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

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

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

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  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 • = 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

  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 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???

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