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Chinese Herbal Medicine (CHM) Poisoning

HKCEM College Tutorial. Chinese Herbal Medicine (CHM) Poisoning. AUTHOR Dr Tse Man Li August, 2013. Presentation. A 55 year old lady with no significant past medical health history Complained of numbness first affecting her face then progressed to her hands and feet since 1 hour ago

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Chinese Herbal Medicine (CHM) Poisoning

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  1. HKCEM College Tutorial Chinese Herbal Medicine (CHM) Poisoning AUTHOR Dr Tse Man Li August, 2013

  2. Presentation • A 55 year old lady with no significant past medical health history • Complained of numbness first affecting her face then progressed to her hands and feet since 1 hour ago • And nausea, vomiting and dizziness • Her vitals • GCS 15/15, BP80/50, P45, RR18/min., SpO2 98% (Rm Air) • H’stix 7 mmol/L

  3. Hyperventilation?

  4. Hyperventilation Unlikely • Hypotension, bradycardia • RR18 without respiratory complain • Precipitating factor present?

  5. What will you do?

  6. Manage in resuscitation room • IV fluid • ECG and electrolytes +/- ABG

  7. What history will you ask?

  8. Food intake Hx • Puffer fish • Big coral fishes: Ciguatera poisoning • Shellfish: neurotoxic, paralytic • Pesticide contamination Others • Mad honey (Grayanotoxin) • Sodium monoglutamate

  9. Herb Intake Hx • Aconite root (烏頭) • Natural cardioactive steroid containing herbs Others (less likely) • Gelsemium elegans (斷腸草) • Rhododendron flower (鬧羊花) • Veratrum spp.root & rhizoma(黎蘆) • Sophora flavescens root (苦蔘) • Sophora tonkinensis root (山頭根)

  10. Progress-Hx • The patient had taken some Chinese Herbal Medicine (CHM) dispensed from a herb shop 2 hour ago. • The numbness and nausea onset 30 minutes after the intake. • ECG monitor: (next slide)

  11. ECG tracing: Junctional bradycardia Frequent VEBs Possible triplet or short run VT?

  12. What will you do?

  13. Management • IV fluid • Anti-arrhythmics: • Amiodarone • Magnesium • Correct any electrolyte abnormalities

  14. What else?

  15. Collect the following and send to HA Toxicology Reference Lab for analysis if possible: • Biological samples (urine and blood) • Herb remnants • Unused herbs • Trace the CHM formula and consult HKPIC for interpretation

  16. The Formula 熟附子1兩半 烏梅1兩雞內金三錢

  17. What is the likely cause of her signs and symptoms?

  18. Clinical Features of Aconite Poisoning • Typical clinical triads of • GI symptoms • Nausea, vomiting, abdominal pain, diarrhoea • Numbness • Paresthesia, weakness(rarely) • Cardiovascular effect • Hypotension, • AV blockage,, • ventricular ectopics , ventricular tachycardia, ventricular fibrillation • Prolong QT, Torsade de pointes • Overdose of Fuzi (熟)附子 • 一両半(15錢) = 45g • Recommended dose <15g

  19. What is Aconite ?

  20. Aconite Poisoning • Aconite is a plant genus that contain toxic aconite alkaloids e.g. aconitine, mesaconitine, yunaconitine…. • Aconite alkaloids are sodium channel effectors that are neurotoxic and highly cardiotoxic • Their roots are used in Chinese Herbal Medicine usually after curing(炮掣): • 川烏 ,草烏,附子,附片,雪上一枝蒿 • Aconite poisoning is the commonest acute Chinese Herbal Medicine related poisoning in Hong Kong and China. ~10 cases are reported annually. • Aconite poisoning is usually severe and can be fatal

  21. 3 commonest causes of poisoning • The commonest causes are: • Overdose Suggested ceiling dose in Chinese Pharmacopeia 2010 Ed: • 川烏Radix Aconiti /草烏Radix Aconiti Kusnezoffii : 一錢(3g) • 附子Radix Aconiti Lateralis : 五錢(15g) • Improper curing/boiling • Contamination of benign herb by plant parts of aconite spp (hidden aconite poisoning)

  22. Management • Activated Charcoal is presented early • Supportive: • IV fluid, atropine for bradycardia, inotroph e.g. dopamine • Anti-arrhythmics: • Amiodarone, • Magnesium • Charcoal haemoperfusion in resistant case • Cardiopulmonary bypass

  23. Management • Potential public interest • Call HKPIC / Notify Department of Health • Outbreak control may be needed particularly for hidden aconite poisoning

  24. Other common acute poisonings associated with CHM

  25. Gelsemium elegans (斷腸草) • Gelsemine and related toxins • Causes bulbar and extra-ocular muscle weakness • Coma and respiratory failure if severe • Management is supportive • Common Causes • Contamination of benign herb e.g.五指毛桃 fruit of Focus plant • Mis-identfication • Intake of parasitic plant growing on Gelsemium elegans

  26. Cardioactive Steroid-containing Herbs & Plants • Naturally occurring cardioactive steroids acts on the Na+/K+ ATPase of cardiocyte, e.g. digitotoxin in Digitalis plants. • Poisoning resembles Digoxin overdose • Present in Chinese herbs: • Toad venom (蟾酥), • Tupistra chinensis (川七or 開口箭) • Also in toxic plants found in HK: • Nerium orleander (紅花甲竹桃), Thevetia perviana (黃花甲竹桃), Strophanthus divaricatus (羊角拗), Cerbera manghas (海芒果) • Poisoning resembles digoxin overdose • Cross-react with some digoxin essay in HA Labs • Digoxin antibody is useful

  27. Anti-cholinergic Poisoning • Typically presents as confusion, delirium, visual hallucination within a few hours after CHM use • Some presents with partial anti-cholinergic toxidrome: • Dilated pupils (blindness) • Dry mucous membrane and skin (dryness) • Urinary retention (fullness) • Red hot skin +/- fever (redness & hotness) • Delirium (madness) • Tachycardia, GI symptoms • Solanaceae or tropane alkaloids e.g. atropine, hyocyamine, scopolamine • Commonest cause: • Substitution of benign herb by Datura flower(洋金花) • Contamination of other benign herb by other unidentified toxic Solanaceae plants • Physostigmine is a effective antidote

  28. Thank You

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