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A 2 Year Old who Presents with Seizures: Whats that Smell? Suzan Mazor, MD Fellow, Toxicology Toxikon Consortium, Cook County Pediatric Emergency Medicine.

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Presentation on theme: "A 2 Year Old who Presents with Seizures: Whats that Smell? Suzan Mazor, MD Fellow, Toxicology Toxikon Consortium, Cook County Pediatric Emergency Medicine."— Presentation transcript:

1 A 2 Year Old who Presents with Seizures: Whats that Smell? Suzan Mazor, MD Fellow, Toxicology Toxikon Consortium, Cook County Pediatric Emergency Medicine Childrens Memorial Hospital, Chicago

2 Suzan Mazor, MD Case 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

3 Suzan Mazor, MD Physical 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

4 Suzan Mazor, MD Differential Diagnosis What is this smell? Smells in toxicology Bitter almond Garlic Rotten eggs Newly mown hay

5 Suzan Mazor, MD Differential Diagnosis What is this smell? Smells in toxicology Bitter almond ……..Cyanide Garlic …...………….Arsenic Rotten eggs………..Hydrogen sulfide Newly mown hay….Phosgene

6 Suzan Mazor, MD Camphor 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

7 Suzan Mazor, MD Camphor 1983: FDA banned sale of oils with > 11% camphor Products with higher concentrations still available Canada, Australia, China Still used as liniment, herbal remedy

8 Suzan Mazor, MD 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%)

9 Suzan Mazor, MD Camphor 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 mg/kg Unlikely toxicity <30mg/kg

10 Suzan Mazor, MD Camphor 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)

11 Suzan Mazor, MD Can You Tell the Difference?? Camphorated oil Castor oil

12 Suzan Mazor, MD Camphor 2001 AAPCC TESS DATA 8505 Exposures 6,518 < 6 years old 89 moderate-severe symptoms, no deaths

13 Suzan Mazor, MD Camphor 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

14 Suzan Mazor, MD Camphor 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

15 Suzan Mazor, MD Camphor Management 1.A,B,Cs 2.Seizure management 3.Decontamination 4.Enhanced elimination 5.Antidotes

16 Suzan Mazor, MD Camphor Toxicity Management 1. ABCs

17 Suzan Mazor, MD Camphor Toxicity Management 2. Seizure management Benzodiazepines Barbiturates Propofol What about Phenytoin? Usually does not work for toxin induced seizures

18 Suzan Mazor, MD Camphor 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

19 Suzan Mazor, MD Camphor Toxicity 4. Hemodialysis + charcoal hemoperfusion Lipid dialysate Successful in case reports, no controlled studies Not widely available

20 Suzan Mazor, MD Camphor Toxicity 5. Antidotes? None

21 Suzan Mazor, MD Camphor Toxicity Camphor-containing mothballs

22 Suzan Mazor, MD Naphthalene Metabolized to naphthols and naptholoquinone Oxidants Hemolysis and methemoglobinemia Caution with G6PD deficiency Other Types of Mothballs

23 Suzan Mazor, MD Mothball Identification

24 Suzan Mazor, MD Mothball Identification Camphor

25 Suzan Mazor, MD Mothball Identification Naphthalene

26 Suzan Mazor, MD Case 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.

27 Suzan Mazor, MD Teaching Points Camphorated oils, medications, mothballs may cause rapid onset of vomiting, seizures, altered mental status Naphthalene in mothballs may cause hemolysis, methemoglobinemia

28 Suzan Mazor, MD Thank You!

29 Questions???


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