cardiac toxins- plants dr julian johny thottian. case 18 yr old unmarried pregnant tamilian female...

Cardiac toxins- Plants

Dr Julian Johny Thottian

Case

• 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting

• PR – 38/mt irregular BP – 90/60mmHg• No focal deficits• Toxic look• CVS- S1 varying S2 with normal split• Chest – NVBS

• Alleged consumption of Nerium Seeds from work site

Investigations

Hb -11.2gm%, TC-11220/cm3 , PLT – 220000/cm3 ESR- 16mm/1st hr

DAY Na( meq/l)

K(meq/l) Bld Urea S creat

1 142 4.1 18 0.6

2 136 3.6 22 0.6

3 138 3.9 19 0.8

4 140 4.5 29 0.6

5 136 4.5 26 0.9

6 138 4.2 26 0.8

ECG before pacing – 24hrs after consumption

Paced

Day 7- when pacing was removed

Patient stay in hospital was uneventful and treated with orciprenaline , electrolyte correction & antibiotic. Patient removed from temporary pacing

• Discharged on the 8th day.

Cardiac Glycosides

Nerium- white oleander (kaner)

• Dogbane family • Ornamental shrub with white & pink flowers• All parts are poisonous including the smoke

while burning• Used as an abortifacient, homicide and suicide• Fatal dose – 15-20 gms of root• Fatal period – 24 to 36 hrs

Cerebra thevetia- yellow oleander ( pila kaner)

• Fatal dose : 8-10 seeds, 15-20gms of root, 5-10 leaves

• Fatal period 2-3hrs

Cerebera odallam (pili kirbir)

• Fatal dose – kernel of one fruit• Fatal period -1-2 days

Aconite (mitha zeher- monk`s hood)

• All parts are poisonous especially the root• Clinical features- nausea , vomiting , profuse

sweating• Hippus • Hypotension, AV BLOCK• Fatal dose – 1gm of root• Fatal period – 1-8 hrs• Treatment –Gastric lavage , atropine

Cleistanthus collinus (oduvan)

• Closely related- it is a glucoside• Blocks cardiac conductive system• Conduction defects• Fatal dose – 200-400gms of leaves• Fatal period – 1-3 days

POPULARITY AS A POISON

• In Sri Lanka, cases of attempted suicide with yellow oleander were extremely rare before 1980. During that year, the deaths of two girls who intentionally ate yellow oleander seeds was widely reported in local newspapers. The practice suddenly became so popular that the number of cases admitted to Jaffna hospital increased from zero in 1979 to 103 in 1983. QJM (1999) 92 (9): 483-485. doi: 10.1093/qjmed/92.9.483

Studies across the world

• Dept of internal medicine, Colombo- a study on 300 patients -Ventricular ectopics and tachycardias are common in digoxin-poisoned patients, but are less common in oleander-poisoned patients

• 53% had AV node conduction block, while 62% had sinus node block; 30% had conduction block affecting both nodes. Only 1% had ventricular tachycardias and 8% had ventricular ectopics

• They report that most of the deaths are due to ventricular arrhythmia

• Mortality is 20% in their study.

Electrocardiography

Increased PR interval, T wave flattening or inversion

Tachyarrhythmias Bradycardia & heart block – SA block and AV Block

Management

• Induction of emesis & activated charcoal

Administering Atropine for severe bradycardia Using Phenytoin or Lidocaine hydrochloride to control arrhythmia. Placing a temporary venous pacemaker Electrical counter shock Digoxin-specific Fab antibody fragments (Digibind).

• Osterloh et al calculated the lethal oleander leaf dose of their patient to be approximately 4 gm.

THANK YOU