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

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

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

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

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

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

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                                                                                                                              

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%)

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 50-500 mg/kg Unlikely toxicity <30mg/kg

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)

Can You Tell the Difference?? Castor oil Camphorated oil

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

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

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

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

Camphor Toxicity Management 1. ABCs

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

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

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

Camphor Toxicity 5. Antidotes? None

Camphor-containing mothballs Camphor Toxicity Camphor-containing mothballs

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

Mothball Identification WILL IT FLOAT??

Mothball Identification Camphor IT FLOATS!!

Mothball Identification Naphthalene IT SINKS!!!

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.

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

Thank You!

Questions???