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

2. 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. 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. Differential Diagnosis
What is this smell?
Smells in toxicology
Bitter almond
Garlic
Rotten eggs
Newly mown hay

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

6. 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. 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. 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. Camphor 5 cc (20% oil) killed a 19 month old Lethal dose 50-500 mg/kg
= 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. 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. Can You Tell the Difference??
Castor oil
Camphorated oil

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

13. 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. 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. Camphor Management A,B,C’s Seizure management Decontamination
Enhanced elimination
Antidotes

16. Camphor Toxicity
Management
1. ABCs

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

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

20. Camphor Toxicity
5. Antidotes?
None

21. Camphor-containing mothballs
Camphor Toxicity
Camphor-containing mothballs

22. Other Types of Mothballs
Naphthalene
Metabolized to naphthols and naptholoquinone
Oxidants
Hemolysis and methemoglobinemia
Caution with G6PD deficiency

23. Mothball Identification
WILL IT FLOAT??

24. Mothball Identification
Camphor
IT FLOATS!!

25. Mothball Identification
Naphthalene
IT SINKS!!!

26. 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. Teaching Points
Camphorated oils, medications, mothballs may cause rapid onset of vomiting, seizures, altered mental status
Naphthalene in mothballs may cause hemolysis, methemoglobinemia

28. Thank You!

29. Questions???