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A 2 Year Old who Presents with Seizures: What’s that Smell?

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Presentation on theme: "A 2 Year Old who Presents with Seizures: What’s that Smell?"— Presentation transcript:

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

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???

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