Plant Poisoning, Emergency Medicine

Basics

Description

Plant exposure is 1 of the most common reasons to contact the poison center
Majority of cases involve unintentional ingestion in children <6 yr old.

Etiology

Identification of ingested plant species should be attempted whenever possible. ‚
Plants with Anticholinergic Properties

Genera include Atropa, Datura, Hyoscyamus, Solandra, and Solanum.
Common names of anticholinergic plants include Jimson weed, deadly nightshade, henbane, and angel trumpet.
Competitive antagonists of acetylcholine at the muscarinic acetylcholine receptor

Plants with Cardiac Glycosides

Genera include Digitalis, Nerium, Thevetia, and Helleborus.
Common names of cardiac glycoside plants include foxglove, oleander, yellow oleander, lily of the valley, and hellebore/Christmas rose
Inhibit Na+/K+-ATPase:
- See separate chapter on Digoxin Poisoning

Plants with Nicotine-like Alkaloids

Genera include Nicotiana, Caulophyllum, and Conium
Common names of plants containing nicotine include tobacco, blue cohosh, and poison hemlock.
Direct-acting agonists at the nicotinic acetylcholine receptor

Plants with Cyanogenic Compounds

Genera include Hydrangea, Malus, Prunus, Sambucus
Common names of plants containing cyanogenic compounds (in some part of the plant) include apricot, cherry, peach, plum, apple, cassava, and elderberry
Metabolized to cyanide, which interferes with electron transport chain and leads to cellular poisoning

Plants with Calcium Oxalate Crystals

Genera include Alocasia, Dieffenbachia, and Philodendron as well as many others
Common names for calcium oxalate " “containing plants include elephants ear, dumb cane, and mother-in-law's tongue
Clinical manifestations occur after release of intracellular calcium oxalate crystals:
- Local tissue exposure to calcium oxalate crystals leads to inflammatory response.

Plants with Pyrrolizidine Alkaloids

Genera include Crotalaria, Heliotropium, Senecio, and Sesbania
Common names of plants with pyrrolizidine alkaloids include scorpions tail, ragwort, groundsel, and rattlebox
Metabolized to highly reactive pyrroles, which are directly hepatotoxic acutely and lead to hepatic vascular proliferation and veno-occlusive disease chronically.

Plants with Sodium Channel Activity

Genera include Aconitum, Delphinium, Leucothoe, Lyonia, Pernettya, Pieris, Rhododendron, Schoenocaulon, Veratrum, and Zigadenus
Common names of plants with aconitine, veratrum alkaloids, and zygacine, all sodium channel openers, include: Aconite (monkshood, wolfsbane, delphinium), veratrum (false hellebore), and zygacine (death camas)
Common names of plants with grayanotoxins, which have variable effects on sodium channels, include sweet bells, rhododendron, azalea, and lily-of-the-valley bush
Variable sodium channel effects depending on toxin, although most lead to prolonged sodium channel influx.

Plants with Toxalbumins

Genera include Abrus, Jatropha, Phoradendron, Ricinus, Robinia, Wisteria
Common names of plants with toxalbumins include rosary pea, mistletoe, and castor bean
Cause direct cellular toxicity by interfering with ribosomal function

Diagnosis

Signs and Symptoms

Anticholinergic

Dry, warm, and flushed skin
Absent bowel sounds
Urinary retention
Agitated delirium

Cardioactive Steroids

Digoxin-like toxicity
Abdominal pain, nausea, vomiting
Multiple cardiac effects, ranging from junctional bradycardia to v-tach/v-fib
‚ ± hyperkalemia

Nicotine-like Alkaloids

Hypertension
Tachycardia ˘ † ’ bradycardia (late)
Diaphoresis
Salivation
Vomiting
Fasciculations
Muscle weakness

Cyanogenic Compounds

Potentially delayed (unlike cyanide gas)
Initial symptoms:
- Abdominal pain, nausea, vomiting
- Lethargy
- Diaphoresis
Followed by:
- Altered mental status
- Lactic acidosis
- Seizures
- Cardiovascular collapse
- Multiorgan system failure

Calcium Oxalate Crystals

Oropharyngeal burning pain and swelling (after biting or chewing)
Ocular exposure results in keratoconjunctivitis
Dermal irritation after dermal contact

Pyrrolizidine Alkaloids

Acutely causes hepatitis
Chronic exposure may lead to hepatic veno-occlusive disease

Sodium Channel Activators

Abdominal pain, nausea, vomiting
CNS: Progress from paresthesias to depressed mental status, respiratory depression, coma, and seizures.
CV: Bradycardia with atrioventricular blocks, progressing to tachydysrhythmias

Toxalbumins

Effects depend on plant (e.g., mistletoe is rarely toxic, whereas ricin can be deadly) and route of exposure
Gastroenteritis, diarrhea, or abdominal pain if ingested
Localized pulmonary effects if inhaled
Diffuse organ dysfunction if injected

Often present with lip, tongue, and oropharyngeal irritation and swelling from oxalate crystal " “containing plants:
- Potential for airway compromise
Usually consume leaves, seeds, and berries
Nicotine group: 1 or 2 cigarettes potentially lethal
Jimson weed:
- Seeds highly concentrated
- 100 seeds equal 6 mg of atropine
- Lethal at 4 " “5 g of leaf
Yellow oleander:
- 2 leaves lethal in 12.5 kg child

Essential Workup

Identification of ingested material
Workup depends on plant ingested

Diagnosis Tests & Interpretation

Lab

Electrolytes, BUN, creatinine, glucose, liver function tests
ABG/VBG for blood pH determination
Digoxin level for cardiac glycoside plants
Lactic acid for cyanogenic plants

Imaging

Differential Diagnosis

Altered mental status:
- Drug use/alcohol
- Seizures
- Trauma
- Cerebrovascular accident
- Hypoglycemia
Digoxin toxicity
Gastroenteritis
Agents causing metabolic acidosis (see Acidosis chapter)
Cardiotoxic drugs

Treatment

Pre-Hospital

Examples of common nontoxic houseplants:
- African violet
- Bird of paradise
- Ficus
- Gardenia
- Grape ivy
- Orchids
- Poinsettia (despite reputation)
- Rubber tree
- Spider plant
- Wandering Jew
- Wax plant
- Zebra plant
Collect seeds, leaves, spores in paper bag.
Contact local botanist.
Syrup of ipecac is not recommended

Initial Stabilization/Therapy

Airway, breathing, and circulation management (ABCs)
0.9% normal saline IV:
- Aggressive volume replacement for dehydration/hypotension
- Initiate pressors for hypotension unresponsive to fluids
Cardiac monitoring
Supportive care for most ingestions

Ed Treatment/Procedures

Supportive care
Rare plants necessitate focused/antidotal therapy

Anticholinergic

Benzodiazepines for agitation
Consider physostigmine for severe agitated delirium

Cardioactive Steroids
Digoxin-specific Fab indicated in: ‚

Significant bradycardia
Tachydysrhythmia
Hyperkalemia

Nicotine-like Alkaloids

Parenteral short-acting antihypertensives such as nitroprusside for hypertensive crisis
Treat seizures with benzodiazepines.

Cyanogenic Compounds

Correction of electrolyte abnormalities
Hydroxocobalamin or prepackaged cyanide antidote kit if severe lactic acidosis or hemodynamic compromise

Calcium Oxalate Crystals

For mild symptoms, popsicles may decrease burning
Viscous lidocaine and analgesics for more severe oral exposure
Copious irrigation for ocular, oropharyngeal, and dermal exposure

Pyrrolizidine Alkaloids

Supportive care
Removal from source. Pyrrolizidine alkaloids have been found in herbal medication products as well as food contaminants
Liver-specific management in conjunction with hepatologist

Sodium Channel Activators

Atropine for bradycardia and atrioventricular blocks
Normal saline bolus for hypotension, or vasopressor therapy if normal saline fails

Toxalbumins
Supportive care based on clinical symptoms: Replace GI losses with intravenous fluids, replete electrolytes. ‚

Medication

Atropine: 0.5 mg (peds: 0.02 mg/kg) IV, repeat 0.5 " “1 mg IV
Cyanide antidote kit:
- Inhale amyl nitrite ampule for 30 sec every minute until sodium nitrite given.
- Sodium nitrite: 10 mL of 3% solution or 300 mg IV over 3 " “5 min (peds: 0.15 " “0.33 mL/kg):
  - Monitor methemoglobin levels to keep <30%.
- Sodium thiosulfate: 50 mL IV of 25% solution or 12.5 g (peds: 1.65 mL/kg)
Digoxin Fab fragments: Empiric dose 5 " “10 vials
Hydroxocobalamin: 5 g IV for adults; 70 mg/kg not to exceed 5 g IV for pediatrics
Magnesium: 2 " “4 g IV
Physostigmine: 0.5 " “2 mg IV
Sodium bicarbonate 8.4%: 1 amp IV push until narrowing of QRS complex

Follow-Up

Disposition

Admission Criteria

Dysrhythmias for cardiac monitoring
Intractable vomiting
Refractory hypotension
Evidence of end-organ damage (e.g., hepatic dysfunction, acidosis) or concern for potential for end-organ damage
Altered mental status

Discharge Criteria

Baseline mental status
Tolerating oral fluids
Normal cardiac activity
Delayed sequelae not anticipated

Lower threshold to admit children: ‚

Tend to eat more concentrated parts of plants
Lower lethal dose
Symptoms less specific

Followup Recommendations

Follow-up with medical toxicologist or primary care physician ‚

Pearls and Pitfalls

Death from unintentional plant exposures is rare.
Intentional exposures from herbal remedies, attempted abuse or therapeutic misadventures can be deadly.
Contact your regional poison center if concerned about a patient ingesting a potentially poisonous plant: 1-800-222-1222

A special thanks to Dr. Harry Karydes, who contributed to the previous edition. ‚

Additional Reading

Froberg ‚ B, Ibrahim ‚ D, Furbee ‚ RB. Plant poisoning. Emerg Med Clin North Am. 2007;25(2):375 " “433.
Nelson ‚ LS, Shih ‚ RD, Balick ‚ MJ. Handbook of Poisonous and Injurious Plants. 2nd ed. New York, NY: Springer; 2007:21 " “34.
Palmer ‚ ME, Betz ‚ JM. Plants. In: Goldfrank ‚ LR, Flomenbaum ‚ NE, Lewin ‚ NA, et al., eds. Goldfranks Toxicologic Emergencies. 9th ed. Chicago, IL: McGraw-Hill Medical; 2011:1537 " “1560.

Codes

ICD9

988.2 Toxic effect of berries and other plants eaten as food ‚

ICD10

T62.1X1A Toxic effect of ingested berries, accidental, init
T62.2X1A Toxic effect of ingested (parts of) plant(s), acc, init

SNOMED

446686000 Poisoning by ingestion of plant (disorder)
29824007 Atropa belladonna poisoning (disorder)
45328004 Digitalis purpurea poisoning (disorder)

Home

Erectile Dysfunction

Doctor123.org