Emergency Approach to Intoxications
Tim Hackett, DVM, MS, Diplomate ACVECC
Many compounds, when absorbed or ingested, can cause harm to
animals and people. Veterinarians are commonly faced with
companion animals that have been exposed to these harmful
compounds. Most po~sonings are the result of curious exploration
by the pet and a quest to taste everything in their path. Some
poisonings are the result of malice, and many simply result from
owner ignorance when pets are g~ven medications without regard
to dose or compatibility. It is the responsibility of the emergency
clinicia~ encountering these cases to prevent further exposure to
the poison, enhance its elimination, and provide supportive and
antidotal care. Antidotes when available are of little value if the
animal has lost any wtal functions. It ~sthe purpose of this article to
focus on the emergency management of intoxlcabons by
reviewing the general principles of triage and emergency care,
and to discuss available procedures to stop the exposure, prevent
further absorption, and hasten elimination of poisons from the
patients body.
Copyright © 2000 by W.B. Saunders Company
A poison is any substance that, when ingested, inhaled, or
absorbed, or when applied to, injected into, or developed
within the body, in relatively small amounts, by its chemical
action may cause damage to structure or disturbance of
function. A toxin is a type of poison; specifically it is a protein
produced by some higher plants, certain animals, and patho-
genic bacteria that is highly toxic to other living organisms.
Such substances are differentiated from the simple chemical
poisons and the vegetable alkaloids by their high molecular
weight and antigenicity.
Telephone Triage
When owners suspect a poisoning, their first impulse may be
to call your hospital for advice. Many times the pet may simply
be sick or nauseous from another medical problem and the
owner is grasping for possible causes. If the animal is showing
any abnormal symptoms, the owner should be instructed to
bring the animal to the hospital immediately, When talking to
pet owners suspecting a poisoning, make sure they protect
themselves from possible exposure to toxic chemicals. Try to
determine what the suspected poison is and how much may
have been ingested, but do not waste valuable time keeping the
owner on the phone. Do ask them to bring any containers with
them so that the exact poison can be determined.
Many owners will call veterinary hospitals for information
From the Veterinary Teaching Hospital, Colorado State University, Fort
Collins, CO.
Address reprint requests to Tim Hackett, DVM, MS, Department of
Clinical Sciences, Colorado State University, Fort Collins, CO 80523
E-mall: thackett @vth.colostate.edu
Copyright © 2000 by W.B. Saunders Company
1096-2867/00/1502-0006510.00/0
doi:l 0.1053/svms .2000.6807
82
about the possible toxic effects of household chemicals or
prescription drugs that an animal may have ingested. Do not be
embarrassed to say, "I don't know" when confronted with these
questions. There are tens of thousands of possible compounds.
Get the owner's name and number and contact a local poison
control office or veterinary poison center. Toxicological re-
sources are listed in Table 1.
Be cautious when recommending any treatment without
seeing the animal. If an animal has ingested a noncaustic
substance within the last 2 hours and is alert, emesis can be
induced. Syrup of ipecac or hydrogen peroxide may be used,
but these measures are best performed in the veterinary
hospital and should not be used unless transport is going to be
delayed for other reasons. Any animal that is obtunded, in
respiratory distress, depressed, seizing, or has ingested a
caustic (acid or alkali) substance or any petroleum product
should not be forced to vomit. Aspiration pneumonitis and
severe esophageal burns are serious, potentially life-threaten-
ing complications.
Initial Assessment
Any antidotal treatment is useless if vital organ function is lost.
Regardless of the type of poison, an initial assessment must be
made of cardiopulmonary and neurological function and
appropriate actions must be taken early to treat any problems
identified. Using the following ABC approach to any sick
animal will keep the emergency team focused on life-
threatening problems.
Airway. Be sure the animal has a patent airway. A qmck
oral exam and finger sweep can remove any obstruction.
Visually inspect the larynx for swelling or obstruction. If the
animal is obtunded, protect the airway by lntubatlon with a
low-pressure cuffed endotracheal tube.
Breathing. Is the animal breathing? Are the breaths of
adequate rate and depth? Is oxygen getting from the lungs into
the tissues? Observation, auscultation, and examination of the
mucous membranes can answer these questions. If the mucous
membranes are pale or cyanotic, supplemental oxygen should
be provided immediately.
Some poisons can cause respiratory depression and hypoven-
tilation. 1 Antiemetics such as apomorphine and xylazine can
also result in car&opulmonary depression. Simply supplement-
ing oxygen can correct the hypoxia associated with hypoventil-
ation; however, hypercarbia (Paco2 > 50 mm Hg) and respira-
tory acidosis may persist. A ventilator may be required to
support the patient until normal function returns. Arterial
blood gas analysis is required to identify hypoxia, hypoventila-
tion, and acid-base disturbances associated with altered respira-
tory function. Blood gas analysis can also help identify severe
metabolic disturbances associated with some toxins.
Circulation. Check pulse quality, heart rate, and rhythm. If
pulses feel weak or irregular, an electrocardiogram should be
Clinical Techmques in SmallAnlmalPractlce, Vo115, No 2 (May) 2000: pp 82-87
 TABLE 1. Veterinary and Human Toxicology Resources
Resource How to Contact
American Society for the Preven- (800) 548-2423 or (888) 4ANI-
tion of Cruelty to Animals--Na- HELP; http://www.napcc.asp-
tional Animal Poison Center ca.org, $30/case
(ASPCA-NAPCC)
AVMA Members Network of Animal http://avma.org
Health (NOAH)
Veterinary Information Network (800) 700-4636; via America Online
Keyword: VIN; from the internet
at http://www.vin.com
American Association of Poison http://www.aapcc.org/director2.htm
Control Centers (AAPCC) (comprehensive list of regional
poison control centers by name,
state, and country)
evaluated. A variety of arrhythmias can be seen with intoxica-
tions, and specific therapy may be necessary to treat pathologi-
cally slow or fast rhythms. 2 Patients in shock should have an
intravenous catheter placed, blood samples drawn, and fluids
ready to administer. If the heart rate is rapid and the pulse
quality weak and cardiac disease is unlikely, shock volumes of
crystalloid fluids should be given (90 mL/kg over 1 hour in a
dog, 40 m!_/kg in a cat). Reassessment is mandatory. Patients
should be continually reevaluated and therapy changed as
needed. With aggressive fluid therapy the heart rate should
slow, the pulses should become stronger, and organ perfusion
should improve. Clinically, the patient's color and capillary
refill should improve and the animal should act more alert.
Packed cell volume and total solids should be rechecked after
half of the total shock volume has been given. If the packed cell
volume has dropped below 25% to 30% whole blood, packed
red blood cells, or a hemoglobin-based colloid (Oxyglobin;
Biopure Corp, Cambridge, MA) may be needed. If the total
solids drop below 3.5 g/dL or less than half of the starting
value, consider a colloid such as plasma, hydroxyethyl starch,
or dextrans.
Neurological Complications
Partial or generalized seizures can be seen with a variety of
poisonings. Generalized (grand mal) seizures are the most
serious form and can result in severe hyperthermia, hypoxia,
metabolic acidosis, and permanent neurological injury. 3 Treat-
ment of severe convulsions or muscle fasciculation becomes an
emergency to prevent these complications. Diazepam (0.5
mg/kg intravenously [IV] or per rectum) is used to control
generalized seizures. When longer-term therapy is needed,
phenobarbital (6 mg/kg IV to effect) will provide prolonged
action. Methocarbamol (44 to 200 mg/kg IV) is indicated for
skeletal muscle relaxation with severe muscle fasciculation.l,3
Treatment Goals
Regardless of the poison, treatment goals are the same: (1)
prevent further exposure, (2) decrease absorption, (3) hasten
elimination, and (4) provide supportive care, and when
available, an antidote. 1,2,4 Removing poisons or preventing
their metabolism to more toxic compounds can prevent further
exposure. Thorough bathing for topical poisons and gastroin-
testinal decontamination for ingested poisons decrease absorp-
tion. Ion trapping is another technique for preventing absorp-
tion by maintaining substances in an ionic form less likely to
pass into systemic circulation. Elimination is hastened with
EMERGENCY APPROACH TO INTOXICATIONS
forced intravenous fluid diuresis, the administration of cathar-
tics to decrease intestinal tranmt, and potentially through the
use of either hemodialyms or peritoneal dialysis.l,2.4
Topical Poisons
To prevent further exposure and decrease the absorption of
topical poisons, the animal should be thoroughly bathed. Large
volumes of warm water and a mild detergent should be used to
completely remove toxic compounds from the skin and hair of
the animal# Acids or bases should not be neutralized because
the resulting chemical reaction could lead to local skin burns.
Instead, dilution, the pollution solution, should be instituted
with copious amounts of warm water. When bathing depressed
systematically ill animals, pay close attention to maintaining
body temperature and protecting the airway. Obtunded, recum-
bent patients can quickly become hypothermic.
If the poison is dry or powdered, it is better to brush or
vacuum the animal. Wetting dry compounds can make i t easier
for them to cross the skin and enter systemic circulation. With
dry poisons, care should be taken to keep the compound away
from the eyes and nose of the patient and the medical team.
Ingested Poisons
Gastrointestinal decontamination involves either emesis, gas-
tric lavage, or both followed by acuvated charcoal and a
cathartic. Gastrointestinal decontamination should be consid-
ered with nearly any suspected intoxication. Transit of stomach
contents usually takes about 2 hours. Gastrointestinal transit
time can vary with the quantity and type of food present in the
stomach. 6 If a patient has recently ingested any toxin, forced
emesis and gastric lavage are practical ways to remove the
toxin, preventing further exposure and decreasing absorption.
Emesis
Early emesis can be an effective way to remove 40% to 60% of
the contents of the stomach. 6 For animals presented soon after
ingesting a toxin, emesis is more effective than gastric lavage in
removing stomach contents. Emesis is also likely to be more
effective with large stomach volumes, larger food particles, or
thick mucus. Emesis is unlikely to be beneficial after 2 to 3
hours of ingesting a poison, r
For vomiting to occur, there must be enough material in the
stomach to forcibly expel. If an animal has ingested a small
amount of a toxic substance, feeding a low-fat gruel may be
beneficial. 1 Foods high in fat can enhance the absorption of
fat-soluble compounds such as organic pesticides.
Emesis should not be induced in depressed or weak patients;
the risk of aspiration is too great to justify the maneuver.
Patients that have ingested caustic compounds such as clean-
ing solutions, acids, or alkalis should not be forced to vomit. 2
These compounds can burn the esophagus, leading to the
formation of strictures. Caustic solutions should instead be
diluted with water or milk and activated charcoal solutions.
Petroleum products can be very viscous, so that emesis and
lavage can result in regurgitation, vomiting, and aspiration. 8
Activated charcoal may be indicated for significant ingestion of
kerosene and terpentme. In general, petroleum compounds are
poorly absorbed and pose little threat to life as long as they stay
out of the lungs. Care should be directed at avoiding aspira-
tion.
83
 Emetics commonly used in small animal practice include
morphine and apomorphine, syrup of ipecac, xylazine, hydro-
gen peroxide, salt, and mustard glycosides (Table 2).
Narcotics stimulate dopammergic receptors in the chemore-
ceptor trigger zone (CRTZ) and the emetic center. The effect of
narcotics at the emetic center is actually to inhibit emesis, so it
is important that these drugs reach the CRTZ before reaching
the emetic center. To accomplish this, apomorphine must be
absorbed quickly from either IV or intramuscular (IM) injec-
tion, because it is less reliable when absorbed through oral
administration.1 To titrate the effect of apomorphme, the tablet
can be crushed, mixed with water, and placed in the conjuncti-
val sac. Although slower and less effective than IV use,
protracted vomiting can be avoided by thoroughly washmg the
conjunctival sac when emesis occurs.
Xylazine is the emetic of choice in cats because It is more
reliable and potentially safer than narcotics. 1,2,4Like narcotics,
xylazine can depress both respiration and heart rate. Close
observation is necessary, and should signs of xylazine-mduced
respiratory depression or bradycardia occur, quick reversal
with yohimbine is in&cared.
Syrup of lpecac is an effective over-the-counter emetic that
causes local irritation to the gastric mucosa and can directly
stimulate the CRTZ when absorbed m sufficient quantity, lz
The alkaloids of ipecac can be toxic themselves, resulting in
&arrhea, cardiac arrhythmias, shock, and death. Toxicity can
be avmded by using the proper compound (7% ipecac in
glycerin--syrup of ipecac) and not using the more concen-
trated fluid extract of ipecac.
Hydrogen peroxide (H202 3%) may be effective aloone, but
can be used with apomorphine if initially unsuccessful. A
second dose can be given within 10 minute if no emesis has
occurred. 2
Table salt, liquid dish detergent, and mustard alkaloids
directly irritate the pharyngeal mucosa but are not reliable
emeucs when compared with the other products previously
discussed. Repeated doses of dry salt can lead to an iatrogenic
hypernatremia and should be avoided.
Gastric Lavage
As with emesis, gastric lavage is only going to be effective early
in the management of intoxication. 6 With stomach transit, the
recovery rate decreases as more time elapses. In one study, only
8% of barium sulfate was recovered 60 minutes after adminis-
TABLE 2. Emetics Used in Small Animal Emergency
Practice
Antlemettc Dose
Apomorphine Dogs, 0.03 mg/kg IV, 0.04 mg/kg IM, or place 1/4 to
1 whole 6-mg tablet in the conjuncttval sac and
dtssolve using ophthalmtc trngating solution.
Thoroughly flush the remammg tablet from the
eye when emesis begms
Xylazme Dogs, 1.1-2 2 mg/kg IM. Cats, 0.44 mg/kg IM or
SC. Reverse wtth yohtmbme 0.11 mg/kg iV or
0.25 mg/kg SC ~fsevere respiratory depresston
or bradycardia occurs.
Syrup of ipecac Dogs, 1 to 2.5 mL/kg PO. Cats, 3~3 mL/kg PO
(7% tpecac) (dtluted 50 50 with water wtll make tt less objec-
bonable for cats).
Hydrogen peroxide Dogs and cats, 1 to 2 mL/kg PO.
(3% H202)
Abbrevtations SC, subcutaneously, PO, orally.
84.
tration, r Gastric lavage is performed using a large-bore, fenes-
trated stomach tube and large volumes of tepid water. The
larger the tube, the better the yield and the more effective the
lavage. The tube should be premeasured from the mouth to the
last nb and marked (Fig 1A). The patient should be sedated or
anesthetized and the airway protected with a cuffed endotra-
cheal tube. The tube is placed in the esophagus to the level of
the last rib (premarked) (Fig 1B). Placement in the stomach is
confirmed by ausculting noises in the stomach while someone
blows into the tube. Instill warmed water slowly, watching for
signs of respiratory distress. Water is instilled and removed
gently until the returning water is clear and free of debns (Fig
2). Volumes of 5 to 10 mL/kg should be instilled at each
exchange. Stomach contents should be saved in plastic and
refrigerated until a decision is made regarding toxicological
testing.
Activated Charcoal
Activated charcoal is an excellent absorbent for the great
majority of toxic substances ingested by small animals. 1
Destructive distillation and oxidizatlon of the charcoal residue
produce activated charcoal with gas at high temperature and
low pH. The final product has pores, which increases the
binding surface area. The large pores on the activated charcoal
stick to ingested material in a nonspecific manner, which
makes it an effective treatment for almost any intoxication.
Keep in mind that these pores will fill with anything so
activated charcoal products should not be mixed with food.
Food will occupy binding sites on the activated charcoal,
decreasing its efficacy.
Alcohols (ethanol, methanol, and ethylene glycol) are not
well absorbed by activated charcoal. 2 Acid and alkali solunons
also are not well absorbed. Activated charcoal not only does
not bind these compounds well, but also may interfere with
more important dilutional therapy (water or milk).
Premixed activated charcoal products often contain a cathar-
tic (sorbitol is used most commonly) to speed the transit of
material through the gastrointestinal tract. Other cathartics
include sodium sulfate (Glauber's salt) and magnesium sulfate
(epsom salt). Caution is advised when using magnesium-
containing cathartics in patients with renal insufficiency and
may worsen central nervous system depression in these
patients. 2
Activated charcoal can be given by orogastric tube after
gastric lavage, or by force feeding in alert patients. Activated
charcoal is often repeated with toxins eliminated through
hepatic metabolism. Enterohepatic circulation occurs when
toxins eliminated in the bile are reabsorbed by the small
intestine. Repeating the activated charcoal can interrupt this
cycling3
Fluid Diuresis
In addition to maintaining cardiac output and tissue oxygen
delivery, intravenous fluid therapy will hasten the elimination
of many poisons through the kidney and urine. 2,4 Crystalloid
fluids given at a rate high enough to result in urine production
of at least 2 mlJkg/h will optimize glomerular filtration and the
clearance of many poisons. These high fluid rates can lead to
signs of fluid overload. Central venous pressure (CVP) offers
an objective measure of the compliance of the right-sided
HACKETT
 mouth last rib

A
r

mark
length with
tape

\~-,'...,., .?.' ~; ,;,;/,:.,..

. . . . _

/
Fig 1. (A) A large-bore stomach tube is premeasured from the mouth to the level of the patient's last rib and marked. (B) The
stomach tube is gently advanced to the level of the mark. Gastric intubation is confirmed by ausculting the stomach while
blowing into the tube. The stomach tube is then connected to a stomach pump. If the patient is recumbent, unconscious, or
unable to swallow, a cuffed endotracheal tube should be placed to protect the airway.

circulation. When the CVP is less than 5 c m H 2 0 , the patient is
tolerating the fluid load; higher values should alert the
clinician to possible fluid overload. Volume overload to the left
side of the heart is harder to measure objecuvely. Pulmonary
arterial catheters are not very practical. Serial thoracic ausculta-
tion for the presence of pulmonary edema should be performed
frequently so that fluid rates can be adjusted and diuretics
administered before an iatrogenic pulmonary edema becomes a
problem.
Ion trapping takes advantage of the fact that the ionic form
of weak acids and bases will not cross cellular membranes.
Ammonium chloride, an acidifying compound, can trap weak
bases such as strychnine in the urine. Alkalinization with
sodium bicarbonate may be useful in eliminating weak acids
such as salicylates and ethylene glycol.l,2
Dialysis
Small water-soluble drugs and poisons with low protein
binding are ideally suited for removal by dialysis. 9,1° Some of

EMERGENCY APPROACH TO INTOXICATIONS 85

 ::-:-.

• ~' ~,--

,;;'// I

r0.5

c: ,'/ tti
water~ /1~ ered
stomach
contents

Fig 2. Two buckets are placed below the patient: one containing warm water and the other empty, for recovery of stomach
contents. Small volumes of the warm water are gently pumped into the stomach. The tube is then moved to the empty bucket,
and fluid and stomach contents are drained. This process is repeated until recovered fluid returns clear.

these compounds (eg, ethylene glycol) are not readily bound
by activated charcoal so that dialysis is an alternative worthy of
serious considerauon by the emergency clinician. Dialyzable
drugs and poisons are listed in Table 3.
Although hemodialysis is now being used successfully in
veterinary medicine, the personnel, expertise, and equipment
required limit its use to specialized referral institutions.
Peritoneal dialysis involves relatively simple equipment, and
although time consuming, can be performed in almost any
practice.
Peritoneal dialysis involves the use of a &alysate solution
cycled through the peritoneal cavity through a catheter. 9 It is
used to remove excess solutes from the plasma to the dialysate
TABLE 3. Drugs and Compounds Readily Removed
by Dialysis
Dlalyzable Compounds
Barbiturates
Boric acid
Bromide
Ethanol
Ethylene glycol
Gentam~cm
Methanol
Salicychcacid
Theophylline
across the peritoneal membrane. Dialysate contains physiologi-
cal concentrations of electrolytes and varying concentrations
of dextrose. Waste products move across the vascular, semiper-
meable peritoneal membrane into the dialysate along a concen-
tration gradient. Frequent exchanges result in the removal of
these products from the body. In addiuon to treating acute
oliguric and anurlc renal failure, early peritoneal dialysis will
assist in the removal of dialyzable toxins. 2,9
Dialysate is commercially available but can be made easily by
adding dextrose to balanced crystalloid fluid solutions. Com-
mercial dialysate typically comes in 2- to 5-L bags. Dextrose is
added to these solutions to make concentrations of 1.5%, 2.5%,
and 4.25%. The higher-concentration solutions are used m
overhydrated patients, and the 1.5% solution is used in
normovolemic animals. Heparin is added at 1000 U/L of
dialysate for the first 2 days of dialysis. This should limit
catheter occlusion by the deposition of fibrin. If commercially
prepared dialysate is unavailable, dextrose can be added to
lactated Ringer's solunon to create a suitable substitute. Lac-
tated Ringer's solution is preferred because it contains lactate
instead of acetate, which can decrease uhrafihration over
time. 9 Because lactated Ringer's solution does not contain
magnesium, this electrolyte should be added to the dialysate or
to any parental crystalloid fluid.
Peritoneal dialysis catheters can be simple feeding tubes or

86 HACKETT
 nism. 11a2 Specific poisons with antidotes are summarized in
TABLE 4. Poisons Common to Small Animal Emergency
Medicine, Specific Antidotes, and Dosages Table 4.

Toxin Antidote Dose

Supportive Care
Acetaminophen N-acetylcysteme 140 mg/kg IV loading
(Mucosil-20; Dey dose followed by 70 Many toxins result in respiratory and cardiovascular depres-
Laboratories, Napa, mg/kg IV or PO stun. Patients should be continually monitored for adequate
CA) every 4 h for 5
doses oxygenation and ventilation. Arterial blood gas analysis, pulse
Anticoagulant rodentl- Vitamin K1 2 5-5 mg/kg PO oximetry, and close attention to mucous membrane color
cide should all be performed in recumbent patients.l,2.4
Chohnerglcs (organo- Atropine 0 2-5 mg/kv IV, IM, SC
phosphates) Prahdoxlme chloride PRN
Body temperature can fluctuate in these patients, and every
(2-PAM; Protopam, 20 mg/kg every 8-12 h effort should be made to keep the patient warm while
Ayerst Laboratories, slow IV or IM preventing iatrogenic hyperthermia. Depressed, obtunded,
New York, NY)
Cholcalciferol Calcltonln 4-6 IU/kg SC every 2-3
debilitated patients should be turned at regular intervals to
h until serum cal- prevent pulmonary atelectasis and pressure sores.
cium is normal A closed urine collection system should be used to assess
Ethylene glycol Ethanol 5% Dogs 22 mL/kg IV
every 4 h for 24 h, urme output and prevent soiling. Urine production less than 1
then every 6 h for mL/kg/h suggest either inadequate fluid therapy or early renal
the next 24 h failure. Close attention to this objective value will alert the
Cats: 5 mL/kg/h CRI
4-methylpyrazole Dogs: 20 mg/kg IV
clinician to serious renal problems while they may still be
(Fomepizole, Anti- initially, then 15 corrected.
zoI-Vet; Orphan mg/kg IV at 12 and Changes in packed cell volume and total serum sohds may
Medical, Min- 24 h, then 5 mg/kg
netonka, MN) IV at 36 h. Not for require blood transfusion or other colloid support. To maxi-
use in cats. mize oxygen delivery, the hemoglobin concentration, intravas-
Lead, arsenic, and Dimercaprol (BAL) 4 mg/kg IM every 4 h cular volume, and cardiac output should be optimized. Fluids
mercury d-Penicillamlne 10-15 mg/kg PO every
12h should be changed based on serum electrolytes, total solids,
Dimercaptosucclnlc 10 mg/kg PO TID packed cell volume, and hemoglobin concentration to opti-
acid (Chemet, Suc- mize oxygen delivery to the tissues.
clmer; McNeil Con-
sumer Products,
Once everything has been done to prevent absorption and
Fort Washington, hasten elimination of any poison, intensive monitoring and
PA) attentive nursing care will provide the patient the time needed
Opioids Naloxone 0 01-0.04 mg/kg IV,
IM, SC PRN
to recover from the toxic insult.

Abbreviations: PO, orally; SC, subcutaneously; PRN, as needed CRI,

continuous rate infusion; TID, three times per day.
chest tubes. Specialized curled fenestrated tubing and column
disk catheters have also been used, although one of these, the
column disk catheter, is no longer commercially available. 9 For
successful, long-term dialysis, the catheter should be placed
surgically. Surgical placement allows for renal biopsy (if
indicated), and more importantly, a partial omentectomy. By
removing the omentum, catheter patency can be maintained
longer.
Advances in the design of the peritoneal &alysis catheter
and the introduction of a new, fluted-T dialysis catheter make
obstruction and hypoalbuminemia less of a concern and have
added a valuable tool to the treatment of certain types of
intoxication. 10
Antidotes
Antidotes are therapeutic agents capable of counteracting the
effects of toxins. They act by a variety of mechanisms:
competition with toxins for target sites or metabolic pathways,
neutralizanon of toxins by specific antibodies or chelating
agents, enhancement of poison elimination or detoxification
by excretion and metabolism, and physiological antago-
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EMERGENCY APPROACH TO INTOXICATIONS 87