Top 10 Toxins Poisonous
To Small Animals
October 8, 2013
Ahna Brutlag, DVM, MS, DABT, DABVTAssociate Director of Veterinary Services
Pet Poison Helpline
abrutlag@petpoisonhelpline.com&Adjunct Assistant Professor
Dept.Veterinary Biomedical Sciences
College of Vet. Med., University of Minnesota
www.petpoisonhelpline.com

3600 American Blvd. W., #725 Bloomington, MN 55431

Pet Poison Helpline ©2012

Did you know?
 The incidence rate of our top three toxicities in small animals
 In 2012 VPI Pet Insurance received
Toxicity/overdose ofOTC and prescription
meds (incl flea/tick)

Methylxanthine toxicity(chocolate, caffeine)

Poisoning of plantorigin (nuts, grapes,onions, tobacco,mushrooms)# of Pets =1,168# of Pets =966# of Pets =750

Avg. Cost per
Pet = $581

Avg. Cost per
Pet = $380

Avg. Cost per
Pet = $507

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working together
 Shared mission in highlighting the importance ofpreparing for accidents and poisonings in small
animals Addressing the cost of veterinary care

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 Pet owners with VPI Pet Insurance spend twice as muchon their pets (single events) than those without VPI PetInsuranceVPI® and Pet Poison Helpline®
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 www.petinsurance.com/healthzone.aspx

 Providing complimentary pet ownereducational materials for your practice –available for ordering First Aid for Your Pet brochure Poisoning Emergencies brochure Toxins in the Kitchen stickers
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Introduction
Ahna G. Brutlag, DVM,MS, DABT, DABVTAssociate Director
Pet Poison Helpline
Minneapolis, Minnesota

P ET P OISON HELPLINEPet Poison Helpline• Animal poison control– 24/7 availability– $39 one-time fee/case– Unlimited case follow-up– Access to multiple specialists (DVM and others)• Board-certified veterinary toxicologists (DABVT, DABT, Board-eligible
ABVT & ABT)
• Emergency/Critical Care (2 DACVECCs, ECC resident)• Internal Medicine (DACVIM)• Herpetology• PharmDs/clinical pharmacologists

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Selected Top 10 Toxins

See full section at www.petpoisonhelpline.com• Chocolate• SSRI antidepressants• ADD/ADHD meds
• Sleep aids
• NSAIDS• Insect bait stations• Silica gel packs/Oxygen
absorber sachets• Batteries• Household cleanersP ET P OISON HELPLINE

ChocolateP ET P OISON HELPLINE

Chocolate• Contain naturally occurring methylated xanthinealkaloids (methylxanthines)– Theobromine– Caffeine• Found in cacao beans, the seeds of the Theobrema
cacao plant9

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Chocolate• Stays in the stomach for a long time!
– Slow absorption (up to 12 hours)• Delayed emesis = OK
• Spontaneous vomiting often occurs with large ingestions.
• Long T½: 17 hours (theobromine)• May need to treat/observe for 72-96 hours
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Chocolate• Methylxanthines (theobromine and caffeine) = toxic
component:
ProductTheobromineCaffeine

White chocolate

0.25 mg/oz

0.85 mg/oz

Milk chocolate

44-60 mg/oz

6 mg/oz

Dark semisweet

135 mg/oz

20 mg/oz

Unsweetenedbaker’s chocolate

390-450 mg/oz

47 mg/oz

Dry cacoa powder

400-737 mg/oz

70 mg/oz

Cacoa beans

300-1500 mg/oz

Cocao bean mulch

56-900 mg/oz
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P ET P OISON HELPLINEChocolate• When do you see signs? (theobromine)– Mild signs (agitation, GI):– Moderate signs (cardiotoxicity):– Severe signs (neurotoxicity):

20 mg/kg
40-50 mg/kg
60 mg/kg• Clinical signs:– Chocolate vomiting– Chocolate diarrhea– Polyuria– Agitation/hyperactivity– Hyperthermia– Cardiac arrhythmias (tachycardia,VPCs)– Tremors– Seizures

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http://www.personal.psu.edu/afr3/blogs/SIOW/2010/09/will-chocolate-really-kill-your-doP ET P OISON HELPLINE

Chocolate: Treatment• Supportive• IV fluids + frequent walks to keep bladder empty• Temperature monitoring• Anti-emetics/pro-kinetics– Maropitant: 1 mg/kg SQ q. 24– Metoclopramide: 0.1-0.4 mg/kg q. 6 SC, IM or 1-2 mg/kg/day as CRI IV– Ondansetron/dolasetron

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Chocolate: Treatment• ECG monitoring• If agitated, tachycardic  sedation:– Acepromazine: 0.05 mg/kg IV PRN– Torbugesic: 0.1-0.4 mg/kg IV PRN• Beta-blocker therapy– Esmolol: 0.25-0.5 mg/kg IV bolus, followed by CRI of 10-200 mcg/kg/min• Anti-convulsant therapy– Diazepam: 0.25-0.5 mg/kg IV PRN– Phenobarbital: 4-16 mg/kg IV PRN
14P ET P OISON HELPLINEPET POISON HELPLINEPET POISON HELPLINE

Serotonin Reuptake Inhibitors (SSRI)• Common Examples:– Fluoxetine (Prozac, Reconcile)– Paroxetine (Paxil)– Sertraline (Zoloft)– Trazadone (Trazolan, Desyrel)– Venlafaxine (Effexor)– Bupropion (Wellbutrin, Zyban): Not a true SSRI, butoverdose can result in serotonin syndrome in dogs andcats.

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SSRIs: Mechanism of action• MOA: This group of drugs works by inhibiting the re-uptake of serotonin at
the presynaptic membrane = more serotonin at synapse– As ↑serotonin, some animals develop serotonin syndrome

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SSRIs: Toxicity• Range of toxicity– Different for each medication– At 2-3X overdose, clinical signs more possible– As the dose of SSRI increases, the risk of serotonin syndromeincreases• Caution!
– Many are rapidly absorbed and have a rapid onset of action– Many come in an extended release version (SR or XR)

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SSRIs: Clinical signs• Low doses: mild to moderate sedation– CNS: agitation, restless, vocalizing, tremors, seizures– GI: hypersalivation, vomiting, diarrhea– Cardiovascular: tachycardia, hypertensive– Respiratory: panting, hyperventilating– Other: hyperthermia• High doses: more severe or serotonin syndrome• Treatment: similar to ADD meds

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http://encefalus.com/wp-content/uploads/2008/08/ritalin.jpg

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ADD/ADHD Drugs• Common examples:– Dextroamphetamine /Amphetamine (Adderall)– D-amphetamine (Dexedrine)– Lisdexamfetamine (Vyvanse)—new!
– Methamphetamine (Dexoxyn)– Methylphenidate (Ritalin/Concerta)• Similar to methamphetamine– Crystal meth

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ADD/ADHD Drugs:
What are they used for?

• ADD/ADHD• Obesity (weight loss)• Narcolepsy• Illegal/illicit purposes

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ADD/ADHD Drugs: MOA• Amphetamines are sympathomimetic compounds• More potent and structurally related to norepinephrine• Stimulate the release of norepinephrine• Directly stimulate alpha and beta adrenergic receptors

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ADD/ADHD Drugs:
Range of toxicity• Methylphenidate (Ritalin): 1 mg/kg can cause agitation• Amphetamine (50% of Adderall) oral LD50 (dog): 20-27 mg/kg• Methamphetamine LD50 (dog): 9-11 mg/kg• One dog fatality from methamphetamine at 3.1 mg/kg

P ET P OISON HELPLINESSRI and amphetamines: Clinical Signs• CNS:– Mydriasis– Agitation– Hyperactivity/over-stimulated– Head bobbing– Tremors– Seizures– Coma– Flicking ears/tail

http://blogs.families.com/media/hyperactive1.jpg

P ET P OISON HELPLINESSRI and amphetamines: Clinical Signs• Cardiovascular:– Tachycardia– Hypertension• Respiratory:– Hyperventilating• Hyperthermia

http://blogs.families.com/media/hyperactive1.jpg

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Decontamination• Rapid onset of clinical signs • Emesis best done in the clinic (not by owner!)• Emesis only if asymptomatic• Emesis only if early!

• Activated charcoal with a cathartic (once)• If “XR” “LA” “SR” multiple doses of activated charcoal• No repeated doses of cathartic

Photo courtesy of Garret Pachtinger, VMD, DACVECCP ET P OISON HELPLINE

Treatment• Monitoring:– Monitor ECG and blood pressure– TPR• Clinicopathologic testing:– Chemistry• Monitor renal function– Urinalysis• Pigmenturia

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Treatment• IV fluid therapy:– Cooling measure– Prevent myoglobinuric renal failure• Hyperthermia:– IV fluids– Stop the agitation/tremoring– Cooling to 103.5ºF/39.7ºC and STOPP ET P OISON HELPLINE

Treatment
Agitation:– Acepromazine• 0.05-0.2 mg/kg IV, IM, or SQ, titrated to effect– Chlorpromazine• 0.5 mg/kg IV, IM, or SQ, titrated to effectP ET P OISON HELPLINE

Treatment• Tachycardia (HR > 170 bpm in dogs):– Blood pressure measurement?
• If hypotensive  IV fluids• If hypertensive/agitated – Sedation (acepromazine)– Beta-blocker (propranolol 0.02-0.06 mg/kg IV)• Seizures:– Phenobarbital 4-16 mg/kg IV or PO PRN, titrated to effect– Diazepam 0.25-0.5 mg/kg IV PRN, titrated to effect• Don’t use with serotonin syndrome?

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Treatment:• Tremors:– Methocarbamol 44-220 mg/kg IV or PO q. 6-8• Serotonin syndrome:– Cyproheptadine (serotonin antagonist)– Dogs: 1.1 mg/kg PO or rectal q. 6-8-12 hours– Cats: 2-4 mg total PO or rectal q. 6-8-12 hours

P ET P OISON HELPLINEPET POISON HELPLINE

Sleep Aids
• Are often benzodiazepines or non-benzodiazepine hypnotics• Examples– Zolpidem (Ambien)– Eszopiclone (Lunesta)• MOA– The non-benzos are similar to benzos as they potentiate GABA
transmission, increase frequency of chloride channel opening 
resulting in inhibition of neuronal excitation

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Sleep Aids
• Range of toxicity– Varies widely with the drug
– Typically have a reasonably wide margin of safety• Time to onset: ~ 1-2 hrs• Duration of signs: ~ 12 hrs

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Sleep Aids: Clinical signs• CNS: ataxia, depression, paresis• But… 40-50% of dogs  paradoxical CNS stimulation!
Hyperactivity, agitation, panting, tremors• Other: nausea, vomiting, diarrhea, hyperthermia• Rare to see excessive respiratory and cardiac depression

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Sleep Aids: Treatments• Decontamination:– Early and judicious use of emetics if no CNS effects observed.
– Activated charcoal + cathartic (A/C/C)

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Sleep Aids: Treatments• If paradoxical stimulation  do NOT treat with benzodiazepines!
• Phenothiazines or barbiturates are preferred• Antidote:– Flumazenil should be used in only severe cases- re-dose asneeded• Re-dose as needed• Monitor carefully for seizures

P ET P OISON HELPLINEP ET P OISON HELPLINENSAIDS• Common products– Ibuprofen: All things Advil or Motrin– Naproxen: All things Aleve or Anaprox– Many things “cold and flu”

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MOA of NSAIDS• Competitive inhibitor of prostaglandin synthesis (cyclooxygenase) ↓PGI2 and PGE2
• Affected organs:– GIT– Renal– Platelet– CNS (high dose)• Sensitivities:– NSAID sensitivity– German shepherds– CatsP ET P OISON HELPLINE

Ibuprofen: Toxic doses (dogs)• 8 -16 mg/kg: Acute and chronic  mild gastritis– On post-mortem, GI ulcers, erosions, and severe
gastrointestinal (GIT) disease present.

• 50 -100 mg/kg: Mild to severe GI upset• > 100- 250 mg/kg: Renal compromise to renal failure• > 300 mg/kg: Fatalities (treated and untreated animals)

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Naproxen: Toxic doses (dogs)• Potent NSAID• Long ½ life! 72 hours!
• Clinical signs: > 5 mg/kg• Study: 22 mg/kg PO X 3 days = duodenal ulcers,perforations, peritonitis

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Ibuprofen and Naproxen• Ibuprofen range of toxicity for 20 kg dog:
– 5 tablets of ibuprofen (Advil, 200 mg tablet) GI ulcers– 15 Advil  acute kidney failure (ARF)• Naproxen range of toxicity for 20 kg dog:
– ½ tablet of naproxen (Aleve, 200 mg tablet)  GI ulcers– 2 tablets of Aleve  duodenal ulcers, perforations, peritonitis

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Clinical Signs with NSAIDS• Pallor• Prolonged CRT• Tachycardia• Tachypnea• Vomiting• Melena– Rectal, rectal, rectal!

Photo credit: Justine Lee, DVM, DACVECC, DABTP ET P OISON HELPLINENSAIDs: Treatment•

Decontaminate (emesis, activated charcoal)––––•

Baseline blood work––•

Time since ingestion?
Gel cap vs. chewable?
Enterohepatic recirculation?
Activated charcoal + cathartic

PCV/TS, renal panel q. 24 hours X 2-3 days
Recheck 3-5 days thereafterIV fluids––Vasodilate renal vessels  prevent ARF
2-3.5X maintenanceP ET P OISON HELPLINENSAIDs: Treatment•

Gastric protectants x 7-10 days––––•

Sucralfate
H2 blocker
Proton-pump inhibitor+/- Misoprostol

Monitor CNS – treat seizures with diazepam

HOUSEHOLD ITEMSP ET P OISON HELPLINE

Insect bait stations• Low concentration abamectin, fipronil, hydramethylnon• Peanut butter/sugar base• Rarely toxic• Plastic foreign body obstruction (FBO) risk
• Treatment: typically not necessary53

P ET P OISON HELPLINEHousehold cleaners• Most household cleaners are not highly toxic orcorrosive—mostly GI irritants• Worrisome products (possibly corrosive)– Ultra bleaches– Drain/oven cleaners– Automatic dishwasher detergent• Laundry detergent pods?
– Aspiration after puncturing
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P ET P OISON HELPLINEHousehold batteries—3 common types• Dry cell
– Grey/black powder inside– Look for evidence on teeth• Button– Size of pencil eraser– Rarely a concern if ingested (too small)• Lithium ion

Button Alkaline
Battery– Risk of fatality if ingested!
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Lithium Batteries• Corrosive to GI mucosa due to electricaldischarge and contents– Li batteries  higher voltage, more tissue
necrosis than button alkali batteries• Onset of signs: within 1-12 h• Diagnostics– Physical exam
– Radiograph• Treatment:– Remove foreign body?
– Administer GI protectants– Re-radiograph

Button Alkaline
BatteryP ET P OISON HELPLINELithium battery vs. hotdog

Courtesy of the Arizona Poison & Drug Information Center57

30 minutes

60 minutes

120 minutes58

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When in doubt, call for the bad ones:• Something you’re not familiar or comfortable
with• ADD medications• NSAID overdoses• SSRIs• Lithium batteries

PET POISON HELPLINEP ET P OISON HELPLINE

Did you get your “wheel of vomit”?
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For veterinary clinics only – one per clinic!

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Thank you for attending!
CE credit FAQs
1.

When will I get my CE certificate? We’ll email it to you within 24 hrs.

2.

I attended the webinar but wasn’t the person who logged in. Can I still get
interactive CE credit? Yes. Send your name and email address to
info@petpoisonhelpline.com by 1pm central time, Oct 9, 2013 (strict deadline).

3.

Can I watch the recorded webinar online for CE credit? Yes.You can receive noninteractive CE credit. Go to the “For Vets” page on our website, www.petpoisonhelpline.com
for more info.
Comments? Questions? Email us! info@petpoisonhelpline.com

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Acknowledgements
Dr. Lynn Hovda&Dr. Justine Lee
Thank you for your contributions!

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Self-study
There just wasn’t enough time to cover
everything we’d hoped to get through. Below area short selection of slides which we think you’ll
benefit from. We’ve included references to otherwebinars which will provide more detail, as well
as reference to published articles.
Enjoy!

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Bulb Fertilizers• Contain– Nitrogen– Phosphate– Potash• Typically wide margin ofsafety• Beware massive ingestion• See PPH Webinar, Plants
Poisonous to Small Animals,April 2012www.petpoisonhelpline.com, For Vets page

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Bone meal/blood meal:• “Organic” but still dangerous!
• Palatable!
• Mixed in with ???
– Organophosphate granules?
– Spring bulbs?

67

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Bone meal/blood meal:• Clinical signs:– Vomiting– Pancreatitis– Foreign body obstruction• Treatment:– Radiographs to evaluate size of bezoar (bone)– Gastric lavage to break up– Anti-emetics– Fluid therapy• IV fluids• SQ fluids– Supportive care68

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Silica gel: Deadly or not?
• Silica gel packets– Found in new shoe boxes, purses,
pill bottles, etc.
– Risk of obstruction if packet ingested– Non-toxic• Not the same as oxygen absorbers!
– Found in food packaging– Contain iron = possible iron poisoning• Black or brown powder• Magnetic69
http://en.wikipedia.org/wiki/File:Oxygen_Absorber.JPG

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Oxygen absorbers – risk to pets?
• Potential for iron poisoning in small dogs
• See PPH Webinar, Baby Products Poisonous to Pets, April 2013 for ironpoisoning detail (www.petpoisonhelpline.com)

Photo credit: Dr. Ahna Brutlag

http://en.wikipedia.org/wiki/File:Oxygen_Absorber.JPG70