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, MD

Fellow, Toxicology

Toxikon Consortium, Cook County

Pediatric Emergency Medicine

Children’s Memorial Hospital, Chicago

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

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

Suzan Mazor, MD

Differential DiagnosisDifferential Diagnosis

• What is this smell?

• Smells in toxicology• Bitter almond • Garlic• Rotten eggs• Newly mown hay

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

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

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

                                                              

                                                              

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%)

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

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)

Suzan Mazor, MD

Can You Tell the Difference??Can You Tell the Difference??

Camphorated oil Castor oil

Suzan Mazor, MD

CamphorCamphor

• 2001 AAPCC TESS DATA• 8505 Exposures

• 6,518 < 6 years old• 89 moderate-severe symptoms, no deaths

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

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

Suzan Mazor, MD

CamphorCamphor

Management 1. A,B,C’s

2. Seizure management

3. Decontamination

4. Enhanced elimination

5. Antidotes

Suzan Mazor, MD

Camphor ToxicityCamphor Toxicity

• Management1. ABCs

Suzan Mazor, MD

Camphor ToxicityCamphor Toxicity

• Management2. Seizure management

• Benzodiazepines• Barbiturates• Propofol• What about Phenytoin?

• Usually does not work for toxin induced seizures

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

Suzan Mazor, MD

Camphor ToxicityCamphor Toxicity

4. Hemodialysis + charcoal hemoperfusion• Lipid dialysate• Successful in case reports, no controlled

studies• Not widely available

Suzan Mazor, MD

Camphor ToxicityCamphor Toxicity

5. Antidotes?• None

Suzan Mazor, MD

Camphor ToxicityCamphor Toxicity

Camphor-containing mothballs

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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Mothball IdentificationMothball Identification

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Mothball IdentificationMothball Identification

• Camphor

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Mothball IdentificationMothball Identification

• Naphthalene

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.

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

Suzan Mazor, MD

Thank You!Thank You!

Questions???Questions???