Initial Instructions to Client

• Transport patient to a veterinarian as soon as possible.
• Delayed transport-keep patient warm; avoid any other stress.
• Warn onlookers about the condition of the patient and danger to themselves.
• May need to muzzle the patient.
• Transport urine (if available), uncontaminated vomitus and suspected toxic materials and their containers to the veterinary facility.
• Use clean plastic containers or clean glass jars for the specimens.

Washing Skin or Bathing

• External toxicants.
• Wash patient's skin or bathe to remove the noxious agent.
• CAUTION: avoid contamination of the people handling the patient.

Emetics

• Of little value beyond 1–2 hours after ingestion of most toxicants; material will have passed into the duodenum.
• Do not induce in unconscious or severely depressed patients or after ingestion of strong acids, alkalis, petroleum distillates, tranquilizers, or other antiemetics.
• Apomorphine-most effective and reliable for use in dogs; availability at any given time unknown; 0.03–0.04 mg/kg IV or IM; emesis occurs in 4–6 minutes; control adverse clinical signs caused by apomorphine with an appropriate intravenous narcotic antagonist (e.g., naloxone at 0.01–0.04 mg/kg).
• 3% Hydrogen peroxide-emetic of choice for home use; 2.2 mL/kg PO, do not exceed 45 mL in dogs; ineffective in cats, not always effective in dogs.
• Ipecac-little efficacy and no longer recommended; never use when activated charcoal is part of the therapeutic regimen.
• Xylazine-most successful in cats (0.44–1 mg/kg IM or SQ). Can be reversed with an alpha₂-adrenergic antagonist such as atipamezole or yohimbine.
• Salt or salt solution is NOT recommended. Salt can be toxic.

Activated Charcoal

• Does not detoxify but prevents absorption if properly used.
• Highly absorptive of many toxicants-organophosphate insecticides; other insecticides; rodenticides; mercuric chloride; strychnine; other alkaloids (e.g., morphine and atropine); barbiturates; ethylene glycol.
• Ineffective against alcohols, chlorate, cyanide, heavy metals, petroleum distillates, sodium chloride, and xylitol.
• Administered after emetic-increases efficacy of toxicant elimination.
• Use easily cleansed area when administering.
• Dosage 1–5 g/kg body weight; generally a single dose administration but some situations require multidose administration (1–2 g/kg PO q4–6h for 24 hours).
• Generally administered with a cathartic such as sorbitol or sodium sulfate; only the first dose should contain a cathartic.
• Hypernatremia has been reported after administration of activated charcoal, especially when a cathartic (sorbitol) is used in a dehydrated patient.

Gastric Lavage

• Effective means of emptying the stomach, but must be used in the first 1–2 hours.
• An appropriate size, cuffed endotracheal tube must be in place prior to starting the lavage procedure.
• Orogastric (stomach) tube size-use the largest possible; a good rule: use the same size as the cuffed endotracheal tube (1 mm = 3 Fr).
• Volume of water or lavage solution for each washing-5–10 mL/kg body weight.
• Infusion cycle-repeated more than 5–10 times.
• After the last cycle and prior to the removal of the orogastric tube, activated charcoal with a cathartic should be instilled.
• Precautions: (1) use low pressure to prevent forcing the toxicant into the duodenum; (2) reduce the infused volume in obviously weakened stomachs (e.g., in a patient that has ingested a caustic or corrosive toxicant); (3) do not force the stomach tube through either the esophagus or the stomach wall.

Oils

• Mineral or vegetable oil-valuable for lipid-soluble toxicants.
• Mineral oil (liquid petrolatum)-inert; less likely to be absorbed.
• Use as a cathartic.

Enemas

• Colonic lavage or high enema-may hasten the elimination of toxicants from the gastrointestinal tract.
• Warm water with Castile soap-excellent solution.
• Commercially available preparations that act as osmotic agents are available.
• Take care to avoid the induction of dehydration and electrolyte imbalances with overzealous treatment.
• Do not use hexachlorophene soaps or phosphate-based enemas in cats.

Diuretics

• Enhance urinary excretion of some toxicants-requires maintenance of adequate renal function.
• If minimum urine flow cannot be established-must use peritoneal dialysis (normal urine output is 1–2 mL/kg/hour).
• Agents of choice-furosemide (2 mg/kg IV q6–8h, if no response increase dose to 4–6 mg/kg IV q6–8h) or mannitol (1–2 g/kg IV slowly over 20–30 minutes q6h).

Manipulating Urine pH

• Classic pharmacologic technique
• Acidic compounds remain ionized in alkaline urine; alkaline compounds remain ionized in acidic urine.
• Intravenous 0.9% sodium chloride-rapid, urinary acidifying agent.
• Intravenous sodium bicarbonate may be used as an alkalinizing agent.
• Ammonium chloride (200 mg/kg PO divided 4 times a day) and ethylenediamine dihydrochloride (1–2 tablets q8h for the average-sized dog)-long-term urinary acidification.

Peritoneal Dialysis

• Indicated for patients with oliguria or anuria.
• Indicated for simple removal of absorbed toxicants in patient with normal renal function.
• pH of the solution-may be altered to maintain the ionized state of the offending compound.

Lipid Emulsion Therapy (ILE or IFE)

• Promising use as antidote for toxicosis from many fat soluble drugs.
• Useful for complications associated with local anesthetic medications. Successfully resuscitated human patients with cardiac collapse related to local anesthetics in particular, but also clomipramine and verapamil.
• Has been used successfully in veterinary medicine to treat toxicity from baclofen, beta antagonists, calcium channel antagonists, ivermectin, moxidectin, and other fat-soluble medications.
• Exact mechanism of action remains unknown, but may act as a lipid sink.
• Potential adverse effects include hyperlipidemia, hepatosplenomegaly, jaundice, seizures, hemolytic anemia, prolonged clotting time, thrombocytopenia, and fat embolism.
• Dosage extrapolated from humans using the 20% commercially available fat emulsion product. Standard Protocol: 1.5 mL/kg IV over 5–15 minutes followed by 0.25 mL/kg/minute CRI over 1–2 hours. Repeat in several hours if signs return and serum in not lipemic. See Appendix V on Antidotes and Other Useful Drugs.