Differential Diagnosis of Common Acute Toxicologic Versus Nontoxicologic Illness

Major Clinical Abnormality	Common Toxicologic Rule Outs	Nontoxicologic Rule Outs
Central nervous system (CNS) abnormalities (excitation and seizures)	Strychnine (rapid onset, rigidity, hyperesthesia, wooden horse–like stance) Metaldehyde (hyperthermia, tremors, shaking) Amphetamines, or cocaine (ingestion in dogs: sympathomimetic effects and hyperthermia) Tremorgenic mycotoxins (Penitrem A, roquefortine) from eating moldy foods (gastrointestinal [GI] signs, hyperthermia, and tremors) Cold medications: pseudoephedrine, ephedrine, some antihistamines (sympathomimetic effects, hyperthermia) Organophosphate (OP) or carbamate pesticides (cholinergic crisis; salivation, lacrimation, urination, diarrhea (SLUD) signs) Pyrethrins/pyrethroids type pesticides (especially permethrin in cats: tremors, shaking, ataxia, seizures, GI signs)	Trauma/head trauma (outdoor animal, external or internal wounds/injuries) Meningitis (fever, hyperesthesia, neck stiffness, and pain) Hydrocephalus (large rounded head; ventrolateral deviation of eyes; seizures Intracranial neoplasia (primary or secondary brain tumor: older animals)
	Organochlorine pesticides (tremors, shaking, ataxia, seizures) Chocolate: caffeine, theobromine, methylxanthines (polydipsia, polyuria, excitation, pacing, GI and CV effects) Zinc phosphide: mole or gopher baits (GI signs, shaking, pulmonary edema) Bromethalin toxicosis: rat or mouse bait (paresis, weakness, ataxia, twitching) Lead (GI signs, nucleated red blood cells [RBCs], basophilic stipling, anemia) Metronidazole (toxicosis in dogs with repeated use: nystagmus, ataxia, weakness, paresis, seizures) Nicotine: tobacco or cigarettes (ingestion in dogs: spontaneous vomiting, shaking, CV effects) Tricyclic antidepressants toxicosis: amitriptyline, clomipramine, imipramine, nortriptyline (agitation, nervousness, ataxia, CV effects; sedation/lethargy at low doses) Brunfelsia plant ingestion (all parts toxic particularly seeds; strychnine poisoning–like signs; vomiting, tremors, stiffness, seizures	Congenital portosystemic shunts (more common in certain breeds, <6 months of age, small liver) Rabies (acute behavior changes, excitation, paralysis) Canine distemper (young dogs: fever, respiratory, GI and CNS signs) Hypocalcemia or hypercalcemia (hypocalcemic tetany, cardiovascular [CV] effects, CNS, renal effects from hypercalcemia) Hypoglycemia (disorientation, ataxia, seizures, serum glucose <60 mg/dL) Idiopathic epilepsy (dogs 1–5 years of age: bloodwork normal) Polycythemia vera (primary or secondary, PCV 65%–81%, brick-red mucous membrane) Uremia (secondary to acute or chronic renal failure [ARF or CRF]) Endotoxemia/septic shock (hemorrhagic GI signs, progressive weakness, abdominal pain)
CNS abnormalities  (CNS depression and seizures)	Ivermectin, moxidectin, and other avermectin toxicosis (ataxia, weakness, depression, tremors, seizures, blindness) Marijuana ingestion (ataxia, hypothermia, urinary incontinence) Benzodiazepine ingestion: alprazolam, clonazepam, diazepam, lorazepam (hyporeflexia, ataxia, CNS excitation: paradoxical reaction) Barbiturate overdose: short acting or long acting (coma, hypothermia, weakness, ataxia) Ethylene glycol: see Acute renal failure (ataxia, drunkenness, disorientation, GI signs) Methanol or ethanol ingestion (GI, signs, ataxia, weakness, depression) Propylene glycol: antifreeze (depression, ataxia, GI signs) Baclofen or other centrally acting muscle relaxant (ingestion in dogs: vocalization, ataxia, disorientation, coma, hypothermia) Amitraz insecticide (depression, ataxia, CV effects, paralytic ileus) SSRI (selective serotonin reuptake inhibitor) and other similar antidepressant toxicosis (SSRI types like fluoxetine, sertraline, paroxetine; CNS sedation or excitation, ataxia, tremors, seizures, mydriasis, tachycardia)	Thiamine deficiency in cats (cats fed mainly fish diet) Coonhound paralysis (ascending flaccid paralysis; raccoon exposure within 2 weeks) Feline infectious peritonitis: dry form (iritis; fever, weight loss, ataxia, seizures) Feline leukemia (lymphadenopathy, nonregenerative anemia) Feline panleukopenia (fever, GI signs, ataxia, neutropenia)
Muscle weakness, paresis, paralysis	Black widow spider bite (cats: swelling, pain) 2,4-D and other phenoxy herbicides (in dogs: ataxia, weakness, GI signs) Metronidazolesee Seizures (in dogs: nystagmus, ataxia, weakness, seizures) Bromethalin rodenticide (see under Seizures; paresis, CNS depression/excitation, twitching, seizures) Coral snake envenomation (cats: local swelling, pain, puncture wound) Macadamia nuts (ingestion in dogs: weakness, ataxia) Concentrated tea tree oil exposure: Melaleuca oil (both cats and dogs: weakness, ataxia, CNS depression)	Coonhound paralysis (muscle pain, ascending flaccid paralysis; raccoon exposure within 2 weeks) Botulism (ascending paresis and paralysis) Tick paralysis (flaccid ascending paralysis) Aortic thromboembolism (cold extremities, weakness)
	Albuterol inhalor ingestion/toxicosis (muscle weakness accompanied by severe hypokalemia; tachycardia, agitation)	Profound anemia (measure PCV) Severe hypokalemia Hyponatremia Tetanus (hyperesthesia, rigidity, muscle spasm, third eyelid visible) Severe hypovolemia Marked hypothermia or hyperthermia Degenerative spinal cord diseases
Acute blindness	Lead, see Seizures (GI signs, behavior changes, nucleated RBCs, basophilic stipling) Ivermectin, moxidectin, and other avemectin toxicosis, see Seizures (ataxia, weakness, seizures, blindness reversible) Salt poisoning (in dogs: excessive sodium chloride ingestion, polydipsia, GI signs, tremors, ataxia, seizures, serum sodium >160 mEq/L)	Retinal detachment or hemorrhage Glaucoma Trauma (penetrating injury of head, face) Acute cataract Optic neuritis Optic nerve disorders (optic chiasm, optic radiation, occipital cortex) Sudden acquired retinal degeneration
Acute renal failure (ARF)	Ethylene glycol toxicosis (ataxia, drunkenness, GI signs, acidosis, azotemia) Easter lily (Lilium longiflorum), Tiger lilies (Lilium tigrinum, Lilium lancifolium), Rubrum or Japanese show lilies (Lilium speciosumf), Day lilies (Hemerocallis sp) (reported in cats, initially GI signs, azotemia in generally 24–72 hours after ingestion) Cholecalciferol rodenticide and other vitamin D3analogue: calcipotriene, calcitriol;see under Hypercalcemia (initial GI signs, hypercalcemia, hyperphosphatemia, CV, and CNS effects, azotemia)	Renal infiltration (with lymphoma) Renal thromboembolism Infectious (pyelonepheritis, leptospirosis, Rocky Mountain spotted fever, borreliosis, feline infectious peritonitis: cats) Urinary tract obstruction Renal lymphomas (more in cats than in dogs)
	Grapes and raisins (ingestion in dogs: initial GI signs, then azotemia in >24 hours, possible pancreatitis) NSAIDs: ibuprofen, naproxen, nabumetone, piroxicam, carprofen, diclofenac, ketoprofen, indomethacin, ketorolac, oxaprozin, etodolac, flurbiprofen, sulindac (initially GI signs, azotemia in 24–74 hours after ingestion in acute cases) Zinc toxicosissee hemolysis (GI signs, pancreatitis, hemoglobinuria, anemia, renal failure) Melamine and cyanuric acid contamination (outbreak in the United States in 2007 from contaminated dog and cat food: crystaluria, azotemia, GI signs)	Chronic renal failure (end stage) Ischemic renal failure (hypotension, trauma, shock, congestive heart failure, anaphylaxis) Neoplasia (adenocarcinoma in dogs; lymphosarcoma in cats) Amyloidosis (immune-mediated) Hypercalcemia (due to any cause) Transfusion reactions Myoglobinuria/hemoglobinuria (due to any cause)
Acute hepatic damage	Carprofen and other NSAID-induced hepatopathies in dogs (within a few days after initiating therapy, GI signs, increased alanine transaminase) Corticosteroids (steroid hepatopathy, long-term use) Phenobarbital (chronic use) Mushrooms: amanita type (delayed onset, 12 hours, GI signs, acute hepatic damage in 1–3 days) Blue-green algae: Microcystis sp (acute onset, GI signs, shock) Iron: multivitamin ingestion (GI signs, shock, acute liver damage in 1–2 days) Copper (copper storage disease; certain breeds can accumulate copper over a period of times) Sago palm or cycad palm:Cycas sp (ingestion: GI signs, liver damage in 1–3 days, seizures) Acetaminophen toxicosis (methemoglobinemia within a few hours, GI signs, increased liver enzymes in 1–3 days) Aflatoxicosis (dogs: mostly from contaminated dog food, several outbreaks reported in the United States)	Hepatic lipidosis (cats: period of stress, anorexia, obese animals) Hepatic neoplasia (primary or metastatic, acute or gradual) Infectious hepatitis (leptospiros, infectious canine hepatitis, canine herpes virus, cholangiohepatitis, liver abscess, histoplasmosis, cocidiomycosis, babesiosis, toxoplasmosis, some rickettsial diseases, feline infectious peritonitis) Acute pancreatitis (systemic) Septicemia/endotoxemia (vomiting, diarrhea, hypothermia, collapse)
	Xylitolsee Hypoglycemia (ingestion in dogs: hypoglycemia within 12 hours, seizures, acute hepatic damage and coagulopathy in 1–3 days)	Heat stroke (high ambient temperature) Shock (weak pulse, poor capillary refill time, progressive weakness) Chronic passive congestion (secondary to cardiac problems)
Presence of acute oral lesions/ulcers	Acid ingestion (corrosive lesions on lips, gums, tongue, salivation, vomiting, fever) Alkali ingestion (same as with acid, esophageal perforation more likely) Cationic detergents: present in several disinfectants (oral burns, salivation, vomiting, fever) Alkaline battery (ingestion: oral burns, salivation, vomiting) Potpourri ingestion (oral burns, salivation, vomiting, tongue protrusion, fever) Bleaches: sodium or calcium hypochlorite (bleach-like smell, salivation, vomiting, wheezing, gagging) Ingestion of phenolic compounds (especially in cats: oral ulcers/lesion may be present, Heinz body anemia and hemolysis may be seen)	Uremic stomatitis (azotemia, GI signs) Periodontal disease (associated with dental calculus; gingival lesions) Trauma (presence of foreign body, grass, stick, bone, porcupine quills) Electrical cord chewing (systemic signs such as dyspnea, pulmonary edema) Systemic lupus erythematosus and other autoimmune diseases (oral lesions and other systemic and cutaneous signs present) Infectious (feline calcivirus infection, feline leukemia virus, feline immunodeficiency virus, feline herpesvirus, nocardiasis, ulcerative necrotizing stomatitis, fusobacterium)
Acute methemoglobinemia, Heinz body anemia, hemolysis or blood loss (anemia)	Acetaminophen (chocolate-brown colored mucous membrane within hours, dyspnea) Local anesthetic toxicosis: lidocaine, benzocaine, tetracaine and dibucaine (methemoglobinemia, CV and CNS effects) Phenazopyridine and other azo dyes toxicosis (methemoglobinemia, hemoglobinuria) Naphthalene mothball ingestion (moth ball-like odor in the breath, hemolysis) Onions and garlic toxicosis (hemolysis in 2–3 days, anemia, coffee-color urine) Zinc toxicosis (metallic object in the GI tract, gastritis, pancreatitis, hemolysis, hemoglobinuria) Iron (mostly see GI signs, hepatic damage, or shock) Anticoagulants rodenticides: brodifacoum, bromadiolone, chlorophacinone, difethialone, diphacinone, pindone, warfarin (hemorrhaging, increased prothrombin time [PT] or activated partial thromboplastin time [aPTT], dyspnea, weakness) Copper (certain breeds of dogs can accumulate copper in the liver) Rattlesnake envenomation (swelling, pain, hemoglobinuria) dl-Methionine toxicosis: GI signs, ataxia, weakness, possible Heinz body anemia hemolysis in cats with large overdose, less likely in dogs	Trauma (overt blood loss) Immune-mediated hemolytic anemia Thrombocytopenia (drug-induced, infectious or immune mediated) CRF (smaller kidneys, azotemia) Infectious (ehrlichiosis, feline leukemia, hookworms, Mycoplasma hemofelis, babesiosis) Severe liver diseases (deficiency of clotting factor can result in bleeding disorders) Disseminated intravascular coagulation (secondary to underlying cause such as shock, neoplasia, septicemia, viral infections, pancreatitis) Inherited bleeding disorders (von Willebrand disease, factor X deficiency, factor XI deficiency) Epistaxis (primary or secondary, trauma, infectious, nasal polyps, malignant neoplasm)
Cardiac abnormalities	Foxglove: Digitalis sp (plant ingestion: GI signs and cardiac arrhythmias) Lily of the valley: Convallaria majalis (plant ingestion GI signs and cardiac arrhythmias) Oleander:Nerium oleander (GI signs and cardiac arrhythmias) Bufo toads:Bufo sp (GI signs collapse, seizures, and cardiac arrhythmias) Azalea and otherRhododendron plant: (GI signs and possible cardiac arrhythmias) Antidepressant toxicosis: (CNS signs, anticholinergic effects) Calcium channel blockers toxicosis: amlodipine, felodipine, verapamil, diltiazem (hypotension, bradycardia or tachycardia, atrioventricular block, pulmonary edema) Beta-adrenergic blocking agents toxicosis: atenolol, metoprolol, propranolol, esmolol (hypotension, tachycardia, bradycardia, weakness Albuterol inhalor ingestion/toxicosis: (tachycardia, agitation, premature ventricular contractions [PVCs], hypokalemia) Alpha-adrenergic receptor agonists overdose/toxicosis: (amitraz, clonidine; hypotension, weakness, collapse, bradycardia, hypothermia)	Automobile trauma (evidence of other injuries) Gastric dilation and volvulus (abdominal distention, dyspnea, shock) Severe anemia (due to any cause of anemia) Severe hypokalemia (due to any cause) Acidosis (due to any cause) Hypoxia (due to any cause of hypoxia) Primary heart disease (cardiomyopathy, valvular heart disease, congenital heart problems, heartworm infestation: heart murmur, cardiomegaly, or evidence of congestive heart failure)
Pulmonary edema	Paraquat herbicide (rare; progressive dyspnea, panting, delayed onset after exposure) Petroleum distillates: kerosene, gasoline, and other hydrocarbons (hydrocarbon smell in the breath, salivation, vomiting, CNS depression, diarrhea, aspiration) Zinc phosphide (GI and CNS signs, pulmonary edema) Smoke inhalation (dyspnea, collapse, panting, shock) Organophosphate or carbamate pesticides (cholinergic crisis, SLUD signs)	Cardiogenic (multiple causes of left ventricular failure) Noncardiogenic (seizures, head trauma, electrical shock) Hepatic disease (secondary to any cause of hepatic disease) Renal disease (any cause of renal disease) Drowning and near drowning Shock (immune mediated, anaphylactic, trauma, transfusion reactions)
	Some organic arsenicals (mainly injectable, melarsamine) Calcium channel blockers toxicosis, see Cardiac abnormalities (noncardiogenic pulmonary edema along with cardiac signs)	Neoplasia (primary or secondary)
GI signs (vomiting, diarrhea, abdominal pain, drooling)	Arsenical herbicides (initial stages: vomiting, abdominal pain, watery diarrhea) Iron toxicosis (multivitamin ingestion in dogs: initial GI signs within hours) Castor beans: Ricinus communis (initial GI signs within several hours) Garbage poisoning (vomiting, diarrhea, dehydration, abdominal pain) Chocolate toxicosis (initial stages: polydipsia, polyuria, vomiting, hyperactivity, tachycardia) Fertilizer ingestion (nitrogen, phosphorous, potash [NPK]: vomiting, diarrhea, polydipsia) Insoluble calcium oxalate containing plants: elephant's ear Caladium sp, dumb cane Dieffenbachia sp, philodendron Philodendron sp, peace lily Spathiphyllum sp (vomiting, diarrhea, oral swelling, salivation) Endotoxins and enterotoxins: staphylococcal, clostridial, E coli, salmonella (severe GI signs, progressive lethargy, dehydration, hypothermia) Zinc oxide (diaper rash ointment ingestion in dogs; mild to severe gastritis) Zinc phosphide (GI and CNS signs, pulmonary edema; liver and kidney damage possible) NSAID toxicosis (initial stages: GI signs with or without blood)	Infectious (feline panleukopenia, canine distemper, canine parvovirus, canine coronavirus, infectious canine hepatitis, leptospirosis, salmonellosis) Internal parasites (hookworms) Dietary discretion (recent change in diet) Foreign body (plastic, wood, metal, bones, partial or complete obstruction) Gastric dilation, volvulus, intussusceptions (abdominal distention, pain, dyspnea, shock) Liver diseases (secondary to liver disease) Kidney diseases (secondary to renal disease, postrenal obstruction, uremia) Metabolic disorders (diabetic ketoacidosis, hypoadrenocorticism) Sudden change in the environment (traveling, weather change, boarding, moving) Inflammatory bowel disease (generally immune mediated)
Hypernatremia (measured serum sodium >160 in dogs and >165 in cats)	Paint ball ingestion (dogs: history of paintball ingestion, polydipsia, vomiting, diarrhea, ataxia) Salt toxicosis (history of inducing emesis with sodium chloride, ingestion of excessive amounts of salt-containing objects [eg, Play-Doh] and foods) Activated charcoal administration (can occur sporadically in some dogs with both single or multiple doses possibly due to fluid shift in the gut) Seawater ingestion (history of visit to a beach, lack of access to fresh water, swimming)	Due to pure water loss (nephrogenic diabetes inspidus, heat stroke, fever, burns, no access to water) Due to hypotonic water loss (severe diarrhea, vomiting, diabetes mellitus, renal failure, hypoadrenocorticism)
Hypoglycemia	Ingestion of xylitol-containing products (ingestion of sugar-free gum, bakery products, hypoglycemia within 12 hours) Ingestion of oral diabetic/hypoglycemic agents (sulfonylureas)	Insulinoma Acute hepatic disease Functional hypoglycemia (idiopathic in neonates, severe exercise) Internal parasitism Adrenocortical insufficiency Endotoxemia
Sudden, acute, unattended, or unexplained death (death within 24 hours of being reported healthy or minimal clinical effects)	4-Aminopyridine; an avicide, trembling, shaking, CV effects, seizures, death 5-Flurouracil ingestion; (topical anticancer; available 2%–5% solution/cream; seizures, vomiting, cardiac arrhythmias; acute death possible with large ingestion 5-Hydroxytryptophan (5-HTP) ingestion; used as over-the-counter sleep aid, antidepressant; accidental ingestion; seizures, hyperthermia; acute death with large ingestions possible Acetaminophen (cats); death likely from methemoglobinemia within hours with large ingestion; cats more sensitive Albuterol inhaler ingestion; asthma medication; dogs chewing the inhaler; acute death with large ingestion possible; cardiac arrhythmias, hypokalemia Amphetamines; recreational or human prescription; hyperthermia, hyperactivity, circling, hypertension, tachyarrhythmias; acute death with large ingestion possible	Cardiac disease Acute hepatic diseases Acute renal disease Parasitism (heavy) internal and external Congenital problems Metabolic disorders (acidosis, alkalosis) Neoplasia/cancer (primary secondary) Gastric dilatation/volvulus Trauma Severe hypoglycemia or hyperglycemia (any cause) Electric shock Excessive Bleeding/hemorrhaging (due to any reason) Infectious cause (endotoxemia/shock)
	Anticoagulant poisoning; internal bleeding 3–5 days post ingestion; signs may not be apparent; acute death due to pulmonary hemorrhage possible Antidepressants (other than tricyclic antidepressants such as SSRI); common human prescription medications; fluoxetine, citalopram, sertraline; acute death possible with large ingestion; CNS and cardiac effects Arsenic: used in ant baits, herbicide; toxicosis uncommon; watery diarrhea, abdominal pain, shock, acute death possible Baclofen and other centrally acting muscle relaxants, prescription drug; coma, hypothermia, death with large ingestion Barbiturates overdose: common anticonvulsant, accidental ingestion of large doses; farm dogs eating flesh/carcass of animals euthanized by barbiturates; coma, hypothermia and death Blue-green algae; history of drinking from a lake/pond; algae on the muzzle; collapse, shock, seizures, liver failure, death Botulism; acute death rare; ingestion of preformed toxins from eating a carcass; progressive weakness, paralysis, death Brunfelsia spp ingestion; strychnine-like signs (seizures, stiffness); dogs attracted to fruit/seed pods/flowers; acute death possible with large ingestion Bufo toad ingestion/mouthing; common in Florida and other southern states; acute collapse, salivation, cardiac arrhythmias, seizures, death Caffeine/theobromin; ingestion of chocolate or caffeine pills; acute death with large ingestion possible; vomiting, CNS signs, cardiac arrhythmias Carbon monoxide poisoning; uncommon, dog confined in garage with car's engine running; bright-red mucous membranes, disorientation, death Cardiac glycoside–containing plants; acute death uncommon; evidence of plant ingestion; lily of the valley, foxglove, oleander, azaleas, kalanchoes Castor beans: acute death unlikely; only possible if several seeds have been ingested, GI signs, liver, kidney damage	Meningitis (rabies, canine distemper Shock (anaphylactic; hypovolemic) Hypocalcemia/hypercalcemia (due to any etiology) Marked hypo or hyperthermia (due to any reason hypovolemic) Drowning, near-drowning Hypocalcemia/hypercalcemia (due to any etiology) Marked hypothermia or hyperthermia (due to any reason)
	Cocaine: recreational drug; acute death with large ingestion possible Ethylene glycol: acute death with large ingestions possible; coma, acidosis, ARF; cats more sensitive Garbage poisoning: history of eating garbage; acute death possible with some Salmonella, E coli toxins; vomiting, progressive shock, dehydration, watery diarrhea, and death Hepatotoxic mushroom (amanita type): vomiting, diarrhea, abdominal pain, shock, liver failure, death Hops (used for beer flavoring): malignant hyperthermia–like syndrome in dogs; acute death possible Ionophores (monencin, lasalocid): dogs eating cattle feed; acute death with large ingestion (premix) possible Iron: prenatal multivitamins; large ingestions, acute death uncommon, vomiting, shock, liver damage Isoniazid ingestion: antituberculosis drug; seizures, acute death due to large ingestions possible Lidocaine and other local anesthetics: uncommon toxicosis; CNS, and cardiovascular effects, overdose likely with injection or sprays Metaldehyde: used as slug bait; seizures, hyperthermia, stiffness, tremors, acute death with large ingestion possible Moldy food ingestion (tremorgenic mycotoxins penitrem A, roquefortine): history of ingestion of moldy food; seizures, hyperthermia, vomiting, acute death possible Nicotine: acute death with large ingestion possible; tobacco products, toxicosis uncommon; GI, CNS, and cardiac effects Organochlorine-type pesticides: lindane, eldrin, dieldrin; use not common anymore; cats more sensitive; seizures, tremors, and acute death OPs/carbamate pesticides: some highly toxic OPs/carbamates like methomyl, aldicarb (tres pasitos), disulfoton; usually SLUD signs present; acute rapid death with large ingestion possible
	Paint ball ingestion (diethylene and other glycols): ingestion of large amounts; acute death uncommon, seizures due to hypernatremia and other electrolyte changes possible Pseudoephedrine: over-the-counter decongestant; amphetamine-like signs; acute death with large overdose possible Pyrethrins/pyrethroids (permethrin in cats): cats more sensitive; use of concentrated products; tremors, ataxia, seizures, death Sago palm/cycas: acute death unlikely; possible if several seeds have been ingested; GI signs, seizures, liver failure Salt (sodium chloride) poisoning: homemade Play-Doh ingestion; inappropriate use as an emetic; seizures, hypernatremia, death possible Smoke inhalation: history of pet trapped in the house during fire Snake bite: Mohave rattlesnake, Eastern rattlesnake; acute death possible Strychnine: used as a rodenticide bait; rapid onset, seizures, hyperthermia, stiffness, death, quick rigor mortis Tetrodotoxins: acute death rare; ingestion of dried puffer fish, pet salamander; paresis, coma, respiratory failure, death Tricyclic antidepressants: prescription medications; amitriptyline, nortriptyline; acute death with large ingestion possible; CNS and CV effects Water intoxication: history of being on the beach/swimming, hyponateremia, hypochloremia, polydipsia Xylitol ingestion: acute death due to severe hypoglycemia possible; acute liver failure seen 1–3 days after ingestion Zinc phosphide: available as gopher bait; vomiting, CNS effects; acute death with large ingestion possible