And if you get a phone call that your one of your patients has eaten some raisins or they've eaten a mince pie, for example, they've had some Christmas puddings, so we're coming up to that time, just get those patients in.

They're unlikely to show any signs of, of, kind of, you know, symptoms until at least like 6 hours post ingestion, and that's gonna be potentially signs like vomiting and diarrhoea, lethargy, some pain maybe in the abdomen. But if we get those patients in sooner rather than later, then we could maybe induce aass and try and get that out of them, so we have less of a toxic effect. So other signs that you may see would be polyuria, some hyposalivation, maybe tachycardia, polydipsia.

So these are things that you, you can also see, but again, normally it's only 6 hours post ingestion, or if we try and get these patients in beforehand, then we can get that, get that, get those toxins up and out via inducing emesis. So treatment for these patients, we want to decontaminate them, as I say, try and get them in sooner rather than later. Give them some activated charcoal, and we need to get these patients on some fluid therapy for a minimum of 48 to 72 hours.

We wanna monitor the ins and outs very carefully to make sure that they're urinating, and to make sure that they're not going into acute kidney injury. Regular kidney value monitoring, so getting some bloods on these patients and then otherwise treatment for AKI in the worst case scenarios. So that would be continuing with fluids, antiemetics, and potentially putting these patients through dialysis.

Right, so our last one, so paracetamol or acetaminophen if you're in the state. So this is super easy to find at home, unfortunately for our dogs and cats. And cats have a much lower toxic dose to dogs, but normally general.

Speaking, cats don't go into everything as much as dogs do. So have a, you know, hopefully a little less chance of of getting into it or they're saying that my, my friends to indoor cats eat everything and would get into everything. So really, who knows?

They literally eat broccoli off the side of the kitchen, you know, kind of side. So I'm sure they would eat some paracetamol as well if it was out and lying about, so never say never. So this is also used therapeutically in dogs as well.

So it's just something to be aware of that you may see it as a drug that you give, you know, to dogs on a on your day to day basis, but this is in a much lower dose and that then isn't toxic to them. So mechanism of action. So paracetamol is metabolised through three different ways.

So this is our glucuronidation, alfaction, and also cytochrome P450. And when we go through this cytochrome P450, then we get a kind of nasty sort of toxin metabolite called Nappy. It's got a really long name which I can't remember exactly.

I'm sure I've got it on the next slide, so then I can tell you then if you, if you'd like to, but otherwise known as napy. And then normally we have a process called we have our glutathione, which would kind of metabolise this napy out and it's not really a problem. Now, when we have a high dose metabolism, paracetamol metabolism, then it already kind of saturates these two other channels of gluconoridation and salactin, which is the main way of metabolising paracetamol out of the system normally.

So then everything has to go through this cytochrome P450 and. It's too much nucky is produced and this glutathione just can't keep up with the metabolization of this nucky. So this kind of gets to be prevalent and and going into the system.

So it's because of this glutathione that is suppressed. And this nappy can cause protein dysfunction, so disruption, cell membrane damage, lipid, oxidation, so degradation of, of lipids as well, and, also the reduction of glutathione can lead to basically cell necrosis, so not good things basically. But we do have a nice little antidote for our metabolism, our paracetamol intoxication.

So we have our, NAC and, again, something that I have a problem saying. So, necetylcysteine, which can be given per also or IV. But it's gonna be definitely for us, the preference would be, would be given an IV, because we kind of get it into them as quick as possible.

And that is a glutathione precursor, so then it can allow for more glutathione to be produced and then more metabolization of this horrible metabolite. So we then then don't get our clinical signs and symptoms hopefully as much. So our signs and symptoms they're gonna be different in dogs than they are in cats, and also the toxic dose is quite different in dogs and cats as you can see here.

So in dogs we tend to see more hepatic signs of failure, so fatigue, diteris vomiting, and we may have some hepatic encephalopathy, and of course liver increased liver values. We also could see some metha hemoglobinemia, but that's less common than in cats. And in cats, we tend to see the opposite.

So we would see more likely, the metha hemoglobinemia, which can, show itself as tachynia and dyspnea. So we have these kind of brown, murky mucous membranes, what kind of looks like cyanosis, and we can also see some icy with that. And so we can have, hepatic failure as well, but as I say, the, in the cats, the metha hemoglobinemia tends to come first.

And here we can see our signs, so the toxic doses, which is sort of 600 mg per gig, but we may see signs already from 10, from 100 milligrammes per kilogramme. And the same here, so toxic dose is just 50 to 100, so that's, you know, much, much lower than the dogs, and we definitely may see signs from 50 milligrammes. So this is why it's really important to kind of get an idea from the owner how much has been eaten.

How much could have been ingested, and if they're really not sure, you know, this sort of thing, I would just get these patients in as soon as possible so that we can kind of induce a mess as soon as possible and kind of get that out of their system. So treatment monitoring for these guys, so as I say, decontamination, so we wanna get that out of it, out of them kind of 4 to 6 hours post ingestion, ideally within 4 hours. We wanna kind of get some appomorphine into them or get some me into them to get that up.

We need to be giving them that activated charcoal as soon as possible and ideally this, an IV, and again, I'm really sorry for the pronunciation of that. I, I, I find it really hard to say, but again, that's something that we would sort of give IV as soon as we can. We need to get some blood work on these guys to keep an eye, see what's going on.

I probably wanna get, if you have it available, some an acid base to see what's going on with the metha hemoglobine anaemia. Also some liver values, we need to get kind of a PCB on them to see if there's any hemolysis going on. And then symptomatic, some fluid therapy, vital parameter monitoring.

So if they are really not doing very well, we need to make sure we're getting an ECG on them. We could, we could put an SBA2, but it's a question of whether it's useful or not because if we have an MFA hemoglob anaemia, it would plateau 85%. If we have some, if we have over 30% of methahemoglobin present, so basically, it may just not be so useful if we have a metha hemoglobiaglobinemia in these patients.

In any case, oxygen is gonna be useful for these guys, and potentially giving them some methylene blue. Again, we've given an IV so it really depends on kind of your clinicians and what they, what's available to you or some absorbic acid, some, some vitamin C. So these are all kind of some things that that could be useful for these patients.

So last little bit, so the nursing considerations, the role of the veterinary nurse with these intox cases, it's really varied. So it's literally telephone triage to nursing the intensive care patients. So we want to be triaging these patients, we're giving them some.

Emergency therapy, we're assisting the vets in prompt treatment, neurological of the neurological patient, kind of giving, making sure that we've got a plan for these neurological patients as well so that we can kind of give them their medication if they need it straight away and very promptly. We may be preparing or monitoring general anesthesias for these guys for the gastric lava, for example, we may be performing the gastric lavage by ourselves under supervision. Recovering these patients, intensive monitoring on the ICU if they, you know, kind of a procedures and they need to be or their state is epileptic and they need to be kind of fully whacked out and sedated.

Obviously those patients may be recumbent, so we need to be you know, nursing the recumbent patient as well and even kind of dialysis patient monitoring. So it's so varied, the nursing care of these patients. And they, they can be really, really rewarding patients.

I, I really tend to like these, these, intox patients, . I'm sorry if I'm saying that a little bit differently because I've been working in German for such a long time that we would tend to say into into intoxication. so that might be, that might sound a little bit funny to my the English audience.

I'm just just a bit aware of that. But as I say, I find these patients really, really rewarding personally because there are so many different aspects that could be involved. It could be really, you know, the little.

Puppy that's eating some chocolate, you get to induce a mess and then they managed, they're not, you know, too symptomatic, so the the clinician decides for them to go home, or it could be, you know, the seizuring snail bait ingestion who comes in totally in status epileptics and you need to stabilise that patients, give them a bunch of drugs, keep them on some CRIs, you know, really intensive monitoring for a good like 24, 48 hours. Placing urinary catheters and whatnot. So as you can see here, it's, it's as you know, as always, the nursing, the nurses's role is, is, is a lot about multitasking.

You can see my colleague is here helping two vets at the same time, you know, you're a bit everywhere, but, but I find these patients can be really, really rewarding. So I hope that was helpful to you. And if you have any questions, then really feel free to contact me.

This is my email address here. And, I've got the, references and resources on the slides as well, and that'll be loaded up, I'm sure to the website. So you can have a look through those if there's anything.

I'm happy to also share with you. If you have any questions, where are my sources and whatnot, feel free to ask. Thank you very much.