Anticholinergic Plant Poisoing


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Anticholinergic Plant Poisoing

  2. 2. Food poisoning vs Ingestion poisoning <ul><li>? Outbreak of ‘food poisoning’ in an old people home </li></ul><ul><li>Eleven patients of age ranging from 60-70yrs brought to ER with common history of ‘ingestion’ of some unknown “bitter” green leafy vegetable two hours prior </li></ul><ul><li>All but one became symtomatic 30-45min after ingestion and had common symptoms of blurred vision and altered mental status. Two had dysarthria and one was comatose. </li></ul>
  3. 3. Examination <ul><li>Vitals : tachycardia, hypertension, elevated temperature </li></ul><ul><li>HEENT: pupils dilated with poor rxn, dry tongue </li></ul><ul><li>Skin : dry and warm skin </li></ul><ul><li>CVS/Resp/Abd: unremarkable </li></ul><ul><li>CNS: Confusion, Delirium, Decreased level of consciousness, Agitation </li></ul>
  4. 4. Operational diagnosis <ul><li>Unknown Poisoning </li></ul><ul><li>Plant poisoning </li></ul><ul><li>Stimulant plant poisoning </li></ul><ul><li>Stimulant plant poisoning with anticholinergic syndrome </li></ul><ul><li>Anticholinergic plant poisoning with tropane alkaloids </li></ul><ul><li>? Datura poisoning </li></ul>
  5. 5. Management <ul><li>Police informed </li></ul><ul><li>Poison information centre called </li></ul><ul><li>Help sought from other departments </li></ul><ul><li>Supportive treatment instituted- O2 therapy, IV access </li></ul><ul><li>Other hospitals communicated- 5 patients transferred to Patan hospital </li></ul><ul><li>Patients constantly monitered, supportive therapy continued (everyone later developed urinary retention and were catheterised). </li></ul><ul><li>Patients were observed in ER overnight and discharged in the morning </li></ul>
  6. 7. ANTICHOLINERGIC PLANT POISONING TROPANE ALKALOIDS – found in all parts of plant, with highest concentrations in roots and seeds Hyoscyamine Hyoscine (Scopolamine) Atropine Mandragorine PLANTS CONTAINING TROPANE ALKALOIDS Dhatura spp. a common recreational hallucinogen Hyoscyamus niger Atropa belladonna Mandragora officinarum Brugmansia spp. Lycium halimiforium Cestrum nocturnum
  7. 14. EPIDEMIOLOGY: Incidence: No national data Common poisoning Usually sporadic, but may occur in clusters Mode of poisoning: ~ recreational overdose ~ ingestion of contaminated foods such as Paraguay tea, hamburger, honey , homemade ‘moonflower’ wine or stiff porridge made from contaminated millet ~ accidental ingestion as edible wild vegetable Mortality: Death rare ( 1993 CDC data reports 2 deaths among 318 cases of Dhatura poisoning in US)- due to trauma sustained during delirium
  8. 15. <ul><li>CLINICAL PRESENTATION </li></ul><ul><li>Symptoms usually occur 30-60min after ingestion and includes a classical anticholinergic syndrome </li></ul><ul><li>Dryness of mouth </li></ul><ul><li>Dyphagia and dysarthria </li></ul><ul><li>Blurred vision and photophobia </li></ul><ul><li>Urinary retention </li></ul><ul><li>Altered mental status- from amnesia and confusion, agitation and hallucination to seizures and coma </li></ul>
  9. 16. Signs Vital signs Tachycardia Hypertension Elevated temperature - hyperthermia HEENT Mydriasis and cycloplegia Dry mucous membrane Skin Warm, dry and flushed Neurological Altered mental status- Agitation Delirium (acute confusional state + hallucination) Muscle inco-ordination, respiratory depression, seizures and coma (rare) Abdomen Diminished bowel sounds Distended urinary bladder
  10. 17. INVESTIGATION: No specific diagnostic studies exist- TIME SHOULD NOT BE WASTED IN ATTEMPTING TO IDENTIFY PLANTS Physostigmine test : if relative certainty cannot be established that toxicity present is due to tropane alkaloid poisoning. It precludes unnecessary CT head and LP. Toxicological analyses is useful in sporadic cases only if co-ingestion of other substance most commonly acetaminophen and salicylate is suspected. ECG if there is marked tachycardia CPK and Urinalysis : if rhabdomyolysis is suspected Blood urea, Serum creatinine, Na and K : to rule out prerenal ARF
  11. 18. TREATMENT Principles: 1 . Control of Agitation 2. Protection from self harm EMERGENCY DEPARTMENT CARE Follow ABCDE of Emergency Medicine Consider GI Decontamination foremost 1.Emesis by Ipecac- contraindicated 2.Gastric Lavage-controversial (increased risk of aspiration!) 24-32 F tube in children 36-42 F tube in adult 3. Activated Charcoal- useful 1-2g/kg po or via nasogastric/orogastric tube Can be repeated after 4-6 hrs
  12. 19. Treatment is largely SUPPORTIVE! Agitation/Hallucination: Reassurance Dark room Chemical restraint with Benzodiazepines Diazepam 5-10mg IV (adults) 0.2-0.5mg/kg IV (children) Lorazepam 1-2mg IV (adults) 0.05mg IV (children) HALOPERIDOL IS CONTRAINDICATED ! Physical restraint – risk of rhabdomyolysis Seizures Diazepam Phenobarbitone Urinary retention Foley catheterisation Urine output should be maintained at 1-2ml/kg/hr
  13. 20. Use of Specific Antidote – PHYSOSTIGMINE- is controversial (risk of cholinergic crisis) Indications: 1. Unresponsive to supportive treatment 2. Tachyarrhythmias with hemodynamic compromise 3. Intractable seizures unresponsive to benzodiazepine 4. Extremely sever agitation or psychosis Hemodialysis and Hemoperfusion is not useful because of high lipid solubility of tropane alkaloids
  14. 21. DISPOSITION: Asymptomatic patients – discharged after 4-6 hrs of observation Symptomatic patients – admitted in ICU setting for monitoring and treatment; and discharged after a symptomfree interval of 6 hrs without supportive treatment or antidote. (symptoms may persist for 24-48hrs)
  15. 22. Beauty lies in the eyes of the beholder.