Aconitum poisoning

Substance

Aconitum 烏頭鹼

本草備藥:  

烏頭: 母. 川烏(四川) , 草烏(野生). 

附子: 附生者

側子: 連生者 

天雄: 形狀細長者

烏喙:形狀兩歧者

五物同出異名 

Common name or Trade name

今中醫中藥所使用附子為烏頭Aconitum carmichaeli Debx.的子根經中藥炮製切片而成

川烏為 烏頭Aconitum carmichaeli Debx.的乾燥母根

草烏為 北烏頭Aconitum kusnezoffii Reichb.的乾燥塊根。[1]

Involving system

-          Mechanism: aconite alkaloids are the fast voltage-gated sodium channel and cause persistent activation. [2]

 

Presentation

-          Altered mental status. [3]

-          Shock [3]

-          Cardiac arrhythmia. [3];

-       BVT, Bidirectional Ventricular Tachycardia:  

-          ventricular dysrhythmia (83%); ventricular fibrillation (23%); Torsade De pointes (9.2%). [2]

-       Bradycardia with hypotension:  (activation of the ventromedial nucleus of the hypothalamus.)

-          Death. [3]

 

Antidote and Treatment

-          Procainamide 100mg IV direct q5 minutes to a maximum of 1 g then maintenance infusion 2 - 6mg/min. (class Ia)

-          Mexiletine 200mg q8h. (class Ia)

-          Amiodarone 150mg stat. then 6支泡500 cc D5W run 34cc/ hr * 6hrs (class III)

then run 17cc/hr.* 18 hrs.

-          CPCR (23%) [3]

-          ECMO [2]

-          Hemoperfusion [2].

 

 

Disposition

Mortality rate: 15% [3]

MICU or CCU if hemodynamic changes/arrhythmia.

 

References

 

[1] Ref: http://yibian.hopto.org/esay/?eno=29

[2]. Coulson JM, Caparrotta TM, Thompson JP. The management of ventricular dysrhythmia in aconite poisoning. Clin Toxicol (Phila). 2017;55(5):313–321. doi:10.1080/15563650.2017.1291944

[3]. 2019 International Conference for Poison Control and Research Development.

 

-- March 19, 2020  

 

-- April 12, 2023   revised. by  Yu-Jang Su.

Atractyloside poisoning

Substance

Atractyloside poisoning

蒼朮苷是菊科植物蒼朮的的根莖中化合物

Common name or Trade name

白术 蒼朮

中藥炮製, 經水煮可以去除毒性. [1]

 

Involving system

抑制mitochondrial的氧化磷酸化作用，影響Krebs循環 [2]   
 

Presentation 

Altered mental status. Convulsion

Vomit, diarrhea. Fever, Abdominal pain, Jaundice.

Metabolic acidosis

hypoglycemia

Acute hepatic or renal pathology [3] 

Antidote and Treatment

Support care [2]

Glucose if hypoglycemia. [2]
 

Disposition

If involves consciousness, organ function deterioration, hemodynamic change: admission. 

 

 

References

[1]. Chen LY, Hu A, Chang CJ. The degradation mechanism of toxic atractyloside in herbal medicines by decoction. Molecules. 2013;18(2):2018–2028. Published 2013 Feb 5. doi:10.3390/molecules18022018

 

[2]. Yip L. 2019 International Conference for Poison Control and Research Development. 2019 Nov 15—7.

 

[3]. Stewart MJ, Steenkamp V. The biochemistry and toxicity of atractyloside: a review. Ther Drug Monit. 2000;22(6):641–649. doi:10.1097/00007691-200012000-00001

-- 18th March, 2020 Yu-Jang Su.

 

海檬果

Substance

Cerbera Odollam

Photo: https://www.123rf.com/photo_73477720_seed-of-pong-pong-tree-suicide-tree-pong-pong-othalanga-cerbera-odollam-.html

 

Common name or Trade name

Pong-Pong Seeds

海檬果.

Cerberus Tree

Sea Mango

Othalanga [1]

Suicide tree

 

Involving system

Cardiac glycosides related arrhythmia

Strong cardiotoxic effects [1] 


Presentation

Nausea, vomiting, thrombocytopenia [1]

Hyperkalemia [1, 2]

Heart block [2] ECG abnormalities [1].

Death [2]

 

Antidote and Treatment

 

Supportive therapy [1]

Atropine followed by temporary pacemaker insertion [1]

Administration of digoxin immune Fab may be considered in severe cases [1]  
Disposition

Hospitalization.

  References

[1] Menezes RG, Usman MS, Hussain SA, et al. Cerbera odollam toxicity: A review. J Forensic Leg Med. 2018;58:113–116. doi:10.1016/j.jflm.2018.05.007 

[2] Wermuth ME, Vohra R, Bowman N, Furbee RB, Rusyniak DE. Cardiac Toxicity from Intentional Ingestion of Pong-Pong Seeds (Cerbera Odollam). J Emerg Med. 2018;55(4):507–511. doi:10.1016/j.jemermed.2018.05.021


-- edited 21th Feb, 2020 Yu-Jang Su.

 

Urinary alkalization and urinary acidification in poisoning

 

尿液鹼化原理是毒物從經由腎臟排除, 毒物為弱酸性的情況, 分佈於細胞外液並且protein binding不強. (像NSAID與protein binding強就無用)

 尿液鹼化適應症:

l  中重度salicylate毒性未達hemodialysis程度

(水楊酸中毒血液透析適應症: https://twmmhedpc.blogspot.com/2019/12/poison-hemodialysis-is-helpful.html

l  Phenobarbital (多劑量activated charcoal較優)[1].

 

l  Chlorophenoxy herbicides (2-4-dichlorophenoxyacetic acid and mecoprop): 須高尿流量 600 mL/h 較有效 [2, 3], forced diuresis 也是有幫忙的[4]

 

l  Chlorpropamide: supportive care/IV dextrose normally sufficient.

 

l  Toxicities of High-Dose Methotrexate [5]

 

尿液鹼化禁忌症

l  本來患者狀況fluid就overload

l  Renal impairment: CKD, uremia.

l  本來血鉀就很低(Uncorrected hypokalemia), 避免低血鉀引發VT [6] 最好keep 血鉀在4—4.5 mEq/L [7] 
 

尿液鹼化併發症:

l  Hypokalemia.

l  Volume overload.

l  鹼血症(Alkalemia);

l  輕度Hypocalcemia
 

尿液鹼化做法:

NaHCO₃^- 1 amp in N/S 1 BT run 125 ml, 有uremia, CHF, CKD 需調整滴速 [8]

1–2 mEq/kg IV bolus followed by 2 mEq/kg per h IV infusion

Sodium bicarbonate 4 amps in D5W 500ml run 250 mL/hr. (可以加20 mEq of potassium chloride避免低血鉀)

Keep urine output of 1 to 2 mL/kg per hour

 

尿液鹼化監測

urine pH 每 15 to 30分測尿的pH 保持7.5 to 8.5.

尿液鹼化曾用於Brazil 與 Iran的organophosphate poisoning 但並無有效實證。[9], 另抗發炎製劑Diflunisal和NSAID 也是無效 [10].

 

尿液酸化

urinary acidification 可以增加弱鹼的移除(包括 amphetamines和phencyclidine), 但產生的相關危險性(例如 rhabdomyolysis) 往往超過尿液酸化原本的好處.  

尿液酸化對MAOI的移除是無效的[4]

REFERENCES

 

[1]: Lindberg MC, Cunningham A, Lindberg NH. Acute phenobarbital intoxication. South Med J. 1992;85(8):803–807. doi:10.1097/00007611-199208000-00004

 

[2]: Bradberry SM, Proudfoot AT, Vale JA. Poisoning due to chlorophenoxy herbicides. Toxicol Rev. 2004;23(2):65–73. doi:10.2165/00139709-200423020-00001

 

[3]: Roberts DM, Buckley NA. Urinary alkalinisation for acute chlorophenoxy herbicide poisoning. Cochrane Database Syst Rev. 2007;(1):CD005488. Published 2007 Jan 24. doi: 10.1002/14651858.CD005488.pub2

 

[4]: Tintinalli’s Emergency Medicine, 8th ed. P.1227

 

[5]: Howard SC, McCormick J, Pui CH, Buddington RK, Harvey RD. Preventing and Managing Toxicities of High-Dose Methotrexate. Oncologist. 2016;21(12):1471–1482. doi:10.1634/theoncologist.2015-0164

 

[6] Tsai IH, Su YJ. Thyrotoxic periodic paralysis with ventricular tachycardia. J Electrocardiol. 2019; 54:93–95. doi: 10.1016/j.jelectrocard.2019.04.001

 

[7] Tintinalli’s Emergency Medicine, 8th ed. P.1268.

 

[8]. Table 176-2. Tintinalli’s Emergency Medicine, 8^th ed. P.1208 -1212.

 

[9]. Tintinalli’s Emergency Medicine, 8th ed. P.1320.

 

[10]: Balali-Mood M, Prescott LF. Failure of alkaline diuresis to enhance diflunisal elimination. Br J Clin Pharmacol. 1980;10(2):163–165. doi:10.1111/j.1365-2125. 1980.tb01734.x

 

 

-- edited 11th Jan, 2020 Yu-Jang Su.