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Cardiac toxins- Plants

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

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Cardiac toxins- Plants

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  1. Cardiac toxins- Plants Dr Julian JohnyThottian

  2. 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

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

  4. ECG before pacing – 24hrs after consumption

  5. Paced

  6. Day 7- when pacing was removed

  7. Patient stay in hospital was uneventful and treated with orciprenaline , electrolyte correction & antibiotic. Patient removed from temporary pacing • Discharged on the 8th day.

  8. Cardiac Glycosides

  9. Nerium- white oleander (kaner)

  10. 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

  11. Cerebra thevetia- yellow oleander ( pilakaner)

  12. Fatal dose : 8-10 seeds, 15-20gms of root, 5-10 leaves • Fatal period 2-3hrs

  13. Cereberaodallam (pilikirbir)

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

  15. Aconite (mithazeher- 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

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

  17. 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

  18. 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.

  19. Electrocardiography Increased PR interval, T wave flattening or inversion TachyarrhythmiasBradycardia& heart block – SA block and AV Block

  20. 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).

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

  22. THANK YOU

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