Download Toxins in Small Animal Medicine

Toxins
in
Small Animal Medicine
Stacy Simmonds, DVM, DACVECC
Top 10 Toxins
2014
ASPCA
Pet Poison Hotline
1.
Human Medications
1.
Chocolate
2.
OTC medications
2.
Rodenticide
3.
Insecticides
3.
Ibuprofen/Acetaminophen
4.
Household items
4.
Insecticidal Products
5.
Human foods
5.
Xylitol
6.
Veterinary medications
6.
Household cleaners
7.
Chocolate
7.
Antidepressants
8.
Plants
8.
Fertilizers and Plant Food
9.
Rodenticide
9.
Grapes and Raisins
10. Home and Garden
10. De-wormer products
Lecture Topics
•
•
Chocolate
•
Xylitol
Human anti-inflammatory
medications
•
Tremorgenic mycotoxins
•
Antidepressant medications
•
Pyrethrins
•
Sympathomimetic drugs
•
Batteries
•
Ethylene glycol
•
Toxins grouped by clinical signs
•
Lily plants
•
Low toxicity substances
•
Rodenticides
•
Options for
decontamination
Be Sure to Ask!
• Do you have original container
• More than one active ingredient?
• Was it an extended release product?
• What is the possible timeframe of ingestion?
• What was the potential lowest vs highest dose
ingested?
• Has your pet vomited?
• How was your pet acting at home?
Dermal Decontamination
•
Water soluble toxicants - Insecticide/pesticide
• Bathe with dishwashing detergent (Dawn)
• Oily or Sticky substances (tar, glue, gum)
• Avoid solvents (gasoline, turpentine)
• Trim affected hair coat
• Vegetable oil, mineral oil, peanut butter – rub into hair
coat until little ‘gummy balls’ develop – then rinse with
detergent
Oral Decontamination
• Insoluble calcium oxalates - philodendron,
dieffenbachia, calla lily, etc
Ourhouseplants.com
• Dilute with milk, yogurt, cottage cheese
• Irritants or Corrosives: lye, drain cleaners, detergents,
bleach, chewed batteries
• 2-6 ml/kg water or milk
Greengardening.com
Wikipedia.org
Emesis
• Dogs, cats, ferrets, pot-bellied pigs
• Potential side effects:
•
•
•
•
•
Apomorphine – CNS depression
Protracted vomiting
Aspiration pneumonia
Gastritis
Increased vagal tone
Myassistancedog.org
Emesis Timing
• Best results if administered within one hour
• Recovery < 80%
• Delayed emesis induction (4-6 hours):
• Salicylates, opiods, anticholinergics, tricyclic
antidepressants, iron tablets, sugar coated substances
• Large amounts of xylitol
• Grapes/raisins/chocolate
• Small moist meal prior to emesis
may improve results
Fastcodesigns.com
Emesis Contraindications
• Species: rabbits, rodents
• Already symptomatic
• Underlying medical concerns:
• History of laryngeal paralysis,
megaesophagus, brachycephalic syndrome
Mysticcat.sg
• Contraindicated toxins:
• Corrosives, acids: lye, bleach, batteries, oven cleaners
• Hydrocarbons/petroleum distillates: tiki-torch oil,
gasoline, kerosene, mineral spirits, furniture polish oils
Emesis Techniques
Apomorphine
• Stimulates dopamine receptors on CRTZ zone
• Mean time of emesis – 18 minutes
• Side effects:
• Protracted vomiting (IM administration)
• CNS depression
Wedgewoodpetrx.com
• Plumb’s Dose for Dogs:
• 0.03 mg/kg IV; 0.04 mg/kg IM
• or crush a tablet and dissolve in saline (0.9% NaCl) solution, instill in
the conjunctival sac, and rinse away after emesis
• Dissolve one 6 mg tab in 6 cc sterile water water then place in 1ml tubes
with a filter and freeze; thaw and give 0.3mg/kg IV
Emesis Techniques
3% Hydrogen Peroxide
• Not first line method and for some contraindicated
• Cats: “generally not recommended” due to hemorrhagic
gastritis and/or esophagitis
• Use: Delayed evaluation by a veterinarian
• Mechanism of action: thought to be gastric irritation
• Dose: (extra-label): 2.2 mL/kg PO
• After 10 -15 minutes – can repeat dose once
• Or 1 tsp/5 lbs with max of 3 tablespoons if >45 lbs
Emesis Techniques
Cats
• Dexmedetomidine -VIN doses:
•
•
•
•
1-2 ug/kg IM
40 ug/cat IM (Plumb’s sedation dose)
0.1ml/cat IM
Side effects
• respiratory depression, bradycardia, hypertension
• Atipamezole
• Xylazine 0.44 mg/kg: (Plumbs – extra label):
• 1.1 mg/kg IM or SQ
• 0.44 mg/kg IM
• Side effects:
• respiratory depression, bradycardia, and hypotension.
• Yohimbine
Conciouscat.net
Assessment of dexmedetomidine and other agents for
emesis induction in cats: 43 cases (2009-2014)
V. Thawley; JAVMA: December 2015
• Hydrogen peroxide (3), Xylazine (25), Demedetomidine (16)
• Emesis effectiveness:
• Hydrogen peroxide: 0/3
• Xylazine: 11/25 - 44%
• Demedetomidine: 13/16 - 95%
• Dose range:
• Xylazine: 0.4-0.5 mg/kg
• Dexmedetomidine: 0.96 – 10 mcg/kg
• Side effects: sedation
• Suggested dosing for feline emesis:
• Dexmedetomidine 7.0 mcg/kg IM
• Dexmedetomidine 3.5 mcg/kg IV
Emesis Techniques
Not recommended
• Syrup of ipecac
• Salt
• Dry powdered mustard
• Liquid dish detergent
• Digital induction
www.pe.com
Gastric Lavage
Indications:
•
Emesis has failed or is
contraindicated
•
Severe
organophosphate/carbamate
toxicosis
•
Severe metaldehyde or
tremorgenic mycotoxin toxicosis
•
Ivermectin ingestion
•
Sago palm ingestion
•
Bromethalin ingestion
• May have poorer recovery of
gastric contents than emesis
• Contraindications:
• Caustic or corrosive substance
ingestion
• Hydrocarbons
Activated Charcoal
• Increases surface area for toxin
• Most effective within 1 hour of toxin ingestion
• Poor binding with:
• ‘ols’ – alcohol, ethylene glycol, xylitol
• Metals – ferrous sulfate, lithium, zinc
• FIRST dose: sorbitol as cathartic
• Cathartics enhance delivery through GI tract
• Dose: 1 – 5 grams/kg – 2 g/kg is “standard”
• Enterohepatic circulation: ½ original dose every 6-8 hours
• Risks
• Aspiration pneumonia
• Electrolyte abnormalities
Shopmedvet.com
** DVM 360.com When and How
to Give Activated Charcoal, Justine
Lee, DACVECC, DABT; 2013
Fluid diuresis
• Goal: maintain renal perfusion and maintain hydration
• Does not enhance excretion of toxins more quickly
Na+ mmol/L
Cl- mmol/L
K+ mmol/L
Ca++ mmol/L
pH
0.9% NaCl
154
154
LRS
130
109
4
P-lyte 148
140
98
5
5.5
140
98
5
7.4
5.0
~3
6.5
Norm R
P-lyte A
Intravenous Lipid Emulsion
Therapy
• Potential mechanism(s):
• Lipid sink
• Improve cardiac performance in cardiotoxic drug overdoses
• USE: Hasten recovery in toxicities related to fat-soluble
compounds
• 20% Intravenous lipid emulsion:
• 1.5 ml/kg IV bolus over 1-2 mins then 0.25ml/kg/min CRI x 30-60
mins
• Can repeat bolus but check peripheral blood sample for lipemia
• Max dose suggested: 8ml/kg/day
Intravenous Lipid Emulsion
Therapy
• Baclofen
• Ivermectin
• Permethrin
• Local anesthetics
• Calcium channel blockers
• NSAIDs
Intravenous Lipid Emulsion
Therapy
• Potential side effects:
• Phlebitis
• Intravascular hemolysis
• Hyperlipidemia/Pancreatitis
• Management:
• Dedicated IV line
• Sterile administration set
• Central line not necessary
Anti-inflammatory medications
(Human)
• Naproxen (Aleve®)
• Ibuprofen (Motrin®)
• Acetaminophen (Tylenol®)
Non-steroidal Anti-inflammatory
medications
• Inhibit conversion of arachidonic acid to prostaglandins
• Prostaglandins:
•
•
•
•
Maintain protective mucous layer in GI tract
Maintain normal blood flow to gastric mucosa
Maintain afferent arteriolar blood flow
Supports normal platelet function
• General treatment:
• Decontamination and fluid diuresis
• GI protectants: Misoprostol, Carafate, Prilosec
• Enterohepatic recirculation:
• Repeated charcoal doses
• Cholestyramine
Emcrit.com
Non-steroidal Anti-inflammatory medications
Naproxen (Aleve®)
• Tablet size: 200 mg and higher
• Dogs
• > 5mg/kg – GI
• > 10 - 25 mg/kg – acute renal failure
• > 50 mg/kg – CNS signs
• Cats
• Any dose is potentially toxic (GI and renal)
• Long ½ life • Multiple doses of charcoal
• IV fluids x 72 hours at 2 x maintenance
• GI protectants x 2 weeks post hospital discharge
Non-steroidal Anti-inflammatory medications
Ibuprofen
•
Tablet size: 200mg, 800mg, 1000mg
•
Dogs:
• ~25 – 50 mg/kg : GI
• >125mg/kg: renal
• > 400mg/kg: CNS
•
Cats:
• >87mg/kg: renal toxicity
•
Treatment:
• Repeated doses of charcoal
• IV fluids x 48 hours
• Misoprostol x 3 days
•
Evaluate chemistry at baseline, 36, 48, 72 hours
•
GI protectants x 2 weeks (Carafate, Prilosec)
Non-steroidal Anti-inflammatory medications
Acetaminophen
• Therapeutic dose in dogs: extralabel: 10-15 mg/kg
• Toxic dose in dogs: > 100 mg/kg – ADR, GI signs
• Recovery time is dose dependent
• > 100mg/kg: Hepatic disease/necrosis
• > 200mg/kg: methemoglobinemia, heinz body hemolytic anemia; KCS
• May take 36-48 hours to appreciate elevated liver values
• Treatment
• * Cimetidine no longer recommended
• SAM-E 20mg/kg
• Vitamin C: 20 – 30 mg/kg PO every 4 -8 hours ~ 3 days
• Methylene blue: not needed if NAC administered; don’t give pre-emptively
Non-steroidal Anti-inflammatory medications
Acetaminophen
• All doses toxic in cats
• More likely to develop methemoglobinemia
Adelaidevet.com
• Usually seen within 2-4 hours
• Heinz body anemia
• Hepatotoxicity
• If no clinical or clin path signs in 36-48 hours, not likely
to develop complications.
N-acetylcysteine
(NAC, Mucomyst)
• Ideally started within 16 hours of acetaminophen
exposure
• Oral: should be diluted to 5% when given orally due to
corrosive injury
• IV: dilute to 5% and give 140mg/kg IV followed by
70mg/kg q 6 hours x 7 treatment.
• Use bacteriostatic filter and consider pre-dose with
Benadryl
Cholestyramine
• MOA: binds bile acids which are then removed via feces
and not reabsorbed
• Toxin Indications:
• Enterohepatic circulation
• Vitamin D, Naproxen, Indomethacin,
Diclofenac, sago palm
Piroxicam,
• Consider charcoal alternating with Cholestyramine 4
hours later – varies with toxin and patient case
Serotonin Syndrome
Overdose vs. Drug interactions
•
Clinical signs: initially sedation followed by agitation, disorientation,
hyperactivity, vocalization, vomiting/diarrhea, tachycardia, hyperthermia,
muscle tremors, hyperesthesia, seizures
•
Human prescription medications
• SSRI’s, SNRI, MAOI’s, TCA, antipsychotics
•
Veterinary medications
• Fluoxetine, Clomipramine, Mirtazapine, Tramadol
•
Illicit drugs
• Amphetamines, NMDA agonists
•
Holistic supplements
• Serotonin
• 5 hydroxytryptophan (5 HTP)
Serotonin Syndrome
Treatment
•
Serotonin antagonists:
• Cyproheptadine:
• Dog - 1.1 mg/kg PO or PR and Cat – 2 – 4 mg PO
• Phenothiazines – non-selective serotonin antagonists
• Acepromazine 0.03-0.1 mg/kg (not more than 3 mg/day)
• Chlorpromazine 0.5mg/kg IM or IV
•
Manage tremors:
• Methocarbamol
•
Seizures
• Diazepam
• Anticonvulsants
•
Cardiovascular abnormalities
• Propanolol for sustained tachycardia or HTN
• Atropine for bradycardia
Healthtap.com
Differential for SSRI’s
•
Sleep medications (zolpidem)
•
Illicit drugs
•
Wild mushrooms
•
Tremorgenic mycotoxins (compost/moldy food)
•
Opiods
•
Sympathomimetics
•
Insecticides (carbamates/organophosphates)
•
Rodenticides (bromethalin, zinc phosphide)
•
Metaldehyde
•
Other metabolic causes
Effexor®
Venlafaxine
• Cats seem to like venlafaxine
• Clinical signs: ~ 2 mg/kg
• Mydriasis, vomiting, tachypnea, tachycardia, ataxia, agitation
• TX: emesis in asymptomatic patients
• AC if extended release formulation
• Monitor HR and BP
• Antagonizing serotonin effects
• Cyproheptadine
• Acepromazine
• Lipid emulsion therapy since lipid soluble
Sympathomimetics
• Amphetamines (adderall), Methamphetamines
(crystal meth), MDMA (ecstasy), Pseudoephedrine,
phenolpropalnolamine, ephedrine, ma huange
• Treat with phenothiazines and barbituates
• Diazepam can increase morbidity and mortality
•
Consider Cyproheptadine
• Elevated BP or agitated
• Consider Ace or Torbugesic
Urine Drug Tests
Consider Cyproheptadine
•
Drug interactions where cyprohepatadine may help without pharmacologic
basis.
•
SSRI’s
•
Tricyclic antidepressants
•
Monoamine oxidase inhibitors
•
Amphetamines
•
Pseudoephedrine
•
Phenylpropanolamine
•
Baclofen
•
Drug combinations – Tramadol and Antidepressants
Ethylene Glycol
• Antifreeze
• Recreational vehicles
• Brake fluids
• Paints
• De-icers
• Cleaners
• Condensers
• Solvents
• Home solar units
• Portable basket ball post
bases
Ethylene Glycol
•
Ethylene glycol 
glycoaldehyde in the liver by
the enzyme alcohol
dehydrogenase.
•
Glycoaldehyde glycolic acid
= metabolic acidosis and renal
epithelial damage
•
Glycolic acid  oxalic acid –
combines with serum calcium
to form calcium oxalate
complexes that crystallize in
the renal tubular lumen
Ethylene Glycol
• 3 clinical stages that can overlap
• Neurologic
• ~ 30 mins – 12 hours
• Cardiopulmonary –
• ~ 12 – 24 hours
• acidosis and electrolyte disturbances
• Renal –
Wcrah.com
• ~ 12-72 hours
• renal tubular injury from calcium oxalate crystals
Ethylene Glycol
Diagnosis
• Acute Kidney Injury – but may • UA: dilute USG, glucosuria, +/take >12 hours post exposure
crystalluria
• Hypocalcemia
• PRN® EG kit: blood test
• Cats may show signs below the
detectable level
• Kacey® EG test:
• Can test positive for any alcohol
• Woods lamp: urine or haircoat
may fluorescence
• Ultrasound: may reveal
hyperechoic renal cortices
• Osmolality:
• 1.86 (Na+ + K+) + glucose/18 +
BUN/2.8
• > 320 mOsm/kg in dogs; > 330
mOsm/kg in cats
• Anion Gap: > 25 mEq/L
Ethylene Glycol
Treatment
•
Induce emesis
•
IVF diuresis
•
Activated charcoal – controversial effectiveness
•
4-methylpyrazole (4-MP)
•
Ethanol
•
Dogs: negative EG test – can discontinue Fomepizole or Ethanol
•
If azotemic, oliguric/anuric  grim prognosis
•
Peritoneal or Hemodialysis – Gold Standard
Ethylene Glycol
4-methylprazole (4-MP)
• FDA withdrew Antizol - Vet approval in early 2015
• Road Runner pharmacy – Compounded - 104$/1.5gm
vial
• Dose Cats: 126mg/kg IV slowly initial dose; 31.25
mg/kg IV @ 12 hours; 31.25 mg/kg @ 24 hours; 31.25
mg/kg @ 36 hours
• Dogs: 20mg/kg IV first dose; 15mg/kg @ 12 hrs,
15mg/kg @ 24 hrs, 5mg/kg @ 36 hrs
Ethylene Glycol
Ethanol
• Ethanol – prevents further metabolism of EG via
inhibiting alcohol dehydrogenase
• Plumb’s – dosing recommendations
• Monitor glucose, electrolytes, IV site
• Side effects:
• CNS Depression
• Worsening metabolic acidosis
• Hyperosmolarity
Lily
Non-toxic
Calla lilies
Peace lilies
Renal Toxic
Lily Species
Hemerocallis spp.
Lilium spp.
• Daylily
• Easter lily
• Lemon daylily
• Tiger lily
• Red lily
• Asiatic hybrid lilies
• Western lily
• Japanese lilies
• Stargazer lilies
Encinavet.com
Lily toxicity
•
All parts toxic – including the pollen
•
GI signs – vomiting, hypersalivation
•
Neurologic signs
•
Acute kidney injury within 12 -72 hours
• Casts can be seen in 12 hours
•
No known antidote
•
Decontamination and supportive care x 48 - 72 hours
•
Good prognosis with treatment if within ~18 hours and not azotemic or
oliguric
•
Dialysis may aid in managing the renal failure until tubular regeneration
occurs
Rodenticide
Anticoagulants
• Restricting production since 2011
• Mechanism: inhibits Vitamin K epoxide reductase
(prevents recycling of Vitamin K1)
• Second generation rodenticides have long duration of
action (30 days or more)
• Some products carry >1 type
of rodenticide
Rodenticide
Anticoagulants
• Factor VII is first parameter affected – short ½ life (PT) –
36 – 72 hours – may appear clinically normal.
• After ~ 72 hours other factors become depleted and
increase the possibility of hemorrhage
• Clinical signs: bleeding anywhere!
• Vitamin K1 – dose 3-5 mg/kg/day split orally
• Caution with SQ injection
• Whole blood or FFP
• Check PT 48-72 hours after discontinuation of Vitamin K
Anticoagulant Rodenticide
Autotransfusion
• USE: Sterile collection set and blood administration
set or in-line blood filter
Petplace.com
Rodenticide
Bromethalin
• Toxic principle: leads to reduction of body ATP.
• Na+/K+ pumps are depleted and myelin cells develop
edema  decreased nerve impulse conduction
• Cats more sensitive
• Clinical signs: within hours to 2 weeks (acute/chronic)
• Muscle tremors, seizures, excitability, ataxia,
paresis/paralysis, seizures, death
• Prognosis: poor with significant neurologic
signs & can have permanent motor damage
Rodenticide
Cholecalciferol -Vitamin D toxicosis
• Increases calcium absorption in GI tract, bone and
in kidneys
• Doses > 0.1 – 0.5 mg/kg necessitate treatment decontaminate
• Most commercial rat baits: 0.075 % concentration
• Half life 17 days!
• Cats: ½ teaspoon of ingestion
may warrant treatment
Vitamin D3
• Vitamin D supplementation (cholecalciferol)
• 1 IU = 0.000002mg
• 40,000 IU = ~ 1 mg cholecalciferol
• Vitamin D
• Decontaminate if dose > 0.1 mg/kg (4,000 IU/kg)
• 0.5 mg/kg
• Calcipotriene: psoriasis cream
• Calcitriol 0.5 mcg tablets
• Decontaminate if > 2.5 ng/kg
Vitamin D toxicosis
Treatment
•
Baseline Ca+ and renal values every 24 hrs x 3 - 4 days
• Can see elevated Ca++ in 24 hours with AKI in 24 hours
• Ca++ x Phosphorus ratio > ~ 60 leads to minimally reversible soft tissue mineralization
•
Admit for fluid diuresis (0.9% NaCl) – sometimes to 4-5 times maintenance
•
If hypercalcemic:
• Prednisone – 1-3 mg/kg PO BID
• Furosemide – PO and IV
• Consider:
• Calcitonin 4-6 IU/kg SQ every 2-3 hours
• Pamidronate
•
Cholestyramine
• 0.3 – 1gm/kg PO every 8 hours x 3 - 4 days. Separate from charcoal x 4 hours.
•
Monitor serum calcium daily for 5-7 days, then at least twice a week if needed.
Continue Lasix, Prednisone, phosphate binder if needed until calcium level improved.
Chocolate toxicity
• Toxic ingredients: Theobromine and caffeine
• Highest in darker chocolates
• Ingestion delays gastric emptying
• Can induce even 6 hours post ingestion
• Undergoes enterohepatic circulation
• Can repeat doses of AC if symptomatic
• Excreted in urine & reabsorbed in bladder
• frequent walks or urinary catheter
Xylitol
• Sweetener for sugar free products
• Clinical signs variable (15 mins – 8 hours)
• Hypoglycemia
• Acute hepatic necrosis
• Dextrose often recommended even if normoglycemic
• Monitor BG every ~ 2 hours and monitor liver values at baseline
and at 24 hours
Tremorgenic Mycotoxins
Mold
• Penitrem A
• Inhibit glycine and GABA (inhibitory neurotransmitters)
• Excreted in bile
• Decontamination: Activated charcoal – repeated doses may be
beneficial
• Clinical signs: hypersalivation, agitation, hypersensitivity
• Treatment:
• Methocarbamol
• Diazepam/Phenobarbital
• Propofol
Pyrethrins
• Insecticides – flea control
• Common occurrence in cats getting spot on treatment
for dogs
• Clinical signs: mydriasis, hypersalivation,
twitching, tremors, seizures
• Dermal decontamination
• Methocarbamol
• Intravenous lipid emulsion can be considered
Batteries
• Alkaline dry cell batteries and Button or disc battery or lithium
• Potential sequela • Mucosal burns – may be delayed by 12-24 hours
• Tissue liquefaction
• Severe esophagitis
• Treatment
•
•
•
•
•
•
Dilute corrosive material w/ milk or water x 15 mins
Emesis – contraindicated with leaking battery
Activated charcoal – not beneficial
If lodged in esophagus – endoscopy to remove
If chewed up – surgical removal ideal
If intact – surgical removal vs bulk diet and gastroprotectants
Enterohepatic Recirculation
• NSAID’s
• Naproxen
• Acetominophen
• Digoxin
• Marijuana
• Caffeine/Theobromine
• Theophylline
• Bromethalin
• Pyrethrins
• Ivermectin
• Antidepressants
• Phenobarbitol
• Organophosphate
insecticides
• Vitamin D rodenticide
Hemolytic Anemia
• Allium
• Brown recluse spider
• Methylene blue
• Propylene glycol
• Zinc
• Phenols
• Napthalene
Methemoglobinemia
• Acetaminophen
• Phenols - disinfectants and antiseptics, mouthwash
and sore throat lozenges
• Chlorate salts - pyrotechnics
• 3-chloro-p-toluidine hydrochloride (Starlicide)
Tremors/Seizures
•
Ethylene glycol
•
Lead
•
Hypoglycemic agents (xylitol, diabetic
medications, Alpha lipoic acid)
•
Avicide
•
Bromethalin
•
Toxic lily plants
•
Methylxanthine
•
Tremorgenic mycotoxins
•
Stimulants (amphetamines, cocaine,
antidepressants)
•
Permethrin (cats)
•
Nicotine
•
Metaldehyde
•
Chocolate
•
Strychnine
•
Paintballs
•
Paintball
•
Tetanus
•
Bromethalin
Liver Injury
• Acetaminophen
• Phenols
• Sago palm
• Castor bean (Ricinus)
• Xylitol
• Blue green algae
• NSAID’s - many
• Iron overdose
• Mushroom – Amanita
• Aflatoxin
Renal Injury
•
Ethylene glycol
•
Sulfonaminds
•
Lilies (cats)
•
Tetracyclines
•
Grapes/raisins
•
Amphotericin B
•
NSAIDs
•
Cisplatin
•
Oxalic acid – rust remover
•
Alpha-lipoic acid
•
Vitamin D metabolites
•
Phenols
•
Rhubarb, shamrock
•
Pine oils
•
Mycotoxins
•
Metals – Arsenic
Low toxicity
• Silica gel packs and litter
• Ant and roach baits
• Glow in the dark sticks/jewelry
• Toilet bowl drop ins
• Super glue
• Paints
• Firestarter logs
Toxin Resources
• Pet Poison Helpline
• # 855 - 764 - 7661
• # 800 - 213 - 6680
• $49 fee
• Animal Poison Control: ASPCA
• #888 – 426 - 4435
• $65 fee
• ASPCA Poison Control mobile app