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## Complete Summary

#### GUIDELINE TITLE

Camphor poisoning: an evidence-based consensus guideline for
out-of-hospital management.

#### BIBLIOGRAPHIC SOURCE(S)

Manoguerra AS, Erdman AR, Wax PM, Nelson LS, Caravati EM, Cobaugh DJ,
Chyka PA, Olson KR, Booze LL, Woolf AD, Keyes DC, Christianson G,
Scharman EJ, Troutman WG, American Association of Poison Control
Centers. Camphor poisoning: an evidence-based practice guideline for
out-of-hospital management. Clin Toxicol (Phila) 2006;44(4):357-70.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16809137)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Camphor poisoning

**Note**: This guideline applies to exposure to camphor alone.
Co-ingestion of additional substances, such as in commercial products of
camphor combined with other ingredients, could require different
referral and management recommendations depending on the combined
toxicities of the substances

#### GUIDELINE CATEGORY

Evaluation\
Management\
Risk Assessment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Emergency Medical Technicians/Paramedics\
Nurses\
Pharmacists\
Physicians

#### GUIDELINE OBJECTIVE(S)

To assist U.S. poison center personnel in the appropriate
out-of-hospital triage and initial management of patients with suspected
exposures to camphor-containing products by:

-   Describing the manner in which an exposure to camphor might be
    managed

-   Identifying the key decision elements in managing cases of camphor
    exposure

-   Providing clear and practical recommendations that reflect the
    current state of knowledge

-   Identifying needs for research

#### TARGET POPULATION

Adults and children with suspected exposures to camphor-containing
products

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Assessment of key decision points for triage:

    -   Patient intent

    -   Route of exposure and estimated dose of camphor

    -   Time since exposure and symptoms

**Management**

1.  Referral to an emergency department

2.  Benzodiazepine administration for convulsion control

3.  Washing with mild soap and water for topical  exposures

4.  Immediate irrigation for ocular exposures, with referral for
    ophthalmologic exam, if symptoms of eye injury are present

5.  Removal of patient to a fresh air environment for inhalation
    exposure, with referral to a healthcare facility based on severity
    of symptoms

6.  Home observation

**Note**: Gastrointestinal decontamination in the out-of-hospital
setting with ipecac syrup and activated charcoal was considered but not
recommended

#### MAJOR OUTCOMES CONSIDERED

-   Signs and symptoms of camphor toxicity

-   The threshold dose for the development of toxicity

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Literature Search**

The National Library of Medicine\'s PubMed database was searched (to
November 2004) using camphor (poisoning) or camphor (toxicity) or
camphor (adverse effects) as Medical Subject Heading (MeSH) terms, all
limited to humans. PubMed was also searched using camphor as a textword
(title, abstract, MeSH term, CAS number) plus either poison\* or
overdos\* or tox\* or intox\*, limited to humans. This latter process
was repeated in International Pharmaceutical Abstracts (1970 to November
2004, excluding abstracts of meeting presentations), Science Citation
Index (1977 to November 2004), Database of Abstracts of Reviews of
Effects (accessed November 2004), Cochrane Database of Systematic
Reviews (accessed November 2004), and Cochrane Central Register of
Controlled Trials (accessed November 2004). Reactions (1980 to November
2004), the camphor poisoning management in Poisindex, and the
bibliographies of recovered articles were reviewed to identify
previously undiscovered articles. Furthermore, North American Congress
of Clinical Toxicology abstracts published in the Journal of
Toxicology-Clinical Toxicology (1995 to 2004) were reviewed for original
human data. The camphor chapter bibliographies in five major toxicology
textbooks were reviewed for citations of additional articles with
original human data. US poison control centers were invited to submit
their current guidelines for the management of camphor exposures.
Finally, The Toxic Exposure Surveillance System maintained by the
American Association of Poison Control Centers was searched for deaths
resulting from camphor poisoning. These cases were abstracted for use by
the panel.

**Article Selection**

The recovered citations were entered into an EndNote library and
duplicate entries were eliminated. The abstracts of the remaining
articles were reviewed, looking specifically for those that dealt with
estimations of mg/kg or ingested doses with or without subsequent signs
or symptoms, time to onset of symptoms, and management techniques that
might be suitable for out-of-hospital use (e.g., gastrointestinal
decontamination). Articles excluded were those that did not meet any of
the preceding criteria, did not add new data (e.g., some reviews,
editorials), or that exclusively described inpatient-only procedures
(e.g., whole bowel irrigation).

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

  ------------------------------------------------------------------------
  **Level of   **Description of Study Design**
  Evidence**   
  ------------ -----------------------------------------------------------
  1a           Systematic review (with homogeneity) of randomized clinical
               trials

  1b           Individual randomized clinical trials (with narrow
               confidence interval)

  1c           All or none (all patients died before the drug became
               available, but some now survive on it; or when some
               patients died before the drug became available, but none
               now die on it.)

  2a           Systematic review (with homogeneity) of cohort studies

  2b           Individual cohort study (including low quality randomized
               clinical trial)

  2c           \"Outcomes\" research

  3a           Systemic review (with homogeneity) of case-control studies

  3b           Individual case-control study

  4            Case series, single case reports (and poor quality cohort
               and case control studies)

  5            Expert opinion without explicit critical appraisal or based
               on physiology or bench research

  6            Abstracts
  ------------------------------------------------------------------------

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Data Extraction**

All articles that were retrieved from the search were reviewed by a
single abstractor. Each article was assigned a level of evidence score
from 1 to 6 using a rating scheme based on that of the Centre for
Evidence-based Medicine at Oxford University (see the \"Rating Scheme
for the Strength of the Evidence\" field). Single case reports were
classified along with case series as level 4. The complete paper was
then reviewed for original human data regarding the toxic effects of
camphor or original human data directly relevant to the out-of-hospital
management of patients with camphor poisoning. Relevant data (e.g., dose
of camphor, resultant effects, time to onset of effects, therapeutic
interventions or decontamination measures given, efficacy or results of
any interventions, and overall patient outcome) were compiled into a
table and a brief summary description of each article was written. This
full evidence table is available at
[http://www.aapcc.org/DiscGuidelines/Guidelines%20Tables/Camphor%20evidence%20table.pdf](http://www.aapcc.org/DiscGuidelines/Guidelines Tables/Camphor evidence table.pdf).
The completed table of all abstracted articles was then forwarded to the
panel members for review and consideration in developing the guideline.
Every attempt was made to locate significant foreign language articles
and have their crucial information extracted, translated, and tabulated.
Copies of all of the articles were made available for reading by the
panel members on a secure American Association of Poison Control Centers
(AAPCC) website.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The American Association of Poison Control Centers (AAPCC), the American
Academy of Clinical Toxicology (AACT), and the American College of
Medical Toxicology (ACMT) appointed members of their organizations to
serve as panel members. To serve on the expert consensus panel, an
individual had to have an exceptional record in clinical care and
scientific research in toxicology, board certification as a clinical or
medical toxicologist, significant U.S. poison center experience, and be
an opinion leader with broad esteem. Two specialists in poison
information were included as full panel members to provide the viewpoint
of the end-users of the guideline.

**Guideline Writing and Review**

A guideline draft was prepared by the primary author. The draft was
submitted to the expert consensus panel for comment. Using a modified
Delphi process, comments from the expert consensus panel members were
collected, copied into a table of comments, and submitted to the primary
author for response. The primary author responded to each comment in the
table and, when appropriate, the guideline draft was modified to
incorporate changes suggested by the panel. The revised guideline draft
was again reviewed by the panel and, if there was no strong objection by
any panelist to any of the changes made by the primary author, the draft
was prepared for the external review process.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The rating scheme for the strength of the recommendation (A-D, Z) is
directly tied to the level of evidence supporting the recommendation.

  -----------------------------------------------------------------------
  **Grade of Recommendation**                          **Level of\
                                                       Evidence**
  ---------------------------------------------------- ------------------
  A                                                    1a

                                                       1b

                                                       1c

  B                                                    2a

                                                       2b

                                                       2c

                                                       3a

                                                       3b

  C                                                    4

  D                                                    5

  Z                                                    6
  -----------------------------------------------------------------------

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

External review of the second draft was conducted by distributing it
electronically to Association of Poison Control Centers (AAPCC),
American Academy of Clinical Toxicology, and American College of Medical
Toxicology members and the secondary review panel. The secondary review
panel consisted of representatives from the federal government, public
health, emergency services, pediatrics, pharmacy practice, and consumer
organizations (see Appendix 3 in the original guideline document).
Comments were submitted via a discussion thread on the AAPCC web site or
privately through email communication to AAPCC staff. All submitted
comments were stripped of any information that would identify their
sources, copied into a table of comments, and reviewed by the expert
consensus panel and the primary author. The primary author responded to
each comment in the table and his responses and subsequent changes in
the guideline were reviewed and accepted by the panel. Following a
meeting of the expert consensus panel, the final revision of the
guideline was prepared.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the weight of the evidence (A-D, Z) and classes of
recommendations (1a-6) can be found at the end of the \"Major
Recommendations\" field.

1.  Patients with stated or suspected self-harm or who are the
    recipients of malicious administration of a camphor-containing
    product should be referred to an emergency department immediately.
    This activity should be guided by local poison center procedures. In
    general, this should occur regardless of the amount ingested
    **(Grade D)**.

2.  Patients who have ingested more than 30 mg/kg of a
    camphor-containing product or who are exhibiting symptoms of
    moderate to severe toxicity (e.g., convulsions, lethargy, ataxia,
    severe nausea and vomiting) by any route of exposure should be
    referred to an emergency department for observation and treatment
    **(Grade D)**.

3.  Patients exhibiting convulsions following a camphor exposure should
    be transported to an emergency department by pre-hospital emergency
    medical care providers **(Grade D)**. A benzodiazepine should be
    used to control convulsions **(Grade C)**.

4.  Patients who have been exposed to a camphor product and who remain
    asymptomatic after 4 hours can be safely observed at home **(Grade
    C)**.

5.  The induction of emesis with ipecac syrup should not be performed in
    patients who have ingested camphor products **(Grade C)**.

6.  Activated charcoal administration should not be used for the
    ingestion of camphor products. However, it could be considered if
    there are other ingredients in the product that are effectively
    adsorbed by activated charcoal or if other substances have been
    coingested. **(Grade C)**.

7.  For asymptomatic patients with topical exposures to camphor
    products, the skin should be thoroughly washed with soap and water
    and the patient can be observed at home for development of symptoms
    **(Grade C)**.

8.  For patients with topical splash exposures of camphor to the eye(s),
    the eye(s) should be irrigated in accordance with usual poison
    center procedures and that referral take place based on the presence
    and severity of symptoms **(Grade D)**.

9.  Patients with camphor inhalation exposures should be moved to a
    fresh air environment and referred for medical care based on the
    presence and severity of symptoms. It is unlikely that symptoms will
    progress once the patient is removed from the exposure environment
    **(Grade D)**.

**[Definitions]{.underline}**

**Grades of Recommendation and Levels of Evidence**

  ----------------------------------------------------------------------------
  **Grade of         **Level of\  **Description of Study Design**
  Recommendation**   Evidence**   
  ------------------ ------------ --------------------------------------------
  A                  1a           Systematic review (with homogeneity) of
                                  randomized clinical trials

                     1b           Individual randomized clinical trials (with
                                  narrow confidence interval)

                     1c           All or none (all patients died before the
                                  drug became available, but some now survive
                                  on it; or when some patients died before the
                                  drug became available, but none now die on
                                  it.)

  B                  2a           Systematic review (with homogeneity) of
                                  cohort studies

                     2b           Individual cohort study (including low
                                  quality randomized clinical trial)

                     2c           \"Outcomes\" research

                     3a           Systemic review (with homogeneity) of
                                  case-control studies

                     3b           Individual case-control study

  C                  4            Case series, single case reports (and poor
                                  quality cohort and case control studies)

  D                  5            Expert opinion without explicit critical
                                  appraisal or based on physiology or bench
                                  research

  Z                  6            Abstracts
  ----------------------------------------------------------------------------

#### CLINICAL ALGORITHM(S)

An algorithm is provided in Appendix 4 of the original guideline
document for the triage of camphor ingestions.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate out-of-hospital triage and initial management of patients
with suspected exposures to camphor-containing products

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This guideline is based on an assessment of current scientific and
    clinical information. The expert consensus panel recognizes that
    specific patient care decisions may be at variance with this
    guideline and are the prerogative of the patient and the health
    professionals providing care, considering all of the circumstances
    involved. This guideline does not substitute for clinical judgment.

-   This guideline has been developed for the conditions prevalent in
    the U.S. While the toxicity of camphor is not expected to vary in a
    clinically significant manner in other nations, the available forms
    of camphor and the out-of-hospital conditions could be much
    different. This guideline should not be extrapolated to other
    settings unless it has been determined that the conditions assumed
    in this guideline are present.

**Limitations of the Published Data**

While there were some published data suggesting a general toxic
threshold dose range for camphor, the data suffered from a number of
limitations, including the following.

1.  Understandably, there were no prospective studies that specifically
    investigated the toxic dose threshold for camphor.

2.  The published data existing for camphor are almost entirely case
    reports and suffer from all of the usual problems attributed to case
    report data including incomplete patient information and unconfirmed
    exposure to the toxin.

3.  The bulk of the literature on camphor was published prior to 1970.
    Many of the case reports are from the early part of the 20th century
    and do not provide the same level of information that is considered
    standard for case reports published in the recent literature.

4.  Only a small number of articles contained any toxic threshold or
    dose-effect information.

5.  Even when such information was presented in an article, there were
    often questions regarding the accuracy of the dose estimate due to
    inherent uncertainties in the history, differences in camphor
    content between products, and sometimes uncertainty with the report
    itself (e.g., confusion between the total product ingested or total
    camphor ingested, use of ambiguous or outdated language).

6.  Dose-effect information was often confounded by the presence of
    co-exposures, differences in decontamination or treatment measures,
    and concurrent medical conditions that could have altered the
    clinical presentation or outcome.

7.  It was difficult, if not impossible, to account for inter-individual
    differences in age, weight, underlying health condition, or other
    factors that might affect camphor\'s toxicokinetics and
    toxicodynamics.

8.  Among larger case series, many of the patients remained
    asymptomatic; doses and/or effects were typically reported as
    ranges, percentages, or means for the cases so that individual doses
    resulting in specific effects could not be determined.

9.  In the few available prospective trials of therapeutic use of
    camphor, camphor was generally administered in small doses or by
    routes that are not expected to occur in the setting of a poisoning.

10. The basic premise upon which the recommendations are based is that
    all camphor products have similar bioavailability characteristics
    irrespective of the formulation and that the amount of camphor in a
    product is the primary determinant in the potential for toxicity.
    This is an assumption for which there are no data, for or against,
    in the literature. This might not be a valid assumption and
    formulation could be a factor in observed differences in toxicity.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Manoguerra AS, Erdman AR, Wax PM, Nelson LS, Caravati EM, Cobaugh DJ,
Chyka PA, Olson KR, Booze LL, Woolf AD, Keyes DC, Christianson G,
Scharman EJ, Troutman WG, American Association of Poison Control
Centers. Camphor poisoning: an evidence-based practice guideline for
out-of-hospital management. Clin Toxicol (Phila) 2006;44(4):357-70.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16809137)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Feb 16

#### GUIDELINE DEVELOPER(S)

American Association of Poison Control Centers - Professional
Association

#### SOURCE(S) OF FUNDING

Health Resources and Services Administration, U.S. Department of Health
and Human Services

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Anthony S. Manoguerra, PharmD; Andrew R. Erdman, MD;
Paul M. Wax, MD; Lewis S. Nelson, MD; E. Martin Caravati, MD, MPH;
Daniel J. Cobaugh, PharmD; Peter A. Chyka, PharmD; Kent R. Olson, MD;
Lisa L. Booze, PharmD; Alan D. Woolf, MD, MPH; Daniel C. Keyes, MD, MPH;
Gwenn Christianson, MSN; Elizabeth J. Scharman, PharmD; William G.
Troutman, PharmD

*Expert Consensus Panel Members*: Lisa L. Booze, PharmD, Certified
Specialist in Poison Information, Maryland Poison Center, University of
Maryland School of Pharmacy, Baltimore, Maryland; E. Martin Caravati,
MD, MPH, FACMT, FACEP, Professor of Surgery (Emergency Medicine)
University of Utah, Medical Director, Utah Poison Center, Salt Lake
City, Utah; Gwenn Christianson, RN, MSN, Certified Specialist in Poison
Information, Indiana Poison Center, Indianapolis, Indiana; Peter A.
Chyka, PharmD, FAACT, DABAT, Professor, Department of Pharmacy,
University of Tennessee Health Science Center, Memphis, Tennessee;
Daniel J. Cobaugh, PharmD, FAACT, DABAT, Director of Research, ASHP
Research and Education Foundation, Bethesda, Maryland, Former Associate
Director, American Association of Poison Control Centers; Daniel C.
Keyes, MD, MPH, FACEP, FACMT, Medical Director, Pine Bluff Chemical
Demilitarization Facility, Associate Professor, Southwestern Toxicology
Training Program, Dallas, Texas; Anthony S. Manoguerra, PharmD, DABAT,
FAACT, Professor of Clinical Pharmacy and Associate Dean, School of
Pharmacy and Pharmaceutical Sciences, University of California San
Diego, Former Director, California Poison Control System, San Diego
Division, San Diego, California; Lewis S. Nelson, M.D., FACEP, FACMT,
Assistant Professor of Emergency Medicine, New York University School of
Medicine, Associate Medical Director, New York City Poison Control
Center, New York, New York; Kent R. Olson, MD, FACEP, FAACT, FACMT,
Medical Director, California Poison Control System, San Francisco
Division, Clinical Professor of Medicine & Pharmacy, University of
California, San Francisco, San Francisco, California; Elizabeth J.
Scharman, PharmD, DABAT, BCPS, FAACT, Director, West Virginia Poison
Center, Professor, West Virginia University School of Pharmacy,
Department of Clinical Pharmacy, Charleston, West Virginia; Paul M. Wax,
MD, FACMT, Managing Director, Banner Poison Center, Professor of
Clinical Emergency Medicine, University of Arizona School of Medicine,
Phoenix, Arizona; Alan D. Woolf, MD, MPH, FACMT, Director, Program in
Environmental Medicine, Children\'s Hospital, Boston, Associate
Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

There are no potential conflicts of interest reported by the expert
consensus panel or project staff regarding this guideline.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Association of Poison Control
Centers](http://www.aapcc.org/FinalizedPMGdlns/camphor.pdf).

Print copies: Available from the American Association of Poison Control
Centers, 3201 New Mexico Avenue NW, Suite 330, Washington, DC 20016

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on November 29, 2006. The
information was verified by the guideline developer on December 13,
2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008