Difference between revisions of "Aconitum toxicity"

(Clinical Features)
(Clinical Features)
 
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[[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 toxicToxicity 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.  
+
*''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 US, it is not a commonly ingested flower, but is responsible for significant morbidity and mortality
 +
**Most poisonous flower ingestions are accidental ingestions by children, which account for roughly 2% of all toxic exposures
 +
**Traditionally, most cases of adult ingestion of toxic flowers that lead to significant symptoms are [[suicide|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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*Neurotoxicity toxicity
 
*Neurotoxicity toxicity
 
**[[Dizziness]]
 
**[[Dizziness]]
**Perioral paresthesia
+
**Perioral [[paresthesia]]
 
**Visual impairment
 
**Visual impairment
**[[Ataxia ]]
+
**[[Ataxia]]
**Paralysis
+
**[[weakness|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
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**[[Arrhythmias]]- most common cause of mortality, include:
 +
***[[Heart block]]
 +
***Ectopic beats
 +
***[[SVT|Supraventricular tachycardia]]
 +
***[[Bundle branch block]]
 +
***Junctional escape rhythms
 +
***[[Ventricular tachycardia]], bifascicular ventricular tachycardia, [[polymorphic ventricular tachycardia]], [[torsades de pointes]]
 +
***[[Ventricular fibrillation]]
 +
***[[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
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**[[respiratory failure|Respiratory muscle paralysis]] often necessitates [[intubation]] or leads to death
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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[[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: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]]
 
[[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
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*Accidental Ingestion vs [[suicide|suicide attempt]]
 
*Aconitum Poisoning
 
*Aconitum Poisoning
 
*Other toxic plant ingestion
 
*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
 
**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
 
*Non-toxic plant ingestion
*Cardiac Glycoside Ingestion
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*Cardiac glycoside ingestion
**Including both pharmaceuticals and ''digitalis'' (Foxglove), which is similar in appearance to Aconitum
+
**[[Digoxin toxicity|Digoxin]] or ''[[digitalis toxicity|digitalis]]'' (Foxglove), which is similar in appearance to Aconitum
  
 
==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 failure|Hepatic]] and [[renal failure|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
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**[[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]]
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**[[Bradycardia]]
 
**[[Bradycardia]]
 
***[[Atropine]]
 
***[[Atropine]]
**[[Arrthymias]]
+
**[[Arrhythmias]]
 
***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
 
 
**May require intubation and mechanical ventilation
 
**May require intubation and mechanical ventilation
 
+
*Suicidal ideation
*Suicidal Ideation
 
 
**Obtain detailed history as to why plant was ingested
 
**Obtain detailed history as to why plant was ingested
 
**If suicidal ideation is suspected, consider psychiatric referral  
 
**If suicidal ideation is suspected, consider psychiatric referral  

Latest revision as of 17:06, 28 September 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 US, it is not a commonly ingested flower, but is responsible for significant morbidity and mortality
    • Most poisonous flower ingestions are accidental ingestions by children, which account for roughly 2% of all toxic exposures
    • 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

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 suicide 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

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
  • Cardiotoxic effects
  • Neurotoxic effects
  • 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.