OK, good evening and welcome to tonight's webinar, by Webinar vet. So this is the first part of a 4 part series on toxicology. I would like to encourage you to be as interactive as you can be during this whole series.
So if you hover over your toolbar, you'll see a comment box, leave your comment in there, and there's also a Q&A box which you can ask questions and I'll read out to our speaker at the end. I hope you're all very excited because you have a great speaker on tonight who I'll go on to introduce in a moment's time. If you do have Twitter, Instagram or Facebook, please share that you are listening to this series and this webinar by using the hashtag #Webinar vet just to get the the message out there about this great series.
Tonight's webinar is sponsored by TM. They're not here tonight, so we do have a small 2 minute presentation just for you to watch before I go on to introduce our speaker. So I'll play that for you all now.
So, first of all off within the range, we have Emiog, which is a licenced appomorphine emetic for dogs only. A lot of you in the UK are quite familiar with it already, and how to dose it. But it comes in in vials of one meal each.
And each one meal vial will do a 10 kg dog, and just make sure you're giving it on licence, as a succut injection. You're aware at busy times of the year, so Easter and Christmas, and you may kind of, go through on a dog quite quickly, just because we do tend to see quite a lot of, dogs at this time of year ingesting chocolate and things like that. So just make sure you stock enough on the shelf.
And unlike the kind of older products, obviously you can use it for, for patients that are poisoned, but it does also have a licence for blunt foreign body, retrieval as well. So if you have a dog that has ingested a sock, say, you can use it on licence to try and make, that dog, bring up the sock for you as well. Next in the range, we have carbido, which is an activated charcoal, specially made for small animal use.
So cats, dogs. Think, it is, ready-made, so it doesn't sediment out like some of the other liquid products do. So you just need to give it a quick little shake and it's, ready to go.
So it syringes quite easily and it will go down things like nasogastric tubes as well. Comes in small bottles of 100 mL and each bottle would do a 20 kg dog or cat, so 20 kg dose, one bottle for 20 kg. And Handley as well, we have, also produced a, activated charcoal guide to go alongside carbidote.
So this guide just tells you, when to give charcoal, when not to bother, so some toxicins actually aren't absorbed well by activated charcoal. With the toxins that are, some toxins we need to repeat the dose of charcoal every 4 to 6 hours. Some we don't.
So the list on the left in blue there will, kind of indicate which ones you should do that. We also have, two vitamin K products, so vitamin K injection and tablets. And as you well know, vitamin K is an antidote for anticoagulant rat poisoning.
Injectable comes in 5 mL vials, and it does have an IV licence, so it just means that you can, get your clotting factors back up to speed, than if you're injecting the products of the cut. And the tablets, are also divisible as well. So once we've, given the injection for our emergency cases, you will need to follow up with tablets, usually for about 4 to 6 weeks in most cases.
And the tablets can be divided, so they, they can be, used to dose more patients as well, a lot easier. Finally, we have, licenced diazepam for cats and dogs, called Zyoppa. It's very similar to the human products that you're probably used to using in the past.
It comes in 5 mg per mL solution, for IV injection. And obviously there's a lot of toxins can cause, neurological signs, seizures, that kind of thing. We have licenced it so that you can use it for those patients, and.
Using pre-anesthetic oxidation protocols as well. I've made a variety of resources for you at TVVM UK to complement the range, so we do have obviously product information, product brochures. Dosing guidelines for, for our products, so just quick guides on how to dose.
We do do a lot of client awareness as well, so, we think it's very important that clients are aware of what can be toxic, toxic within the home for their pets. And so we do things like posters, client leaflets that you can hand out, and things like, display kits for your waiting room as well, you know, sort of around kind of Easter and Christmas of poison dangers in the home. We do have the activated charcoal use guide, like I said, and we do have 9 poisoning guidelines as well, which are very popular with vets and nurses in practise.
So they'll kind of take you through different poisons and and how to treat and what to look out for, and any antidotes that might be available and that kind of thing. So currently, like I say, we have 9, but there, there are things that we do continually add to. So keep checking back our websites just to see if we've added any further ones.
If you wanted any of our literature, then please just email us, or you can download a lot of it from our website as well, or feel free to give us a call. Excellent, so plenty of useful information there on the anti-tox range supplied by TM and you can just go on those websites if you need any more information. OK, so.
Now I'll introduce tonight's wonderful speaker. So we have Lindsay Keelle Gregory. She's an American and European specialist in emergency and critical care, as well as an RCVS recognised specialist in this field.
Lindsay graduated from the Royal Veterinary College in 2004 and spent some time in small animal first opinion practise before completing a residency in emergency and critical care at the University of Pennsylvania in the USA. Following this, she spent 8 years as a lecturer in emergency and critical care at the Royal Veterinary College. Lindsay enjoys all aspects of emergency and critical care medicine, but has a particular interest in respiratory emergencies and medical mechanical ventilation.
OK, Lindsey, over to you. That's great. Well, thank you very much for the introduction and thank you everyone for, for listening to to this series.
So as we hopefully know, this is the first of 4 webinars on this series on toxicology and We're gonna start off today with the, the basics, so the initial or the sort of general approach to, to any poisoned patient. With the focus on today's webinar being your sort of an initial priorities. So, of all of the things you have to do with these patients, basically, where do you start?
What do you do first? And we'll plan to cover other topics as the weeks go on, so notably, updates on decontamination and decision making to do with that, use of antidotes and their application in some case examples, and then some other common types of intoxication will be covered in later webinars as well. If we start off tonight's talk, so this, this for me is, is a common occurrence really in any practise or hospital setting where an owner calls up to say that that Fluffy ate something that they shouldn't and, This 9 out of 9 out of 10 times tends to be the, the first point of contact with the case, unless the client just, just shows up with the patient, which obviously happens sometimes too.
And during this talk, we'll, we'll cover really an approach to what we do with these patients. And any stressful situation, having an approach really just helps make it feel better, and helps us have a starting point, helps make sure that we don't miss anything important. And the things that we'll, we'll learn will hopefully be applicable across any toxicology case that you, you subsequently see.
So the, the aim of this initial telephone contact we have with the, the client, the owner of the, the potentially poisoned patient, it is twofold for me. The first is to try and, and calm down the client, and certainly it's been my experience that, it can be a really stressful situation for these owners to have their pet, having been poisoned. Maybe it's, it's something that the owner feels potentially responsible for, and that they're, they're really, really worried.
And so to try and and help them and help us get the information we need out of the client, it's about starting that initial process of the calming them down and getting them to sort of to work with us if they possibly can. And then obviously, the, the other aspect to it is very importantly is to try and get enough information to try and figure out if there's cause for concern. So, do we think that there's been a clinically significant, exposure of the patient to a toxin?
And if so, how bad could this possibly be? Are we likely to see potentially side effects from that? If so, how bad?
And, and our worst case scenario is this, a potentially, fatal, reaction that we've got going on as well. So, It's just trying to work out how, how worried we are. With the ultimate question that we want to answer is, do we need to see this pet on, on an urgent basis and do they need to come down even if it's out of hours?
Do they need to come down even though morning appointments are fully booked, etc. And are they likely to need any emergency treatment? And this is one of those things whereby given time is of the essence in the majority of intoxication cases, and it's really important that we try and get as much relevant information from these owners about this poisoning in quite a short period of time just to help with this, this decision making so we know where we're heading with this potential case.
And with that in mind, there's, there's lots of things for us to, to find out. And I've listed some of the questions on this slide and the, the next, as to kind of questions that are going through my mind to try and build up a picture as to how worried I, I should be with this patient. But it's safe to say that the owner might well answer the question, very quickly without necessarily having to go through all of these questions to say, yep, you, you definitely need to come down.
So, For example, you know, if they say that they have a small dog who's just eaten 0.5 kg of dark chocolate, then I, I probably know I need to see that patient. Whereas if they say early on that their dog's eating some oral contraceptive pills, again, I know I, I just don't need to worry about that regardless.
So. It might be as we work through this series of questions that we, we figure out the urgency and, and decide what the next plan is, or it might be that we need to figure out the answers to most of these to, to work out a plan as to what's, what's best to do. So for me, the kind of thought process behind some of these questions, estimated body weight kind of stands to reason we're trying to figure out about toxic doses and exposures, so that's quite a, a relevant consideration from a dosing perspective.
Sigmament as well. Certain breeds being more predisposed to certain things. So a good example might be if an owner calls up to say that they've got a, a collie type dog who's, accidentally ingested some ivermectin, some horse worm on the, the yard that they were on that day.
I know I need to be really, really worried about that patient because that's a breed that might be more susceptible, and we'll kind of cover some of these more specifics as these webinars go on as well. But again, it's, it's building up that picture of, of how worried we should be. Something that's important to figure out early on is whether or not the exposure has been witnessed or suspected.
A lot of the times it's, it's witnessed or strongly suspected. But there are occasional times, and this happened to me a lot when I was a resident in the States. I, I, I don't think people necessarily got along that well with their neighbours oftentimes, and the, the pet became unwell and the, the client automatically blamed the neighbour and thought the neighbour must have poisoned the dog.
So, It might be hard to tell on the phone exactly what's, what's going on in some of those, those cases, but to try and figure out how suspicious we are about an intoxication, or do we think at this point the pet's unwell because it has some a chronic, disease process and could make a more routine appointment, but potentially. So just trying to again work out what the, what the deal is there. Asking questions about how long ago exposure occurred and what route the exposure occurred by, really questions in there so I can get my mind working as to is some kind of decontamination attempt appropriate.
And if so, how am I gonna go about doing that? So I'm sort of future planning as to what I might do with this pet if, if needs be. And obviously, we need to know about the, the poison, the toxin, was it just one?
Was there more than one? It's entirely possible and, and, and quite commonplace, in, in some particular exposures. And then the specific details of, of the toxins.
So how much was it 4 tablets, for example, of paracetamol, what was the concentration of those tablets? Again, working out a sort of a dose in our mind's eyes thinking about this patient's body weight as well. Sometimes owners might be very specific that it was one tablet, sometimes they just report that the, the pot was, was kind of chewed up and, and there's some missing and they don't know.
So is it, is it possible for them to tell us, was this a brand new bottle when they last saw it, or were they kind of a month into treatment and there probably weren't that many left. So what's our, what's our worst case scenario for how much this pet could have eaten? And also exactly what was the, the, the, the product.
And I say this because we, we generally, and I, I do this all the time as well. I, I hear a drug that, a patient might have been exposed to, for example, and I'm starting to think about what it does, what might happen, without necessarily thinking about the different potential formulations and Specifically, if, if drugs are suspended or extended release products, then it might be that the, the toxicity profile of that drug is, is different and I need to approach that patient a little bit differently as well. So, again, building up this, this important picture early on.
I also want to get an idea if, if I'm starting to think through that this, this could be a clinic clinically significant toxin, is to figure out are there any clinical signs yet. . And I want to know that, partly so I can start building up a mental image of how sick this patient is for when it probably is gonna come in and see us.
But I want to know that they're consistent with the toxin that's been reported, so there's no potential for, for more than one thing going on or, or something a little bit more complicated. The severity of the signs, how they started, what's been happening can really tell me is this, is this an early intoxication or late depending on the toxin involved as well. So it, it is building up that, again, that all-important picture as to what's actually been happening.
It's also really, really important to ask, is the patient they're calling out the only animal that's potentially been affected? And we'll talk about this again later, but we want to make sure that this, this is indeed the, the only patient that we, we need to be dealing with and we're not ignoring anybody else who might be quite important. Briefly, without getting a whole life history necessarily and finding out a pre-existing medical conditions or concurrent medications that might complicate our our management of this intoxication.
And seeing if they can get access to the exact container, if this is a drug they have in the house, getting them to bring it with them. If, for example, this is maybe a poison that's been put down by a sort of a pest controller, can they find out exactly what it is that that, that pet might have been exposed to just to help, help us get more information a little bit later on. So what sort of things are owners likely to say their pets have been exposed to when they, when they call up?
What can we reasonably expect? And again, the, the old adage, common things are common, but what actually are, are we talking about as common toxicities in, in dogs and cats, in this country at the moment? Well, The VPIS has some really quite nice data on this.
So annually they produce a, a, a report which is a summary of all of the cases that they've dealt with over the, the previous year. And the last one that is available that I could review is the, the 2017 data. I'm presuming the 2018 data will be coming out in the near future.
But of, of, advice calls that they took, 85% of those came from dogs and, I think 14% from cats, with the, the 1% being a variety of, of rabbits and, and various other creatures, which is kind of interesting reading in itself. So mostly dogs, and these were the top 10, poisons for dogs and cats in general. So you can see quite a few of the usual suspects on there, some that we may have predicted, some maybe not.
The 3 in bold so non-steroidal anti-inflammatories, the anticoagulant denticides and chocolate toxicity are the three top, or 3 most common inquiries, in, in dogs, of which ibuprofen being the most common reason that a dog would I say a dog would seek advice from BPIS, but advice will be sorted out that dog from the BPIS rather. And in cats, a little bit of a different population, lilies being the most common agent in those at the moment, but It's safe to say, although this was the, the data from 2017. If you look at the data from, from years gone by, it's clear and I think this fits with our clinic experience that what pets get exposed to changes over time.
So, A good example of that is, is permethrin and containing products, with exposure to those in cats becoming much less common, maybe because of better, client education or labelling or just restrictioning in cats getting hold of that sort of stuff. So it does change over time, but, but clearly we're just gonna deal with whatever is presented to us in practise. So, I don't know if it necessarily changes our, our practise, so much.
What's also interesting if, if you're, if you are into this stuff, and you want to kind of have a look at this, this annual report, as I said, it's freely accessible on the, the website there. And what's interesting is it also mentions intoxication associated with fatality, which is interesting as well, both from euthanasia and, and from, from death, so there's that natural kind of difficulty in interpreting the, the outcome of those, . Cass potentially, but it does show the value that the information that's there that if we can send on follow up from the cases that we have dealings with the BPIS from, I think it really, really helps build up their sort of portfolio of information they can send back as well.
And also, if you're, you're interested, I'm, I can assure you I'm not going to touch any more on this for this webinar series, because I, this is the extent of my knowledge on the subject. But they do have some information on rabbit, intoxication cases as well, which apparently reentified injection and then chocolate injection are are common. And there ends my rabbit knowledge.
But if you're interested, then there's a, a, a lot of other stuff you can have a look at in those reports as well. In the report as well, I found this statistic which I just thought was, was staggering, of the number of inquiries that they receive annually and the number of agents involved in potential poisoning and I think it's, it's very, very safe to say that we cannot possibly carry all of this information around in our heads. So almost as much as, as the uses of having an approach to these patients, and knowing where we can access that information quickly, when we're in a time crunch, we've got a patient that we need to make decisions on, and it's really, really useful.
And it's also the, the, the issue comes up that if we're having patients ingesting or being exposed to more than one agent, is there, is that a consideration of their interactions that we need to consider these potentially more complex patients than if they just had a single agent. So there's, there's clearly, a lot of questions come up from these patients. And I think most people are probably familiar with these services, but it'd be remiss of me not to mention it specifically that, I think for me, I tend to use the BPI estimate as my sort of first line for getting additional information and, and getting these sort of cases logged and, and out there for kind of, the, the collective wisdom as well.
Currently working on a, a membership level where you can have different levels depending on how many, times you access that service annually. Obviously with different fees associated but with top-ups available. So, you can kind of tailor it as, as you wish.
And as I said, I, I think it's a, a great first line, service for these sorts of patients. But also, I think, many people will probably, probably be aware, but in association, there's actually an animal poison line for, for pet owners as well, kind of links to this website here. It's been running for a couple of years now and has the basic, it's basic function is to act as a triage service for pet owners, so they can really find out, do they need to go to the vet or not.
. It's very clear it doesn't give any treatment advice. It's very much the triage should you be worried, should you not? And it's a service that is available 24/7 where the, the owners are led through a series of questions of sort of very obviously basic form of, of what we'd be kind of Inquiring about in terms of signalment, what and how they ingested or got hold of something, how long ago, all those sorts of things.
And tries to, to, yeah, sort through those patients to see if they do need any, veterinary help in the clinic or not. I think most of the time, on the phone, we can help make some decision as to do you need to be seen, do you not? And there will be some cases that, that are managed at home, by the owners rather than coming into the clinic.
And that may well be because based on what they've said, we're 100% sure that the exposure is non-toxic, that there's absolutely nothing that we would do if we saw them. There's no reason for concern whatsoever. They, they really just need to stay at home with nothing further.
But of course, there may well be cases where it would be nice to have them come in, but for whatever reason, it just isn't happening. So if there's cases where we'd prefer to see them but they are in a home environment still then. During that initial phone discussion, it's important that we're briefing the owner as to what could potentially happen, what things that they should watch for, and, and again reiterate, if this happens, you, you have to come in, the time frame involved and, and what they can expect, just so that they, they have a plan B if they do change their mind and, and do, do elect to come into the, the clinic as well.
We'll talk about induction of emesis in the, the home environment in the the next webinar when we're talking more about decontamination. But I, I think for me it's something that I'd only really consider in truly, truly, truly exceptional circumstances and we'll discuss that more with potential agents, pros and cons, and, and the sort of decision making behind that in the the next webinar as well. But If in doubt, we've kind of said if we should really recommend that the, the pet should come to the practise for further evaluation if, if we think that there's any possibility of, of a toxicity having occurred.
And, and this rather colourful looking slide here I appreciate is, is my general approach for how I work through a toxicology case. And I think it's safe to say when most of us are presented with a poisoning or a toxicity case, and the mind typically leaps towards the sort of expected effects of a toxin or making the patient vomit or charcoal or getting hold of, you know, an antidote. And all of those things that are on this, this general clinical approach, and they are all really important things.
But There are several steps that we need to go through initially, and starting with basic patient assessment and performing any life saving measures before we have an opportunity to get through to that stuff. And quite simply put, we need to be able to stabilise and keep the patient alive to be able to treat the intoxication and So that's what we'll kind of start with. We'll work through this, this list some today and picking up some more details in the follow-up webinars as well.
But starting off with that initial patient assessment. And for me, I treat the intoxicated patient like any other emergency patient. So they'd undergo an immediate triage just shortly after they come to the hospital, just like you or I would if we went to, to a human, hospital facility.
Where we're trying to figure out is how, how much of an emergency is this, are there any life-threatening abnormalities and, and what we need to do. And again, this is an example of where we're, we're trying to focus our attentions on the patient and specifically how they're affected and what we need to worry about rather than the poison itself. And so the first of the things that I would do very simply and very briefly is I'm just kind of first laying eyes on those patients.
I'm assessing the, the ABC. So I'm looking to see, is there an airway, is the patient making useful breathing efforts and is there a heartbeat with pulses and It's not really, it doesn't really take a genius to say if the answer to any of these questions is no, then we've got a, a major issue that isn't going to be solved with making the patient vomit and we're, we're resorting to sort of immediate life-saving attempts and and CPR, etc. So, It's a useful screen.
It's a good starting point, if our minds are kind of busy with all of the kind of thoughts as to how we're going to deal with a particular patient. And if a patient passes this test, then great, we've got some, some thinking time to kind of look a little bit further, but if it doesn't, we've got a sort of immediate plan as to what we need to do. The next thing I do with any emergency and again with a, a toxicology patient, it kind of passes this, this step a little bit because we might already know some information, but What we would do with any standard emergency is to, to get a capsule history.
So realistically, for me, that means in 30 seconds, certainly less than a minute. I'm trying to just figure out why the patient's there. So this isn't the full medical history.
It's not figuring out if it's got a food allergy, all of those kind of things that build up the bigger picture later on, etc. This is just signalling why they're here today, and is there anything super important that I need to know in the short term? Normally this is trying to sort out who we need to worry about.
But for me, if there's any possible intoxication, and that could be an immediate threat to that, that patient's well-being. And so the capsule history here doesn't necessarily screen patients as well as it's made in a sort of standard emergency setting. The next thing we'll do is to do what's termed a major body systems assessment, which many of you have probably heard of, I'm guessing in the context of assessment of any emergency patient as well.
And the premise behind this is these patients can potentially be quite overwhelming if they're quite unstable from a, a poison maybe we haven't dealt with before, for example. And what this, this does is it, it's a way of looking at that patient critically to say, are you stable or not? And Although there's lots of different organ systems and, you know, we're thinking about how they may be affected by a toxin.
Really, if, if a failure of one of the, the body's body systems is, is gonna cause the demise of the patient and, and kill them, then that's gonna be heart, brain or lungs. Anything else will, could cause the demise of a patient, but it would be through one of these three systems. So, When we're looking at these patients in, in the initial stages, we're really streamlining our exam to look at those three systems to say, is there anything here that's, that's gonna kill my patient first?
More specifically for each of these, it's nothing new, it's nothing fancy, it's nothing expensive. It's just looking at the physical exam, maybe a bit more critically and grouping, the findings to a particular body system altogether. So rather than doing the nose to tail approach, for example, I would look at everything to do with the respiratory system and then make a judgement call to say, am I happy with everything stable or not stable.
Same with the neurologic system, and same with the cardiovascular system. So things that we would routinely look at, as I said, there's nothing new here. But it's just making a decision about, does that mean the patient is, is stable or not?
And in the context of a toxicology case as well, more specifically, it's a really good screen to look for signs of potential toxicity. So, Let's say I've got a, a patient who's ingested, chocolate, and I'm thinking that this might cause cardiovascular, side effects, then this is a really good opportunity to get that initial heads up as to is this patient likely to be, be, is it symptomatic now, or where are we, where we're at in time. So, this is a good way of sort of sorting through those patients.
Typically, after we've initiated a life saving measures, as a, as a result of that initial assessment, then we think about running a, an emergency database. So thinking about any urgent and straightforward, mostly patient side diagnostics that would just help figure out again, is there anything markedly abnormal or life-threatening that we, we, we need to deal with. And again, this applies to any emergency patient that has a, a specific role in the, the poisoned patient as well.
And although it can pick up abnormalities in general, such as things that we'd want to know about, such as hypoglycemia or anaemia or, or other things that may make us, really concerned. We also have the opportunity to tailor this to the exact patient and the poison that we, we sort of have in the back of our mind in terms of potentially expected adverse effects, or looking for, for evidence for the things that might confirm our suspicion as to what might be going on. And There's lots of things written down here.
These are things that we could think about doing, but I would strongly argue that not every patient needs everything on this list. I don't think we'd ever get anything done if, if that were the case, . So we're, we're really using our judgement of the situation of the patient to decide what's important, what's gonna change what we, what we do.
But some of these tests can really change what we do if they used appropriately. So for example, if we have, an anticoagulant denticide patient presenting a couple of days after it maybe got into some rat bait, using emergency ultrasound to look for, free fluid in, in various body cavities, suggestive internal bleeding can be really helpful. The same for maybe a non-steroidal anti-inflammatory toxicity where we're looking, we're concerned about, could, could there be perforation in the GI tract, then, a brief ultrasound of the abdomen for free fluid might be a really quick, way of picking that up very, very quickly and Also, other cardiovascular measures again, if we're specifically worried about, say, the chocolate toxicity, worried about arrhythmias are are really useful point in time to sort of answer those questions.
And then after our initial assessment, if we do find anything that needs stabilising, then, then this is the, the time to do it. Because if we're Really have anything markedly unstable in and of our major body systems. You have to ask the question is, is this the right thing to, to maybe induce emesis?
Probably not, until the patient's more stable. Certainly, it would suggest that the patient's already symptomatic and therefore, your, your window for decontamination might have closed anyway. So there's lots of reasons why we're justified in, in stabilising the, the patient in this way first.
So, Again, anything that we found that's abnormal that we consider to be life-threatening, we we're gonna fix that. So, say the patient with internal bleeding, fluid therapy for the shock, . Oxygen therapy for respiratory distress, aggressive seizure and tremor control or management of other symptoms of the, the intoxication, whether that be hypoglycemia, hypothermia, etc.
So again, going back to that sort of what does the patient look like, what do we need to fix? So it's kind of step down on our, our little approach is to think about getting the, the toxicology history and this is one of those things where we, we might already be all over this a little bit, but it's, it's a chance just to make sure we, we've figured out, we know as much as we, as we need to, but Just to reiterate that although things are often happening in a sort of continuum with these patients, everything's sort of doing a little bit of everything at the same time. We should be making sure that our patient is stable or is, is in the process of being stabilised and whilst we're getting this information or using members of our team to kind of fill in gaps, from the, the owner, for things that we need to know as well.
And Although this is, you know, a toxicology webinar series and we, we love a good antidote. If there's something that, you know, we can, we can use to fix something, then, then that's great, but If we think about antidotes, how often they're available, then it's probably less than 10%, probably more like less than 5% of the time for our sort of intoxication. So it's not like the history is likely to reveal this, this sudden, golden bullet, magic bullet rather.
And so again, it's getting that patient treated first and filling in the history, as we go along. And as I said, a lot of these, these questions, it's the same things that we're thinking about on that initial phone consult, which may well have been curtailed by the fact the, the owner said something that made us think, yeah, you need to come in regardless, you may as well just sort of, you know, get, get on your way and come in. So it's filling in the gaps and, and making sure that we know as much as we possibly can, about this.
And oftentimes owners may have a slightly clearer head. To be able to answer these questions a bit more accurately now that they're at the practise, they feel like they're, they're here something's being done as opposed to that kind of initial anxiety of calling, is is this gonna be a problem kind of thing as well. Again, the clinical signs we're hopefully getting, a consideration for that based on our patient assessment.
But also just bearing in mind again, is, is this the, is this patient that we're seeing the, the only animal that's, that's affected and I had a case when I was a, a resident that was a pair of dogs brought in by a guy who was a pest controller for his living. So he had a big truck and in the back of his truck, he had more poison than than you can possibly imagine. You can probably see where this story's going.
And he saw that one of these bags had gotten into and he brought his dogs in and he said it's this dog here, it's definitely this one. The other dog, yeah, too well behaved, it's not gonna be that one. And to cut a long story short, we induced Emeys in the dog that he was suspicious had eaten, the poison, nothing much came up at all, induced Emoys in the other one and it just could not bring up enough blue stuff.
So, It's always worth asking the question, if there are any other pets at home, could, could, was this the like the first time they could have been exposed to this again, just to make sure that we're not the, the owner and potentially ourselves as well aren't jumping to conclusions about what, what could possibly have happened. And we mentioned earlier about access to the container, getting owners to, to bring it with them, . And this for me is is an example of where access that packaging is super helpful is the the average rodenticide ingestion.
And although again common things are common and we tend to see in the VPIS, you know, say that we, we see a lot of anticoagulant regentant side intoxication. We do know that not all anticoagulants are the same. It's a wide range of agents.
And we do know that there's other drugs as well that, that have been used historically or, or could in the future come into use to, in these sorts of products like choliccalcipherols that can, cause ionised hypocalcemia. Prometholin being a, a pretty nasty one, that causes, cerebral edoema and really marked, markedly severe neurologic signs associated with the pretty poor prognosis once they become clinical for that. But other newer ones as well, things like zinc phosphide and strychnine and, and various other things that we are going to approach different needs that we're gonna treat differently, have a different prognosis and I found my generic stock picture of a bag of poison from, from Google Images here, but it, it's just blue stuff.
We really don't know what what to expect from this without asking the questions as to what specifically is in there as well. Once we've got our toxicology history, and we know about the exact toxin that we're dealing with, the next thing in my mind is to find out or to learn more about what that expected behaviour of the toxin is in the body. So what can we expect and, and what do we need to do to manage that patient specifically.
And Lots of questions here, that we're gonna use to help decide on a decontamination strategy, how worried we should be, the prognosis. Is there any treatment that we might need to sort of consider for this patient, for example. So it's kind of things here that we're, we're sort of thinking about and that if we get a consult or seek advices, it'll be kind of points that would have been considered as well.
So, Some examples, what's the toxic dose is, has a toxic dose been ingested or exposed? What's the lethal dose 50 that would sort of be, what's the LD 50 that will be the, the lethal dose in 50% of animals exposed. So if we're up there, then we know where we're really need to be worried.
Mechanism of actions. So again, what, what can we expect in terms of clinical effects? Is there a particular pH disturbance associated with the, the toxins?
So how's that relevant? Well, if, if there's a particularly acidic or alkaline substance, it can be really caustic to mucosal surfaces and that might impact our decision whether or not to induce emesis if that may have previously seemed appropriate. Has it absorbed?
Does it bind charcoal? Is that an effective therapy as, as, we sort of heard from the, the TVM range, you can get these guidelines to say, to, to look that information up pretty readily as well. So those are all, all important questions and there's more as well.
So there's lots of things to, to find out. Has it metabolised, I, you know, Is it liver? Is it lungs?
Is it kidney? Are the metabolites worse than the initial poison? So ethylene glycol being a good example of that, that the metabolites are actually sort of more dangerous than the initial thing that was ingested.
When would you expect clinical signs? So if we're 6 hours in, is, is that window passed when the patient should have been showing signs if it was going to, or could it be sort of 1224 hours down the line? Is there an antidote that we can use?
Is it lipid soluble? Could we consider lipid therapy? Would repeated doses of charcoal be affected?
How's it excreted? How might, pre-existing organ dysfunction affect how a patient handles a toxin? So for example, if this is a, a chronic kidney disease dog who's now ingested, something that's potentially nephrotoxic, how would that change how we handle the patient?
So lots of things for us to kind of think about and, fill in the gaps. So far in this talk, we've been thinking about patients who have presented with the history of fluffy 8 XY and maybe Z, for example. But sometimes we see patients where we just don't really know what's wrong with them, and what happens quite a lot, to be honest.
But in, in this context, they, they come in and, and it's possible they've been poisoned, but it hasn't been witnessed. It might not necessarily be suspected by the owner. It's us putting those clues together to say this is what we think might have happened.
And for me, these are kind of times I, I become a bit suspicious. So it's not to say these are all poisoning cases, but just times that I think about it. And as a general rule, it's a previously healthy animal that maybe after a period of being unsupervised, probably especially so, now has something markedly wrong with it that just doesn't really make sense.
It would just necessarily come out of, of, of nowhere. So, Especially the organ systems listed here, so the gastrointestinal, neurologic, any cardiac arrhythmias or, or major organ failure that's just come out of nowhere previously healthy, bang, think could this be a poison? Neurologic toxins, again, very common in these previously healthy animals.
Maybe they were out for a walk, they were on witness, maybe, maybe seen chewing on something, and now they have progressive tremors and twitching and maybe seizures. Is it possible it become symptomatic for their, their brain tumour they've always had, possibly a little bit suspicious, at least raise the question is, could this be a poisoning? And then opportunities, so change of diet, change of environment, or just ability to access various medications they, they could have gotten into as well.
So moving on from the, the history and information finding, the next step for me with these patients will be to try and minimise any further poison absorption beyond what's already in there, and think about antidotes. So this is sort of the, the damage limitation part of the approach that the intoxicated patients. So, It's safe to say this, this is a time sensitive thing.
Obviously, if we're trying to minimise poison absorption, we need to get on with that as quickly as we can. So it's feasible that these steps are happening around the same time as we're we're getting information, so we're not sort of incurring costly delays in time. But making sure that we know enough to be able to make the appropriate decisions is, is probably, what we need to know.
And the next webinar coming up in this series is about decontamination of these patients and, using things like hypomorphine and the, the activated charcoal as we heard about at the start of this webinar, thinking about, the, antidotes as well, and we talk about, all of these things in a lot more detail in the, in the next two webinars coming up. The other things we do need to consider as well that I thought I'd mention at this point in time is, is there anything else that we can do to help eliminate any poison that's already been absorbed. So that decontamination isn't really gonna reach or that isn't gonna be dealt with by an antidote of some kind.
And thinking about would diuresis be appropriate specifically for any toxins that are really excreted, hence that's kind of an important question that we, we need to know about the properties of the toxin or toxins that are nephrotoxic to try and sort of support the kidney. And generally speaking, unless there's a reason not to, thinking about giving, fluid rates, above maintenance rates for a, a period of 48 to 72 hours, sort of picking a number there to buy enough time to hopefully support the, the kidneys through the whatever it's been injured by. Making sure that we're not above all doing no harm, so avoiding fluid overload and again, we can talk about specific toxins later in this webinar series and thinking about can we cheat the system a little bit to try and help toxin out of the body and A little trick I've used it a couple of times with really, really bad chocolate toxicity cases, is we know that those metabolites are eliminated through the urine, but we do know that if they are sat in the urinary bladder, they'll actually be reabsorbed across the bladder wall again and that where they can be toxic again.
And so a really bad chocolate toxicity, you kind of can picture perhaps picture one that you've seen yourself. A good way of, of trying to get those metabolites out of the body once and for all is to the place a urinary catheter and a closed and collection drainage system so that the urine is formed and it leaves the body. And that's quite a nice way of, of helping eliminate any absorbed poison as well.
As well, if if we find out that, a, a poison that's been, patient's been exposed to it is lipid-soluble, then we can think about lipid therapy. And specifically, we're talking about something like the intralipid 20%, which is something that's been used for a while in, in other, other formulations. But over the last few years has really gained a lot of momentum as being a, I wouldn't say an antidote per se is probably the wrong term, but a way of, of eliminating absorbed lipsoluble, toxin as well.
And we, again, we can sort of talk about application of this in cases in, in later webinars, as well. And so we've mentioned quite a few things that we may want to give in terms of decontamination, antidotes, various other therapies. It might be that you work somewhere where you see a large proportion of toxic logic emergencies.
And I mean, that sounds pretty good to me. That may not sound that great to you. I don't know what your perspective on this is.
But if that's the case, you may well have all of this stuff in stock or the vast majority of it. And so if anything comes in, you're, you're sorted, you're good. It might be that you don't see that many of these things, and frankly, it's just not worth it to have everything on this list in, in your practise at any point in time.
If you're in that situation, then the good news is that if you are using the BPIS for kind of your advice that you can access what's what's called Tox box, which some of you may well have heard of before, which is A sort of a teaming up of, of vets now and the VPIS to say that It's a way of providing access to these sort of emergency drugs for toxicology cases without having to stop them in your, your clinic the whole time necessarily. So, There's all of the products on this, this list, are, are typically contained within this, this so-called to box, and they're located at different vets now branches across the UK. So this is the map taken from the the VPIS website where there's a lot more details about this, as well as some other practises locally as well, but again, you can be put in contact with them through the the VPIS.
And, it's a good way of kind of getting hold of things. So apomorphine, I think, you know, it's possible that, you know, you have a particularly busy Easter coming up, maybe you run out, who knows? Simily with charcoal, but maybe intoxications that you might not be, seeing on a regular basis, you need stuff for.
So acetylcystine is the antidote for paracetamol. Vitamin K intralipid as we kind of talked about, methocarbamol is, otherwise known as rebaxin, which is a nice, skeletal muscle relaxant, can be really quite nice for, your sort of permethrin and metaldehyde toxicities as well as sort of tetanus patients as well. If you're seeing any of those at this time of year like we are, then they're all things that can be quite easily accessed, through this means as well.
The kind of the moving on through these steps as well, then the next thing I do is once I'm kind of making efforts to try and damage limit, as we said, I'll think about clinically evaluating the patient as, as we're going through this as well, including whether or not any further diagnostics are needed. And I think we're saying it may well be that a patient comes in and we know exactly what it ate, when it had it, what clinical signs we might expect from that, and therefore, it's not really a diagnostic challenge and we're all done diagnostics, but There might be a patient where we think it was an intoxication and we're looking for maybe supportive evidence to say, yeah, that's, that's the, we want to confirm the suspicion of what it had, or we might be wanting to investigate, say, for example, I know this is a toxin that can cause an acute kidney injury, so I want to see if the patient is aotenic to sort of stage how symptomatic they, they might be for that. Those are reasons we might do further diagnostics.
Or it might well be that we kind of want to run routine blood work because we, we don't, maybe this patient had a preexisting disease, you know, maybe this was the, the kidney disease dog that's now gotten into a drug that it shouldn't have, you know, where, where are we starting? What, where can it go downhill from here. So those are all kinds of reasons we might need to do stuff, but as I said, it might not be applicable to, to every patient.
But some of the kind of diagnostics I might think about doing, again, tailored to the specific poison the specific patient, but If I'm thinking about, you know, one of my worst case scenarios, that glycol poisoning, thinking about doing a urinalysis to look for the specific crystals, if I can measure ionised calcium in a practise setting, then, then measuring that because having a what tends to be a really quite marked ionised hypocalcemia in these patients is, is really quite suggestive in the absence of other disease processes that would do that. On a different note, and coagulation testing, so clearly not indicated in, in every single one of these patients, but, if we're suspicious about anticoagulant identicide toxicity, and we've got a patient who's been exposed a couple of days ago and we're starting to think if this is a patient who's become coagulopathic, then coagulation testing would be, would be indicated in those. But interpretation of these diagnostics can also help us in, in a patient like this who might come in with, with a bleeding tendency, and we don't know if this was a relay intoxication or if the patient has another bleeding tendency inducing disease.
Actually looking at the sort of pattern of those coagulation tests, so the, the relative prolongation of the PT versus the APTT can really help answer that question whereby Anticoagulantide patients tend to have relatively more prolonged PT than the APTT, which is in contrast to pretty much most of the things that will cause a bleeding tendency such as, you know, end-stage liver failure or, you know, hemophillias or, or DIC or those other kind of less, less amenable to, to treatment type things that we might see. So. It might be that the diagnostic is again to confirm things or it might be to sort of stage where we're at with things as well.
And we'll explain more about this when we talk about antidotes and a couple of webinars time too. We might think about if we're running blood gases in practise and encourage people to do that. It's one of my, one of my kind of favourite things.
Maybe I have a bit of a bias there, but it can be really helpful in these patients just to get some, some extra information. And if you have an unexplained metabolic acidosis and a patient who is is neurologic, then thinking about things like ethylene glycol and metaldehyde poisoning are really reasonable as as both things that, that can cause that as well. But we might well see other abnormalities based on, suspicions.
So, you know, looking for glucose abnormalities, with potential causes that we sort of would be used to. So Xylitol is a strong suspect for hypoglycemia and intoxication, or radiographs if we're worried about heavy metal. So again, sort of tailored to the individual patient.
But we do need to be careful how we interpret some of these things and, and one of the, the tests that we do need to be especially careful with is the sort of when we're trying to diagnose ethylene glycol, and again, we'll talk about this later in the context of antidotes, but This is clearly a toxin where it's the one of the most time-sensitive toxins that we have where we really need to get it out of there like yesterday if if a patient has ingested some and so confirming that suspicion early is really important. And this is whereby Woodley have little test strips that you can get hold of, which are quantitative. It's sort of like a, a dipstick colour change, really quite easy to interpret, needs a really small amount of blood.
Can detect levels really quite soon after ingestion. So sounding great so far, sounding exactly what we need, but We do need to kind of be aware that there may well be a sample window that we can only interpret these findings in that might vary with the, the patient and various other factors and we don't want to rely just on one single diagnostic test to kind of confirm or deny a suspicion of a potentially concerning toxin as well. So.
Having in-house testing is, is really useful, but we do need to make sure we're interpreting that in in the line of the, the patient's findings and, and timing and so on, what we'd expect for that poison, that we've been working hard to find out so far as well. And it might well be, therefore, that we might think about do we need specific toxicology testing. And so what used to be the, the CTDS lab testing group, is now the veterinary pathology group and accessed by this website, and they have a really wide range of toxicology testing, including, there's a tonne of stuff there.
If you look at their website, there's really an extensive list of, of everything that they can test for. Certainly things that are, are really quite helpful are confirming anti-pregnant rodenticides. If you've got a patient with a bleeding disorder and you're thinking, is there internal bleeding for for another reason, or was there denticides, this can measure levels and give you that answer for sure.
I can tell you some people got metalda high toxicity. So is that the cause of a terrible acute onset seizures as opposed to do I need to, you know, potentially refer this to a neurologist to kind of further assessment? Is this some kind of illicit substance the patient's been exposed to, or is this really markedly abnormal neurologic function.
So, quite, quite sort of useful, things to useful questions to have answered. And typically the turnaround hasn't been that helpful as as a whole, not a criticism of this group at all. I, I find it a tremendously useful service, but 3 to 5 days later is, is too slow for, for a lot of things.
But what's notable is that next day results of some panels may be available at at a cost, naturally. But that may help answer some of those questions, as well. But again, a little bit like the ethylene glycol test strips, the results they can provide are only as good as the quality of the sort of the history and the samples that we submit as well.
So we can need to interpret those findings in, in the context of of that as well. And so I just wanted to spend the last few minutes just finishing up on other places that I found quite useful to to look for stuff and well at the start of this webinar did a much better overview than me in terms of things from the TVM website and some really nice guides and dosing guides and sort of protocols just to sort of have up as a sort of where to go if if if there is a sort of intoxication. So plenty of kind of downloads that you can, can then can go to as well.
But also on that, that website, there's some other links to, to various things. So a couple of really nice lists of sort of poisonous plants, links to databases that can help help tell you what an active ingredient is in the human drug, which is, is quite a useful thing. And as well as, sort of helping figure out exactly what you can expect from a specific anticoagulant as well, given they can have such different behaviours.
So quite a lot of information on there for you to have a, a browser if you're interested. And some kind of selected textbooks, obviously, there can be delays or sort of lags behind it in knowledge, in what's published in textbooks versus what's kind of current thinking, but certainly the, the combined BSAVA, DPIS guide, to poison, nice kind of starting point, not meant to be a sort of the sole guide to how we manage these cases, but, but as a starting point nonetheless. Some specific toxicology books out there, .
The small and critical care medicine textbook, something I, I use quite commonly. Probably worth having a look in the 1st and 2nd editions. Some of the toxicology chapters were in the 1st edition, not the second, if you're kind of looking at the.
And then if it's a specific veterinary drug, then looking in, in plums or some other kind of formula is helpful to kind of get an insight as to what can be seen in an overdose situation as well. Other places to look if anybody, does subscribe to the Veterinary Information Network or Bin. If you have an academic email account, if anybody listening does, then you can get free access to that.
And there's a tremendous amount of information on there, with various drug calculators, online formularies, and proceedings on the subject of toxicology as well as anything else you ever wanted to know. Discussion forums as well where there are, boarded toxicologists on there answering questions and it's a 24/7 service. So, that can be a really useful place to kind of look and sort of philtre the information you get from there.
But a couple of other places that I used when I was, practising in the states, they actually their websites do have a lot of helpful resources as well. So the pet poison helpline and the, poison control groups, have nice things again, a little bit like, we saw on the TVM website sort of this, this theme of spotting pet poisons in the home to kind of help with client awareness. This is an example from the pet poison helpline.
Really quite nice and not forgetting Doctor Google, really, really don't need to put a link to the website for that, but, there's a place to go for pet got into random human drug. What, what's the active ingredient? Where do we kind of start with that?
So that's a, a place to look and. Given this recording is taking place just before Easter, it seems appropriate to give a special mention to how we're going to deal with the, the deluge of chocolate toxicity patients, and there's lots of calculators out there, but, this one from, from vets now I think is really quite user friendly for If you don't know exactly how, what the exact weight of, of the chocolate was eaten, it helps you approximate, was this a sharing bag, was this a sort of a cake, an advent calendar, etc. So it just helps you kind of approximate and we'll tell you if if you need to worry.
So again, you can kind of play around with this. You can enter, you know, a 10 kg dog and have them eat a 1 kg of white chocolate and it says it's all fine, but You can give the same dogs 10 grammes of cocoa powder and it tells you it's a serious emergency. So it's just kind of useful for just playing around and and getting that information nice and early, so.
I think that's the, the majority of the stuff I wanted to cover in this, this initial webinar that that sort of approach and that sort of general structures to things to do, what to think about, what to do first, and as I said, we'll explore lots of these kind of things in, in more detail as the webinar series goes on. So hopefully that was helpful. You picked up a couple of useful things to, to apply, but I'm happy to to take any questions you have.
Excellent, thank you very much, Lindsey, absolutely brilliant webinar and thank you again for dialling in. While we wait for some questions, I'd just like to encourage everybody, if you do have any comments please leave write those in the comments box so that we can tailor any future webinars and again, any questions, just pop in the Q&A box and I'll ask Lindsay any questions that you might have. If you do have Twitter, Instagram, Facebook, please share away, just use the hashtag #TheWebinar vet.
And finally, I'd just like to say another massive thank you to TM for sponsoring this series of webinars on toxicology. OK, so let's go to our questions. So we have one fla from Florin in Romania.
She had a case a few weeks ago, a medium breed dog which ate and trap. It's a product which is a paste which you apply to the ground and it's made to attract ants. The owner was unable to tell me the name of the product, but a search on the internet has shown that it contains some salt and sugar, but it seems to be a very small quantity.
Do you think this may pose a problem, and would it need a mess? Mm. Great question.
I have to say I have zero experience dealing with, with any similar product, which is, is often the way given the kind of the, the huge numbers of, of different things that our, our patients can ingest. I guess from a sort of first principle standpoint, I guess in terms of the sugar aspect of it, if there was a, a huge amount in there enough to kind of make the patient hypoglycemic, maybe the dog's gonna to urinate a little bit more, might potentially be dehydrated, but I, I don't really, I struggle to kind of make a story how that's going to make the patient terribly symptomatic. The sole component of it worries me a little bit more as to kind of assuming this is like a sodium chloride kind of salt.
Was there enough to kind of cause hyponatremia. So I guess that will be the, the thing that would worry me a little. I might think about checking electrolytes, but certainly would make sure that the pet had access to sort of water to make sure that there's no hyponatremia from that, but I guess that may well, if, if this is particularly irritant could cause some vomiting some of the GI signs, so I guess I'd be sort of monitoring to make sure the patient was able to sort of drink to kind of offset any electronic disturbances that had happened, .
In terms of inducing mess, I suppose it depends on, on timing of exposure, so. It it's kind of a lot of theoreticals, but if there was enough salt in there to to kind of cause massive electrolyte disturbances, you could make a story that could cause neurologic signs, which then I'd be really nervous about inducing emesis on. So it potentially depends on time of the exposure did just happen, is it all completely asymptomatic.
In which case, I, I think it would be, I think it would seem reasonable based on the sort of very limited amount. I know about this particular toxin to induce emesis, but if there was any, any hint this was symptomatic, then I think I, I would probably steer clear. So I'm interested in feedback about how the, how the dog did, because yeah, as I said, it's not something I've, I've necessarily seen before.
Lovely, thank you very much. And we have one from Patrick asking how do you treat cats with lily exposure? Cats with lily exposure, very, very nervously is is probably how I'd summarise it.
So. I'm very, I'm very conscious of the fact that I, I, at this point in, in my career, I, I work in a referral hospital, so I, I probably see the worst of the worst. I've kind of filtered out the ones that have done great and I just see the disaster.
So if I hear sort of lily poisoning, I, I think I assume the worst and I think the literature would support that as well. I'm actually doing a sort of a, a course at the moment in sort of dialysis training and sort of extra corporeal therapies of which lily poisoning has been sort of discussed quite a lot of being obviously a cause of sort of acute kidney injury. And it seems if you do get acute kidney injury to that, if you do get the toxication that causes acute kidney injury, it can be pretty bad, as in failing medical management requiring some kind of advanced therapies to kind of give you a chance through it, so.
For that reason, I, I'm, I go really hard on, on these sort of lily intoxicated patients. So although my success rate of inducing MSF caps isn't, isn't great, as we're gonna talk about in the next webinar, these are ones that I'm trying everything I've got to try and induce MSI. I'm bathing them in case there's any kind of pollen or anything on their, their fur.
I'm, I'm doing everything I possibly can to decontaminate them, giving them charcoal. Honestly, I don't know if it helps or not, but I feel like I should be doing, doing something. And then, whereas with some other agents that might be nephrotoxic, I might have a discussion with the clients and say, you know, we could do fluids for a couple of days or, you know, you could watch at home.
I think with a lily cat I'd be strongly suggesting that we did fluids for 48 to 72 hours. I get a baseline creatinine and I'd be monitoring urine output, usually indirectly, so just kind of weighing in constant sheets or kind of using cat core and measuring it if I can just to make sure that urine output is sort of being maintained, check a creatinine a couple of days later, and just, just really expecting the worst. So if, if it happens, I find it before it finds me a few days down the line, but I've had some, to be honest, I've had some disasters from really minor exposure to the lilies, so bites or relief and then the kidneys have, have really not functioned well.
So I'm, I'm really aggressive with these upfront. I'm very honest with the illness that if this goes bad, it could be, could be really bad as well. But it's the, the right time of year for it.
So, I'm hoping all the extra sort of publicity out there about lilies are bad will, will get out to people. I'll be less of them this year. But yeah, tricky cases.
Lovely, thank you very much. And one from Emma. So for seizuring animals, you said to treat aggressively with anti anti-seizure medication, which drug would you reach for first and is diazepam too short lasting?
So, so I guess with the, there's a really, really good question. I'm trying to think, there's not necessarily a short answer to it. It's something that we will discuss in more detail as well.
So if I don't answer it very well at the moment, we'll definitely catch up on, on this sort of thing again, but I would use that to come as my first line agent, because it's well it's something I'm familiar with. I kind of know what it does. I, you know, we can access it really quickly and it tends to be effective in the short term, but.
Generally speaking, there's kind of toxins that cause seizures like the tremogenic microtoxins, the permethrins, the metaldehydes, and that sort of thing. They would, I would expect them to cause seizuring beyond that single dose of diazepam, so I'd definitely use it, but I would be using it to get seizure control sort of quickly whilst I'm coming, coming up with Plan B. And then I'm thinking about other agents, whether they, you know, whether they need levoracetam, whether they need phenobarb, whether or not we need to sort of escalate to propofol and various other drugs.
So definitely use it as a first line, but I'd be sort of planning my, my next step, basically, expecting that the worst of those sorts of things, thinking about if I can eliminate the toxin in the other way. So for some of these really bad neurotoxins, you know, if lipid therapy might be appropriate for the tremogenic ones, and the permethrins. Whether or not with the metaldehyde toxicity, whether or not there's so much stuff in there, whether gastric labage might be appropriate, so the diazepas buying me time to kind of come up with my, my master plan basically as to what else I can do.
Yeah, definitely worth a try, but isn't gonna be the sort of sole treatment, sadly, but it will touch on this more, couple of weeks' time too. Perfect, thank you very much. And we have one from Louise.
This is in two parts, so I'll ask you the 22 different sections. Is fluid therapy recommended for high dose chocolate toxicity given the risk of absorption in the bladder? And if so, what rate?
OK. I would say definitely yes, indicated because it does help with that sort of diuresis, that kind of flushing out, that kind of getting rid of stuff. .
The kind of the reabsorption of metabolites is more a kind of a secondary issue, so it's not necessarily driven by the fluid therapy. So it would be something I'd have to address what address whether or not they were on fluids anyway. They can, I mean, you've probably seen cases like this as well where they're really quite markedly cardiovascular unstable with arrhythmias and, and various other things as well as potentially getting a little bit behind on their fluids with any sort of GI compromise that they get at the same time.
So I think they definitely benefit from fluids for sort of general cardiovascular stability, given the other kind of strains on the system, but then the really bad ones, I'll just kind of have the extra cheat at the end to sort of help there. Then not absorb anymore, but that would be independent of the fluid therapy or not. So overall, yeah, I would go ahead with, with fluid therapy to, to effect basically.
Excellent, and you've just answered the second part as well. So the next part was just about the cardiac arrhythmias. So you've just answered that also.
And we have lots of comments coming through to say thank you very much and what a great webinar this was. So that tends to be the end of the questions. I'd just like to again just remind you to share away on social media, say a massive thank you to all of our listeners for logging in, and again thank you to TBM for sponsoring this series, and a massive thank you to you, Lindsey, for delivering this webinar and also for phoning in and continuing to the end of the webinar as well and answering all the questions.
No worries at all. Thanks everyone for listening and yeah, it's been some great questions and then, yeah, we'll we'll, yeah, do the same again, same again next week, I think. Lovely, thank you very much and I hope to see you all again next week for the next series.
