The presentation includes epidemiology of poisonous plants, classification based upon latest publication from poison centre- Sri Lanka. It goes in to details of Jatropha circus, Glorriosa superba, Thevetia Peruviana, Datura stramonium, Tabernaemantona dichotomy, Strychnus nut vomica toxicity.

1. POISONOUS PLANTS
Dr KTD PRIYADARSHANI
REGISRAR IN EMERGENCY MEDICINE
TEACHING HOSPITAL PERADENIYA
2023/04/19

2. OBJECTIVES
• Epidemiology
• Classification
• Jatropha circas
• Gloriosa superba
• Thevetia peruviana
• Datura stramonium
• Tabernaemantana dichotoma
• Strychnos nux vomica

7. CLASSIFICATION
GI toxin plants CVS Neurotoxic
1. Ca-Oxalate crystals
• Habarala
• Lucky plant
2. Toxalbumin
• Olinda
• Endaru
3. Colchicine
• Niyagala
4. Alkaloids
• Kepunkiriya
5. Amatoxin
• Mushrooms
1. Cardiac Glycosides
• Kaneru
• Diya kaduru
1. On CNS
• Goda Kaduru
2. Anticholinergic
properties
• Aththana
• Divi Kaduru
3. Cyanogenic glycosides
• Manioc
• Hodala

8. BEHETH ENDARU
Ricinus communis

9. TOXICITY
• Toxic part – seeds
• Toxic substance – toxalbumin (ricin)
• Lethal dose – 1mg/ kg
• If chewed 2 seeds are enough
• intact seeds doesn’t cause toxicity
• Toxicity –
• inhibition of protein synthesis, interference of apoptosis, direct cell
membrane damage, alteration of cell membrane structure and
function and release of inflammatory cytokine mediators

10. CLINICAL FEATURES
• Ingestion – within 4-6 hrs, but many late as 10 hrs
• Acute phase –
• GI symptoms,
• less commonly hematemesis, Malena
• Late phase –
• cytotoxic effects on liver, kidney and adrenals after 2-5 days
• Hypoglycemia, retinal hemorrhages, hematuria, convulsions, hepatic necrosis,
ARF
• Skin contact - anaphylaxis

11. MANAGEMENT
• If beans are chewed gastric lavage and activated charcoal
• Symptomatic management
• Fluid balance, hydration
• RFT,LFT,FBC,CPK – leukocytosis, increased transaminases, CPK, RFT,
bilirubin seen
• ALF & ARF manage appropriately
• Oral NaHCO3 used to alkalinize urine (benefit not known)

12. WETA ENDARU
Jatropha circas

13. TOXICITY
• Toxicity is same like beheth endaru.
• Difference is GI side effects appears faster, within 15 mins.

14. NIYAGALA
Gloriosa superba

16. TOXICITY
• Toxic part – all parts, highest is the tuber
• Toxic substance – colchicine
• Effect is mostly on cells with rapid turnover, so GI and bone marrow
• So diarrhea and decreasing absolute number of cells
• Lethal dose – adult – 6mg (10 g of tuber)
• Children – 0.5 to 0.8 mg/kg

17. CLINICAL FEATURES
Symptoms – 3 overlapping phases
• Phase 1 – first 24 hrs after ingestion
• N,V, numbness and tingling around mouth, throat burning, abd pain, bloody diarrhea
• Phase 2 – 24 hrs to 7 days after ingestion
• Multiorgan dysfunction
• BM suppression – marked leucopenia thrombocytopenia
• Ileus, resp depression, rhabdo, metabolic acidosis, liver, renal failure
• Metabolic – Ca, K, Na, Po4 reduction, occ hyperkalemia
• Coagulopathy, hematuria, altered mental status, seizures, coma, ascending polyneuropathy
• Ventricular arrhythmias
• Alopecia- 10 days
• Phase 3- Recovery

18. MANAGEMENT
• In very large ingestions gastric lavage, Activated charcoal
• Multiple doses can be given as enterohepatic circulation of colchicine
• Symptomatic management – dehydration, oxygen, metabolic acidosis,
antibiotics if leucopenia, coagulopathy
• Colchicine has high volume of distribution – forced diuresis, peritoneal
and hemodialysis, exchange transfusion not effective
• Forced diuresis with in first 24 hours- to eliminate colchicine- up to 3rd day
• Colchicine specific Fab fragments & filgrastim- but not tested

19. KAHA KANERU/ YELLOW OLEANDER
Thevetia peruviana

23. TOXICITY
• Toxic parts – all parts, highest the fruit
• Toxic substance – cardiac glycosides
• Toxicity –
• Reversible inhibition of Na/K ATPase pump
• Increase intracellular sodium and decrease
intracellular K- So intracellular Ca increases
• Cause enhanced cardiac contraction
• Ventricular premature contractions and
tachyarrhythmias
• Hyperkalemia due to elevated extracellular K
• Direct vagotonic effect – brady and heart
block

24. CLINICAL FEATURES
• clinical features of all Kaneru are similar and mimic digoxin poisoning
• But these has GI side effects
• N,V,D, abdominal pain within minutes, Irritation to mouth
• CNS effects – confusion, dizziness, drowsiness, weakness
• Visual disturbances – photophobia, mydriasis, scotomas, decreased color
vision and acuity
• Cardiac effects

25. MANAGEMENT
• Activated charcoal, Multiple doses of AC
• Monitor- PR, BP, Respiration, Cardiac monitoring, SE 4 hourly
• Convulsions- BDZ
• Bradycardia algorithm for bradycardia – maintain HR 60-90
• Atropine bolus
• Atropine infusion
• Transcutaneous pacing in severe brady

26. MANAGEMENT
• Hyperkalemia management –Ca- Stone heart- all were chronic digoxin
toxicity cases
• NaHCO3 bolus
• Insulin dextrose
• Correct hypomagnesemia
• Antidote – kaneru tab 800 mg irrespective of age, sex or body weight
• Dissolved in 100ml of NS given as Infusion over 20 min
• Digoxin large volume of distribution. so other methods not useful

28. PINK KANERU
Nerium oleander

29. MANAGEMENT
• All parts are toxic
• Contain several cardiac toxins
• Management is same as thevetia peruviana

30. ATHTHANA
Datura stramonium

34. TOXICITY
• Toxic parts – all parts contain in following decreasing order, Flowers,
stems, seeds, leaves, roots,
• Toxic substance – belladonna alkaloid – atropine, hyocyamine,
scopolamine
• Lethal dose – single seed ingestion is lethal

35. CLINICAL FEATURES
• Symptoms – anticholinergic
• starts from 30 minutes, last 24-48 hrs
• In mild poisoning – anticholinergic features
• Severe poisoning – SVT, Ventricular arrhythmias
• Agitation, confusion, delirium, hallucination, bizarre behavior
• Hyperthermia, rhabdomyolysis, coma, resp depression, ARF
• Direct ocular exposure – mydriasis, cycloplegia

36. MANAGEMENT
• Similar to atropine poisoning
• Gastric lavage, Multiple dose activated charcoal 4 hrly till stools become
black
• Symptomatic management
• Hyperthermia- external cooling
• Convulsions- BDZ
• Physostigmine in severe delirium and agitation

37. DIVI KADURU
Tabernaemantana dichotoma

38. TOXICITY
• Toxic part- Fruit
• Toxic substance - similar to Atropine, Strychnine, alkaloids

39. CLINICAL FEATURES
• Symptoms
• Mild – N,V,Hematemeis
• Severe - Dryness of the mucous membranes , thirst , dilatation of
pupils, Loss of consciousness, delirium, convulsions, hallucinations,
anxiety, agitation

40. MANAGEMENT
• Gastric lavage
• Activated charcoal
• Symptomatic management
• In severe agitated delirium give physostigmine 2mg IV slowly. It may be
repeated in 20 minutes (Pediatric dose is 0.5 mg IV slowly).
• If no improvement is observed, the dose may be repeated at 5 minute intervals
to a maximum of 2 mg.
• Hyperthermia- External cooling methods
• Convulsions, delirium - BDZ

41. GODA KADURU / BITTER NUT
Strychnos nux vomica

42. TOXICITY
• Toxic part – all parts, highest fruit
• Toxic substance – Alkaloid strychnine
• Toxicity – postsynaptic glycine R at brain stem and spinal cord
• Inhibitory effect is lost
• Hyperexcitability of muscles

43. CLINICAL FEATURES
• Symptoms – within 15 -30 minutes
• Prodromal stage lasts for 12 hours –
• apprehension, restlessness, Muscle twitching, cramps and
hyper-reflexes
• Clinical stage –
• violent seizures while being fully alert, Ophisthatonus, trismus,
risus sardonicus
• Repeated symmetrical painful convulsions. Hyperthermia,
metabolic acidosis, rhabdomyolysis, myoglobinuria and renal
failure
• Consciousness is lost following repeated convulsions and
death results from respiratory failure.

44. “risus sardonicus” ,
“trismus”(locked jaw) Opisthotornus

45. MANAGEMENT
• Quiet and dark environment
• Gastric decontamination not recommended as rapid absorption and
induction of seizures
• Symptomatic treatment
• Convulsions- BDZ
• Acidosis- bicarbonate
• Correct electrolytes
• Need treatment for weeks

46. REFERENCES
• Management of plant poisonings- national poisons information center
• Management of poisoning- Prof Ravindra Fernando 4th edition
• K S, Mundkur S, Aroor S, Kumar S, Kashyap H. Yellow Oleander Poisoning
in Children- A Report of Two Cases. Pediatr Oncall J. 2014;11: 117-118.
doi: 10.7199/ped.oncall.2014.65