|
Key Questions Introduction References
Patient Outcome Annotated
Bibliography Questions A
2 Year Old who Presents with Seizures: Case Presentation A 3 year-old female is presented to the ED with a generalized tonic clonic seizure. The child had been previously well, but had a recent upper respiratory infection. She was being administered an over the counter cold remedy. At home, she had an abrupt onset of vomiting, followed by a seizure within 30 minutes. 2 doses of lorazepam were given, followed by an IV load of phenobarbital, after which the seizure stopped. Physical exam revealed a temperature of 38 degrees centigrade, pulse 126, respirations 28, blood pressure 96/palp and oxygen saturation 99% on 100 % oxygen. The child was somnolent and lethargic. There was an aromatic "mothball" odor on the breath. Pulmonary, cardiac, and abdominal examinations were within normal limits. She could localize to painful stimuli and demonstrated spontaneous eye opening and movements. Routine laboratory investigations, including basic chemistries, glucose, CBC and lumbar puncture were all within normal limits. A
2 Year Old who Presents with Seizures: Key Clinical Questions:
Key Learning Points
A
2 Year Old who Presents with Seizures: Background, Risk factors and Epidemiology According to 2001 data from the American Association of Poison Control Centers Toxic Exposure Surveillance System (TESS), there were 8,505 exposures to camphor-containing products. Of these, there were 89 moderate to severe outcomes, and no deaths.(1) In 1983, the FDA banned the sale of oils containing > 11% camphor, but products with higher concentrations are still available in other countries. (2) Common camphor containing products include mothballs, antiseptics, muscle liniments, and cold remedies. Most camphor poisoning result from ingestion of camphorated oil when it is mistaken for another medication (castor oil). There have been case reports of toxicity due to ingestion, dermal, intranasal, intraperitoneal and transplacental administration of camphor.(2-5)
Camphor is synthesized from the hydrocarbon pinene, a turpentine derivative. It causes CNS depression and seizures, and its mechanism of action is unknown. (2)
Patients with camphor toxicity emit a characteristic aromatic odor. Symptoms begin abruptly, 5-90 minutes post-ingestion, and consist of emesis, seizures and CNS depression.(2,3)
Routine laboratory workup of seizures, including serum electrolytes, calcium and glucose, and head CT if indicated, should be considered. Camphor and its metabolites can be measured in blood or urine, however, levels are not available in real-time, and levels do not correlate with symptoms.(2,3)
As with all patients, attention to the ABCs is of foremost importance. Benzodiazepines should be first-line agents used for seizures. If benzodiazepines are unsuccessful, barbiturates may also be used. Phenytoin is not recommended for toxin-induced seizures. The skin of a patient with
dermal exposure should be irrigated. Ipecac is contraindicated, due to
potential for rapid deterioration of mental status. Gastric lavage may
be considered if the patient presents soon after ingestion. Activated
charcoal may be effective; its efficacy remains unstudied. Hemodialysis
(with a lipid dialysate) and charcoal hemoperfusion have been used for
camphor toxicity, with varying results.(6) These modalities are not widely
available, and not currently recommended. There is no specific antidote
for camphor poisoning.(2,3) Patients presenting with significant
toxicity from camphor ingestion should be admitted to a monitored setting.
Consultation with a medical toxicologist through a regional poison center
may be helpful to guide therapy.
A
2 Year Old who Presents with Seizures: Patient Outcome Diagnosis: Camphor Toxicity The child had been found
2 hours prior to presentation with an open jar of Vicks Vapo-rub. It
was estimated that approximately 1 tablespoon was missing (1 tablespoon
contains 0.7 grams of camphor). No further seizures occurred. The child's
lethargy resolved over the next 24 hours and she was discharged.
1. Initial management of patients presenting with camphor overdose should include all of the following except?
2. Which of the following physical properties can differentiate camphor from naphthalene?
3. In 1983, the FDA banned products containing greater than what percent camphor?
4. Which of the following statements is true regarding naphthalene?
5. Common camphor containing products include:
1. Answer d. 2. Answer d. 3. Answer b. 4. Answer c. 5. Answer e. |