Difference between revisions of "Aconitum toxicity"

(Clinical Features)
Line 8: Line 8:
 
*Symptom onset typically between 3 minutes and 6 hours after ingestion with gradual progression of severity
 
*Symptom onset typically between 3 minutes and 6 hours after ingestion with gradual progression of severity
 
*Nonspecific GI symptoms  
 
*Nonspecific GI symptoms  
**Nausea, vomiting, diarrhea
+
**[[Nausea]], [[vomiting]], [[diarrhea]]
 
*Neurotoxicity toxicity
 
*Neurotoxicity toxicity
**Dizziness
+
**[[Dizziness]]
 
**Perioral paresthesia
 
**Perioral paresthesia
 
**Visual impairment
 
**Visual impairment
**Ataxia  
+
**[[Ataxia ]]
 
**Paralysis
 
**Paralysis
**Seizures
+
**[[Seizures]]
 
**Coma
 
**Coma
 
*Cardiotoxicity
 
*Cardiotoxicity
 
**May present with chest pain, palpitations, and syncope
 
**May present with chest pain, palpitations, and syncope
**Hypotension
+
**[[Hypotension]]
**Bradycardia
+
**[[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
 
**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  
 
**Cardiotoxic effects are often persistent and recurrent due to delayed clearance of toxic alkaloids  
*Respiratory Toxicity
+
*Respiratory toxicity
 
**Respiratory muscle paralysis often necessitates intubation or leads to death
 
**Respiratory muscle paralysis often necessitates intubation or leads to death
  

Revision as of 03:46, 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
  • Neurotoxicity toxicity
  • 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.