a 2 year old who presents with seizures: whats that smell? suzan mazor, md fellow, toxicology...
TRANSCRIPT
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A 2 Year Old who Presents with A 2 Year Old who Presents with Seizures: What’s that Smell?Seizures: What’s that Smell?
Suzan Mazor, MD
Fellow, Toxicology
Toxikon Consortium, Cook County
Pediatric Emergency Medicine
Children’s Memorial Hospital, Chicago
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Suzan Mazor, MD
Case PresentationCase Presentation
• 3 year-old presents with a GTC seizure
• Recent URI symptoms, no significant PMH
• Over the counter cold remedy
• Abrupt onset of vomiting, seizure within 30 min
• Seizure stopped after 20 minutes• 2 doses of Lorazepam were given
• Phenobarbital load
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Suzan Mazor, MD
Physical ExamPhysical Exam
• VS: 38.0, 96/palp, 126, 28, sat 99% (100%O2)
• Somnolent / post-ictal
• Aromatic odor on breath
• Pulmonary, cardiac, abdomen: normal
• Localized to painful stimuli
• Spontaneous eye opening and movements
• Routine laboratory examinations all normal
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Suzan Mazor, MD
Differential DiagnosisDifferential Diagnosis
• What is this smell?
• Smells in toxicology• Bitter almond • Garlic• Rotten eggs• Newly mown hay
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Suzan Mazor, MD
Differential DiagnosisDifferential Diagnosis
• What is this smell?
• Smells in toxicology• Bitter almond ……..Cyanide• Garlic …...………….Arsenic• Rotten eggs………..Hydrogen sulfide• Newly mown hay….Phosgene
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Suzan Mazor, MD
CamphorCamphor
• Bark/leaves of Cinnamomum camphora tree
• Synthesized from hydrocarbon-pinene• turpentine oil derivative
• Uses of camphorated oils• aphrodisiac, contraceptive, abortifacient,
liniment, antiseptic, cough suppressant• Common ingredient in OTC preps,
mothballs
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Suzan Mazor, MD
CamphorCamphor
• 1983: FDA banned sale of oils with > 11% camphor
• Products with higher concentrations still available • Canada, Australia, China• Still used as liniment, herbal remedy
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Suzan Mazor, MD
Camphor Camphor
• Common camphor containing products• Mothballs• Antiseptics
• Campho-phenique (10.8%)
• Muscle liniments• Camphor spirits• Cold remedies
• Vicks Vapo-rub (4.7%)• Vicks Vapo-steam (6.2%)
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Suzan Mazor, MD
CamphorCamphor
• 5 cc (20% oil) killed a 19 month old• = 10 cc (2 tsp) Campho-phenique• = 16 cc (1 tbsp) Vicks Vapo-steam• = 20 cc Vicks Vapo-rub
• Lethal dose 50-500 mg/kg
• Unlikely toxicity <30mg/kg
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Suzan Mazor, MD
CamphorCamphor
• Case reports of toxicity • Ingestion
• Mothballs, Camphorated oils, OTC products• Dermal• Intranasal• Intraperitoneal• Transplacental
• Most poisonings due to ingesting camphorated oil• mistaken for other med (castor oil)
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Suzan Mazor, MD
Can You Tell the Difference??Can You Tell the Difference??
Camphorated oil Castor oil
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Suzan Mazor, MD
CamphorCamphor
• 2001 AAPCC TESS DATA• 8505 Exposures
• 6,518 < 6 years old• 89 moderate-severe symptoms, no deaths
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
• Clinical manifestations• Aromatic, pungent odor • Symptoms begin abruptly
• 5-90 min post-ingestion
• GI symptoms • Emesis with camphor odor• Abdominal pain, oropharyngeal irritation
• CNS• Seizures within minutes• Confusion, agitation, CNS depression
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
• Diagnostic testing• Camphor and metabolites can be measured
in blood or urine• Levels not available in real-time• Levels do not correlate with symptoms
• No other specific labs
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Suzan Mazor, MD
CamphorCamphor
Management 1. A,B,C’s
2. Seizure management
3. Decontamination
4. Enhanced elimination
5. Antidotes
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
• Management1. ABCs
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
• Management2. Seizure management
• Benzodiazepines• Barbiturates• Propofol• What about Phenytoin?
• Usually does not work for toxin induced seizures
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity• Management
3. Decontamination• Wash substance off patient if dermal exposure• Ipecac?
• NO! Quick changes in mental status possible
• Gastric Lavage?• Probably not useful unless available IMMEDIATELY• Liquid is rapidly absorbed• ?NG suction
• Activated charcoal?• Efficacy not studied
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
4. Hemodialysis + charcoal hemoperfusion• Lipid dialysate• Successful in case reports, no controlled
studies• Not widely available
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
5. Antidotes?• None
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
Camphor-containing mothballs
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Suzan Mazor, MD
• Naphthalene• Metabolized to naphthols and
naptholoquinone• Oxidants• Hemolysis and methemoglobinemia
• Caution with G6PD deficiency
Other Types of MothballsOther Types of Mothballs
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Suzan Mazor, MD
Mothball IdentificationMothball Identification
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Suzan Mazor, MD
Mothball IdentificationMothball Identification
• Camphor
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Suzan Mazor, MD
Mothball IdentificationMothball Identification
• Naphthalene
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Suzan Mazor, MD
Case CourseCase Course
• The child had been found 2 hours PTA with an open jar of Vicks Vapo-rub.
• 1 tablespoon was missing (=0.7g camphor).
• No further seizures occurred.
• Within 24 hours the lethargy resolved and she was discharged.
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Suzan Mazor, MD
Teaching PointsTeaching Points
• Camphorated oils, medications, mothballs may cause rapid onset of vomiting, seizures, altered mental status
• Naphthalene in mothballs may cause hemolysis, methemoglobinemia
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Suzan Mazor, MD
Thank You!Thank You!
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Questions???Questions???