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Pet Poison Helpline ©20153600 Amer ican Blvd. W., #725 B loomington , MN 55431www.petpo isonhe lp l ine .com

Decontamination Myths and Realities for Dogs and Cats

“Should I give milk, Doc?”

Katherine Peterson, DVM, DACVECCEmergency and Critical Care Specialist

Pet Poison Helpline

September 29, 2015

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TOP 5 TOXICITIESTOP 5 TOXICITIES

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Introduction

Katherine Peterson, DVM, DACVECC

Emergency and Critical Care Specialist

Pet Poison Helpline

Minneapolis, Minnesota

Objectives• Familiarize with indications for decontamination• Topical

– Ocular– Dermal

• Inhalation• Gastrointestinal

– Emesis– Gastric lavage– Activate charcoal – Whole bowel irrigation– Surgery

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Indications for decontamination

• The 6 Ws for interrogation

– Who- signalment, PMH

– What – toxin or not

– When – exposure happen

– Where – did it happen

– Why – ingestion, accidental dosing, malicious

– How – route of exposure

When to decontaminate

• To inhibit or minimize toxin absorption and to promote excretion or elimination from the body

• To remove or dilute topical irritants or corrosives

• When the benefits of decontamination outweigh the risk

• When the exposure may cause harm to the patient!

Ocular Decontamination

Myth: Every ocular exposure must be treated in the clinic…you only have two eyes.

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Ocular Decontamination• Irritant or corrosive to the eye

– pH (acid vs alkaline)– Key words on bottle (caution vs danger)– If it causes burns to the skin…it’ll damage the eye

• Perform as quickly as possible• Have owners start at home • Best flush to use:

– Eye wash*– LRS or saline– Tap water– Avoid eye drops (Visine or redness reducers)

Ocular Decontamination• Irritant

– Owner may be able to perform

– Irrigate for 10-15 minutes– Monitor for signs of irritation

• Pawing or rubbing at the eye• Redness• Lacrimation• Squinting • Swelling

– Symptomatic pets should be evaluated by a DVM

• Corrosive– Owner should attempt to

irrigate at home for 15-20 minutes

– Veterinarian should irrigate the eye 15-20 minutes with eye wash

– Fluorescein stain– Topical antibiotic ointment or

drops– Use an Elizabethan collar (E-

collar) to preventing self-trauma

– Monitor for signs or worsening

Dermal Decontamination

Myth: Just rinse it off the they’ll be fine

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Dermal Decontamination• Indications

– Corrosives or irritants– Systemically absorbed toxins– Glues or adhesives– Prevent oral exposure by self-grooming– Remove unwanted substances– Paresthesia– Burns

• Use personal protective equipment– Gloves – Glasses or goggles– Gown or long sleeves

Dermal Decontamination

• Irritants– Caution– Mild redness/irritation– Rinse/bathe– Topical vitamin E

• Corrosive– Alkaline – Acid– Rinse for 15 minutes– Bathe with dish soap– Burn care

Dermal Decontamination• Systemically or orally absorbed toxins

– Tea tree oil

– Topical pain creams

– Estrogen creams

– Pyrethrin (cats)

– Psoriasis cream

– 5-FU

• Bathe 2-3 times with a degreasing dish soap

• Activated charcoal may be indicated

• Blood work and supportive care will depend on toxin type

iherb.com

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Dermal Decontamination

• Glues/Adhesives

– Typically non-toxic

– Adhere to eyelid, teeth, skin/fur

– Loosen with oil

– Bathe

– Clip fur

– Do nothing?

• Gasoline/hydrocarbons

– Typically non-toxic

– Defatting dermis

– Small risk for aspiration

– Inhalation-CNS depression

– Bathe multiple times with degreasing dish soap

Dermal Decontamination

• Burns

– Treatment depends on the degree and BSA

– If within 2 hours, rinse with cool water for 30 minutes

– First degree-lavage and topical

– Second or third degree-debridement, SSD• Metabolic derangements

• Nutrition

• Pain control

Inhalation Decontamination

Myth: Just a little fresh air is all they need.

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Inhalation Decontamination• Remove animal from the source• Minor irritants = fresh air • Concentrates or corrosives

– Bleach and ammonia mixture

• Smoke inhalation– Carbon monoxide – decreased oxygen carrying– Toxic chemicals - variable– Thermal injury – edema, erosions , ulcerations– Hydrogen cyanide – cyanide toxicity

• Animals with underlying respiratory disease may require more intensive treatment.

Inhalation Decontamination: Birds

• Very sensitive

• Fragrance, Teflon, respiratory irritants

• Treatment

– Remove from source

– Humidified oxygen cage

– Heat support

– Fluids

Gastrointestinal Decontamination

Myth: Vomiting is always indicated

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Gastrointestinal Decontamination

• Types

– Emesis

– Gastric lavage

– Endoscopy

– Surgery

– Whole bowel irrigation

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When to decontaminate• Patient factors

– Signalment

– Underlying medical conditions

– Status on presentation

• Toxin factors– What is it?

– How bad it is?

– How long ago was it?

– What was the route of exposure?

– When does it cause clinical signs?

Success of emesis

• Gastric content recovery

– 49% (range 9-75%) with emesis < 30 minutes after ingestion

– 17-62% 1 hour after ingestion

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When to induce vomiting up to 6 hours out

• Grapes, raisins

• Chocolate

• Xylitol gum

• Bezoars

• Massive ingestions

• Drugs that decrease gastric emptying– Opioids

– Salicylates

– Anticholinergics

– Tricyclic antidepressants

How we induce emesis: dogs • Apomorphine

– Synthetic opiate, stimulates dopamine receptor in CRTZ – 0.03 mg/kg IV– 0.04 mg/kg IM– Crush tablet to administrate conjunctivally

• ½ tab small dog• 1 tab big dog

– Give naloxone if too sedate; will not reverse vomiting

• H202

– 3%, fresh, bubbly, non-expired– Gastric irritant– 1-2 ml/kg (1/2 to 1 tsp per 5 lbs)

How we do NOT induce vomiting in dogs

• Salt

• Syrup of ipecac

• Digital stimulation

• Liquid dish soap

• Raw eggs

• Tabasco

• Mustard

• Any other creative thing owners come up with!

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How we induce emesis: cats

• Xylazine– a-2 adrenergic agonist– Dose: 0.44 mg/kg, IM– Antidote: yohimbine 0.25-

0.5mg/kg IM• Dexmedetomidine

– a-2 adrenergic agonist– 5-10 mcg/kg IM– Antidote: antisedan- equal

volume in mls• Cons:

– Efficacy – 50%– Excessive sedation– Cardiovascular collapse

How we do NOT induce vomiting in cats

• H2O2 – Not very effective– Hemorrhagic gastritis

• Apomorphine– Not effective

When NOT to induce emesis:• Symptomatic!

• Already vomited to bile/empty

• History or risks of aspiration pneumonia

– Laryngeal paralysis

– Megaesophagus

When NOT to induce emesis:• Sharp/dangerous objects

• Corrosive agent– Punctured batteries, disc batteries

– Alkaline substances pH>11

– Acidic substances pH <3

• Hydrocarbons

– Gasoline

– Kerosene

– Motor oil

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When to be cautious to induce emesis

• Brachycephalic breeds

• Heart disease

• Seizure history

• Young animals

• Geriatrics pets

• Recent surgery

• Non-toxic ingestion

Species that do not vomit!

• Rabbits

• Ruminants

– Sheep, cattle, llamas, and goats

• Horses

• Birds

• Rodents

– Chinchillas, rats, gerbils

When to consider gastric lavage• May be more effective at removing gastric contents

• Species that cannot vomit

• Symptomatic patients with large ingestion

• Large amount of stomach contents

• Unsuccessful emesis

• Deadly meds:• Calcium-channel blockers

• Beta-blockers

• Baclofen

• Metaldehyde

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Gastric lavage• Sedation, intubation, endotracheal insufflation

• Right lateral recumbency with the head tilted down at an approximately 20⁰ angle

• Measure tube to the last rib

• Flush 5-10 ml/kg warm water through a large-bore stomach tube

• Agitate stomach

• Aspirate or gravity drainage of stomach contents

• Activated charcoal– Anti-emetic + Elevate head

– Keep intubated until able to protect airway34

Gastric lavage

www.atdove.org

Gastric lavage

• Contraindications– Hydrocarbons– Corrosive– Recent surgery– Risk for bleeding or injury– Unstable

• Risks– Aspiration pneumonia– General anesthesia– Esophageal or gastric rupture– Electrolyte imbalances

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Activated charcoal

• Suspension of charcoal– Without cathartic – With cathartic (commonly sorbitol)– UAA Gel

– Pills?

• May bind to toxins in GI tract– Physical contact

– Non-polar compounds

• Limited data

• Risk vs benefit

Activated charcoal dosing• Single dose:

– 1-2 g/kg of AC + cathartic

• Multiple doses:– 1g/kg of AC without a cathartic – Every 6-8 hours X 3-4 dose– Wait for doses to pass– Monitor Na – Indications:

• SR, XR, ER• Enterohepatic recirculation

Pros of activated charcoal

• Readily available

• Relatively inexpensive

• Suspected to bind to most toxicants

• Even with delayed administration, ↓ absorp�on by 25-30%

• Can administer with food to encourage ingestion

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Cons of activated charcoal

• Unknown benefit

• Difficulty of administration

• Messy

• Vomiting after administration

• Diarrhea/changes to stool

• Hypernatremia

• Binds to therapeutic medications

Contraindications for AC administration

• >2 hours after exposure

• Non-toxic ingestion

• Alcohols – Ethanol

– Ethylene glycol

• Xylitol

• Heavy metals

• Salt/playdoh ingestion

• Paintball ingestion

Contraindications for AC administration

• Symptomatic• Dehydration• Hypernatremia• Hypovolemic shock• Decreased GI motility/Ileus• Recent surgery• Protracted vomiting• Risk for aspiration pneumonia

– Unprotected airway– ↓ LOC– Excessive sedation/agitation– Forced feeding

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Contraindications for AC administration

• Ingestion of a caustic substance or hydrocarbon– ↑ aspira�on pneumonia

• Endoscopy (obscure visualization)

• Abdominal surgery of the GIT

• Gastric or intestinal obstruction

Cathartics: Why do we use them?

• Osmotic – draws water into GIT

• Accelerated speed of drug transit through GI

• ↓ time for toxin absorption

• ↓ time for desorption of toxin from AC

Whole Bowel Irrigation

• Indications

– Enteric coated drugs

– Iron

– Sustained or extended release drugs

– Packets of drugs

• NE or NG tube

• Polyethylene glycol

– 25-40 ml/kg PO followed by a continuous oral infusion of 0.5 ml/kg per hour until

• Treat until radiographic clearance or clear effluent

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Endoscopic or Surgical Removal

• Endoscopy– Coins– Non-leaking batteries (esp button batteries)– Patches (fentanyl, lidocaine)– Bottles/plastic– Other metals– Evaluate for injury to esophagus/stomach

• May be delayed depending on patient stability– General anesthesia– Cost– Operator dependent

Surgery

• Unable to vomit or remove endoscopically– Sharp objects– Large foreign bodies– Gorilla glue!– Medication bezoars– Leaking batteries– Large number objects– Bread dough

• Rumenotomy– Foreign body objects or large amounts of ingested

toxins.

Should I give milk?

• In general…NO!

– Causes gastroenteritis in dogs and cats

• But…may be useful for insoluble calcium oxalate plants or with fluoride toxicity.

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When in doubt, call 800-213-6680

• Something you’re not familiar or comfortable with

• Odd clinical signs

• Animals with preexisting disease

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