A 2 Year Old who Presents with Seizures: What’s that Smell?
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A 2 Year Old who Presents with A 2 Year Old who Presents with Seizures: What’s that Smell?Seizures: What’s that Smell?
Suzan Mazor, MDFellow, Toxicology
Toxikon Consortium, Cook CountyPediatric Emergency Medicine
Children’s Memorial Hospital, Chicago
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Suzan Mazor, MD
Case PresentationCase 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
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Suzan Mazor, MD
Physical ExamPhysical 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
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Suzan Mazor, MD
Differential DiagnosisDifferential Diagnosis
• What is this smell?
• Smells in toxicology• Bitter almond • Garlic• Rotten eggs• Newly mown hay
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Suzan Mazor, MD
Differential DiagnosisDifferential Diagnosis
• What is this smell?
• Smells in toxicology• Bitter almond ……..Cyanide• Garlic …...………….Arsenic• Rotten eggs………..Hydrogen sulfide• Newly mown hay….Phosgene
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Suzan Mazor, MD
CamphorCamphor
• 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
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Suzan Mazor, MD
CamphorCamphor• 1983: FDA banned sale of oils with > 11%
camphor• Products with higher concentrations still
available • Canada, Australia, China• Still used as liniment, herbal remedy
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Suzan Mazor, MD
Camphor 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%)
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Suzan Mazor, MD
CamphorCamphor• 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
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Suzan Mazor, MD
CamphorCamphor• 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)
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Suzan Mazor, MD
Can You Tell the Difference??Can You Tell the Difference??
Camphorated oil Castor oil
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Suzan Mazor, MD
CamphorCamphor• 2001 AAPCC TESS DATA
• 8505 Exposures• 6,518 < 6 years old• 89 moderate-severe symptoms, no deaths
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Suzan Mazor, MD
Camphor ToxicityCamphor 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
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Suzan Mazor, MD
Camphor ToxicityCamphor 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
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Suzan Mazor, MD
CamphorCamphor
Management 1. A,B,C’s2. Seizure management3. Decontamination4. Enhanced elimination5. Antidotes
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity• Management
1. ABCs
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity• Management
2. Seizure management• Benzodiazepines• Barbiturates• Propofol• What about Phenytoin?
• Usually does not work for toxin induced seizures
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Suzan Mazor, MD
Camphor ToxicityCamphor 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
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
4. Hemodialysis + charcoal hemoperfusion• Lipid dialysate• Successful in case reports, no controlled
studies• Not widely available
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
5. Antidotes?• None
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Suzan Mazor, MD
Camphor ToxicityCamphor Toxicity
Camphor-containing mothballs
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Suzan Mazor, MD
• Naphthalene• Metabolized to naphthols and
naptholoquinone• Oxidants• Hemolysis and methemoglobinemia
• Caution with G6PD deficiency
Other Types of MothballsOther Types of Mothballs
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Suzan Mazor, MD
Mothball IdentificationMothball Identification
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Suzan Mazor, MD
Mothball IdentificationMothball Identification• Camphor
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Suzan Mazor, MD
Mothball IdentificationMothball Identification• Naphthalene
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Suzan Mazor, MD
Case CourseCase 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.
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Suzan Mazor, MD
Teaching PointsTeaching Points• Camphorated oils, medications,
mothballs may cause rapid onset of vomiting, seizures, altered mental status
• Naphthalene in mothballs may cause hemolysis, methemoglobinemia
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Suzan Mazor, MD
Thank You!Thank You!
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Questions???Questions???