Aconitum toxicity: Difference between revisions

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==Aconitum Ingestion==
==Background==
===Background===
''Aconitum'' spp is a genus of over 250 flowering plants including Monkshood, Wolf's bane, Aconite, Leopard's bane, mousebane, blue rocket, and queen of poisons. In the United States, most poisonous flower ingestions are accidental ingestions by children and account for roughly 2% of all toxic exposures; aconitum is not a commonly ingested flower in the United States, though is responsible for significant morbidity and mortality worldwide. Traditionally, most cases of adult ingestion of toxic flowers that lead to significant symptoms are suicidal attempts. A recent increase in aconitum poisoning has been reported secondary to an increase in available herbal medications utilizing the plant. All parts of Aconitum are toxic, with the roots being most toxic.  Toxicity is due to Aconite alkaloids bind to open voltage-gated sodium channels, producing a hyperpolarized state, with permanent activation of the channels. Most herbal preparations undergo decoction process where plant is boiled to hydrolize alkaloids.
 
[[File:Aconite.jpg|thumbnail|Aconite]] [[File:Monkshood.jpg|thumbnail|Monkshood]]
[[File:Aconite.jpg|thumbnail|Aconite]] [[File:Monkshood.jpg|thumbnail|Monkshood]]
[[File:Map of American Aconitum Distribution.png|thumbnail|A map of the distribution of Aconitum across the United States]]
[[File:Map of American Aconitum Distribution.png|thumbnail|A map of the distribution of Aconitum across the United States]]
''Aconitum'' spp is a genus of over 250 flowering plants including Monkshood, Wolf's bane, Aconite, Leopard's bane, mousebane, blue rocket, and queen of poisons. In the United States, most poisonous flower ingestions are accidental ingestions by children and account for roughly 2% of all toxic exposures; aconitum is not a commonly ingested flower in the United States, though is responsible for significant morbidity and mortality worldwide. Traditionally, most cases of adult ingestion of toxic flowers that lead to significant symptoms are suicidal attempts. A recent increase in aconitum poisoning has been reported secondary to an increase in available herbal medications utilizing the plant. All parts of Aconitum are toxic, with the roots being most toxic.  Toxicity is due to Aconite alkaloids bind to open voltage-gated sodium channels, producing a hyperpolarized state, with permanent activation of the channels. Most herbal preparations undergo decoction process where plant is boiled to hydrolize alkaloids.


==Clinical Features==
==Clinical Features==
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==Differential Diagnosis==
==Differential Diagnosis==
[[File:Veratrum Viridae.jpg|thumbnail|Veratrum Viridae (False Hellebore) has a similar toxic profile as aconitum]]
[[File:Death Camas.jpg|thumbnail|Zigadenus glaberrimus (Sandbog Death Camas) has a similar toxic profile as aconitum]] [[File:Larkspur.jpg|thumbnail|Delphinium (Larkspur) has a similar toxic profile as aconitum]]
[[File:Foxglove.jpg|thumbnail|Digitalis (Foxglove) is the natural predecessor of the cardiac glycoside digoxin which can also mimic aconitum toxicity]]
*Accidental Ingestion vs Suicidal attempt
*Accidental Ingestion vs Suicidal attempt
*Aconitum Poisoning
*Aconitum Poisoning
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*Cardiac Glycoside Ingestion
*Cardiac Glycoside Ingestion
**Including both pharmaceuticals and ''digitalis'' (Foxglove), which is similar in appearance to Aconitum
**Including both pharmaceuticals and ''digitalis'' (Foxglove), which is similar in appearance to Aconitum
[[File:Veratrum Viridae.jpg|thumbnail|Veratrum Viridae (False Hellebore) has a similar toxic profile as aconitum]] [[File:Death Camas.jpg|thumbnail|Zigadenus glaberrimus (Sandbog Death Camas) has a similar toxic profile as aconitum]] [[File:Larkspur.jpg|thumbnail|Delphinium (Larkspur) has a similar toxic profile as aconitum]] [[File:Foxglove.jpg|thumbnail|Digitalis (Foxglove) is the natural predecessor of the cardiac glycoside digoxin which can also mimic aconitum toxicity]]


==Evaluation==
==Evaluation==
*EKG
*[[EKG]]
*Elevated CPK and troponin levels with or without myocardial infarction may occur
*Elevated CPK and [[troponin]] levels with or without myocardial infarction may occur
*Hypokalemia often noted
*Hypokalemia often noted
*Acid-base disorder including Respiratory acidosis, Respiratory alkalosis, and metabolic acidosis common
*Acid-base disorder including [[respiratory acidosis]], [[respiratory alkalosis]], and [[metabolic acidosis]] common
*Hepatic and renal impairment are common
*Hepatic and renal impairment are common


==Management==
==Management==
*GI Symptoms
*GI Symptoms
**Administration of activated charcoal (0.5-1.0 gm/kg up to 50g) within 1 hour
**Administration of [[activated charcoal]] (0.5-1.0 gm/kg up to 50g) within 1 hour
***No prospective studies so recommendations are case dependent
***No prospective studies so recommendations are case dependent
***Avoid in patients actively vomiting or with altered mental status
***Avoid in patients actively vomiting or with altered mental status
**Gastric Lavage
**[[Gastric lavage]]
***Typically not recommended in most toxic ingestions due to risk of aspiration but applicable in plant ingestions because of large volume of organic material ingested
***Typically not recommended in most toxic ingestions due to risk of aspiration but applicable in plant ingestions because of large volume of organic material ingested
**Osmotic Laxatives
**Osmotic laxatives
**If in austere environment with limited resources and delayed extraction time:
**If in austere environment with limited resources and delayed extraction time:
***0.5 ounces (15mL) Syrup of Ipecac orally with 500mL of water
***0.5 ounces (15mL) [[Syrup of Ipecac]] orally with 500mL of water
***Manual induction of vomiting
***Manual induction of vomiting


*Cardiotoxic Effects
*Cardiotoxic Effects
**Hypotension
**Hypotension
***IV Fluids
***[[IV fluids]]
***Vasopressors if hypotension is persistent
***[[Vasopressors]] if hypotension is persistent
**Bradycardia
**[[Bradycardia]]
***Atropine
***[[Atropine]]
**Arrthymias
**[[Arrthymias]]
***Monitor patient on telemetry until 24hrs after symptomatic resolution
***Monitor patient on telemetry until 24hrs after symptomatic resolution
***Lidocaine, procainamide, flecainide, or amiodarone
***[[Lidocaine]], [[procainamide]], [[flecainide]], or [[amiodarone]]


*Neurotoxic Effects
*Neurotoxic Effects
**Seizure Activity
**[[Seizure]] activity
***Benzodiazepines
***[[Benzodiazepines]]


*Respiratory Failure
*Respiratory Failure
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#Chisholm, Hugh, ed. (1911). "Aconite" . Encyclopædia Britannica. 1 (11th ed.). Cambridge University Press. pp. 151–152
#Chisholm, Hugh, ed. (1911). "Aconite" . Encyclopædia Britannica. 1 (11th ed.). Cambridge University Press. pp. 151–152
#USDA National Resources Conservation Services. Plant Profile Aconitum L. Monkshood https://plants.usda.gov/core/profile?symbol=ACONI. Accessed 4/26/2019.
#USDA National Resources Conservation Services. Plant Profile Aconitum L. Monkshood https://plants.usda.gov/core/profile?symbol=ACONI. Accessed 4/26/2019.


[[Category:Toxicology]]
[[Category:Toxicology]]
[[Category:Environmental]]
[[Category:Environmental]]

Revision as of 03:44, 17 May 2019

Background

Aconite
Monkshood
A map of the distribution of Aconitum across the United States

Aconitum spp is a genus of over 250 flowering plants including Monkshood, Wolf's bane, Aconite, Leopard's bane, mousebane, blue rocket, and queen of poisons. In the United States, most poisonous flower ingestions are accidental ingestions by children and account for roughly 2% of all toxic exposures; aconitum is not a commonly ingested flower in the United States, though is responsible for significant morbidity and mortality worldwide. Traditionally, most cases of adult ingestion of toxic flowers that lead to significant symptoms are suicidal attempts. A recent increase in aconitum poisoning has been reported secondary to an increase in available herbal medications utilizing the plant. All parts of Aconitum are toxic, with the roots being most toxic. Toxicity is due to Aconite alkaloids bind to open voltage-gated sodium channels, producing a hyperpolarized state, with permanent activation of the channels. Most herbal preparations undergo decoction process where plant is boiled to hydrolize alkaloids.

Clinical Features

  • Estimated lethal dose of wild plant is 1g
  • Symptom onset typically between 3 minutes and 6 hours after ingestion with gradual progression of severity
  • Nonspecific GI symptoms
    • Nausea, vomiting, diarrhea
  • Neurotoxicity toxicity
    • Dizziness
    • Perioral paresthesia
    • Visual impairment
    • Ataxia
    • Paralysis
    • Seizures
    • Coma
  • Cardiotoxicity
    • May present with chest pain, palpitations, and syncope
    • Hypotension
    • Bradycardia
    • Most common cause of mortality are arrhythmias which include heart block, ectopic beats, supraventricular tachycardia, bundle branch block, junctional escape rhythms, ventricular tachycardia, bifascicular ventricular tachycardia, polymorphic ventricular tachycardia, torsades de pointes, ventricular fibrillation, and asystole
    • Cardiotoxic effects are often persistent and recurrent due to delayed clearance of toxic alkaloids
  • Respiratory Toxicity
    • Respiratory muscle paralysis often necessitates intubation or leads to death

Differential Diagnosis

Veratrum Viridae (False Hellebore) has a similar toxic profile as aconitum
Zigadenus glaberrimus (Sandbog Death Camas) has a similar toxic profile as aconitum
Delphinium (Larkspur) has a similar toxic profile as aconitum
Digitalis (Foxglove) is the natural predecessor of the cardiac glycoside digoxin which can also mimic aconitum toxicity
  • Accidental Ingestion vs Suicidal attempt
  • Aconitum Poisoning
  • Other toxic plant ingestion
    • Including plants with similar symptoms and management such as Veratrum spp (American hellebore), Zigadenus spp (Death Camas), and Delphinium spp (Larkspur) the former two of which are often mistakenly ingested due to their similarity to non-toxic, edible plants
  • Non-toxic plant ingestion
  • Cardiac Glycoside Ingestion
    • Including both pharmaceuticals and digitalis (Foxglove), which is similar in appearance to Aconitum

Evaluation

Management

  • GI Symptoms
    • Administration of activated charcoal (0.5-1.0 gm/kg up to 50g) within 1 hour
      • No prospective studies so recommendations are case dependent
      • Avoid in patients actively vomiting or with altered mental status
    • Gastric lavage
      • Typically not recommended in most toxic ingestions due to risk of aspiration but applicable in plant ingestions because of large volume of organic material ingested
    • Osmotic laxatives
    • If in austere environment with limited resources and delayed extraction time:
      • 0.5 ounces (15mL) Syrup of Ipecac orally with 500mL of water
      • Manual induction of vomiting
  • Respiratory Failure
    • May require intubation and mechanical ventilation
  • Suicidal Ideation
    • Obtain detailed history as to why plant was ingested
    • If suicidal ideation is suspected, consider psychiatric referral

Disposition

  • All patients suspected of aconitum ingestion should be admitted for 48 hours regardless of symptom presence due to sudden onset of severe symptoms

References

  1. Graeme, Kimberlie A. "Ch. 65 Toxic Plant Ingestions." In Auerbach, Paul S.; Cushing, Tracy A.; Harris, N. Stuart. Auerbach's Wilderness Medicine (7th ed.).Philadelphia: Elsevier, Inc.
  2. "Poisoning." Forgey, William W. Wilderness Medicine Beyond First Aid (5th ed.). Guilford, Connecticut: The Globe Pequot Press.
  3. Adami, Francesco; Paganussi, Peter; Perone, Giovanna; Bera, Paola; Braga, Giosue; Concoreggi, Carlo. Recurrent Ventricular Arrhythmia Caused by Ingestion of Aconitum (Monkshood) Flowers. Wilderness & Environmental Medicine (2018); 29(4): 411-416.
  4. Chisholm, Hugh, ed. (1911). "Aconite" . Encyclopædia Britannica. 1 (11th ed.). Cambridge University Press. pp. 151–152
  5. USDA National Resources Conservation Services. Plant Profile Aconitum L. Monkshood https://plants.usda.gov/core/profile?symbol=ACONI. Accessed 4/26/2019.