ANTICHOLINERGIC ANTICHOLINERGIC PLANT POISONINGPLANT POISONING

Dr. Roshan KarkiDr. Roshan Karki

Food poisoning vs Ingestion Food poisoning vs Ingestion poisoning poisoning

? Outbreak of ‘food poisoning’ in an old people home? Outbreak of ‘food poisoning’ in an old people home Eleven patients of age ranging from 60-70yrs brought Eleven patients of age ranging from 60-70yrs brought

to ER with common history of ‘ingestion’ of some to ER with common history of ‘ingestion’ of some unknown “bitter” green leafy vegetable two hours priorunknown “bitter” green leafy vegetable two hours prior

All but one became symtomatic 30-45min after All but one became symtomatic 30-45min after ingestion and had common symptoms of blurred vision ingestion and had common symptoms of blurred vision and altered mental status. Two had dysarthria and one and altered mental status. Two had dysarthria and one was comatose.was comatose.

ExaminationExamination

VitalsVitals: tachycardia, hypertension, elevated temperature: tachycardia, hypertension, elevated temperature

HEENT: HEENT: pupils dilated with poor rxn, dry tonguepupils dilated with poor rxn, dry tongue

SkinSkin: dry and warm skin: dry and warm skin

CVS/Resp/Abd: CVS/Resp/Abd: unremarkableunremarkable

CNS: CNS: Confusion, Delirium, Decreased level of Confusion, Delirium, Decreased level of consciousness, Agitationconsciousness, Agitation

Operational diagnosisOperational diagnosis

Unknown PoisoningUnknown Poisoning

Plant Plant poisoningpoisoning

StimulantStimulant plant poisoning plant poisoning

Stimulant plant poisoning with Stimulant plant poisoning with anticholinergicanticholinergic syndrome syndrome

Anticholinergic plant poisoning with Anticholinergic plant poisoning with tropanetropane alkaloids alkaloids

??DaturaDatura poisoning poisoning

ManagementManagement

Police informedPolice informed Poison information centre calledPoison information centre called Help sought from other departmentsHelp sought from other departments Supportive treatment instituted- O2 Supportive treatment instituted- O2

therapy, IV accesstherapy, IV access Other hospitals communicated- 5 Other hospitals communicated- 5

patients transferred to Patan hospitalpatients transferred to Patan hospital Patients constantly monitered, Patients constantly monitered,

supportive therapy continued supportive therapy continued (everyone later developed urinary (everyone later developed urinary retention and were catheterised).retention and were catheterised).

Patients were observed in ER Patients were observed in ER overnight and discharged in the overnight and discharged in the morningmorning

ANTICHOLINERGIC PLANT POISONING

TROPANE ALKALOIDS – found in all parts of plant, with highest concentrations in roots and seeds

HyoscyamineHyoscine (Scopolamine)AtropineMandragorine

PLANTS CONTAINING TROPANE ALKALOIDS

Dhatura spp. a common recreational hallucinogen

Hyoscyamus niger Atropa belladonnaMandragora officinarumBrugmansia spp.Lycium halimiforiumCestrum nocturnum

EPIDEMIOLOGY:

Incidence: No national dataCommon poisoningUsually 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

CLINICAL PRESENTATION

Symptoms usually occur 30-60min after ingestion and includes a classical anticholinergic syndrome

Dryness of mouthDyphagia and dysarthriaBlurred vision and photophobiaUrinary retentionAltered mental status- from amnesia and confusion,

agitation and hallucination to seizures and coma

SignsVital signs Tachycardia

Hypertension Elevated temperature - hyperthermia

HEENT Mydriasis and cycloplegiaDry mucous membrane

Skin Warm, dry and flushedNeurological Altered mental status- Agitation

Delirium (acute confusional state + hallucination)Muscle inco-ordination, respiratory depression, seizures and coma (rare)

Abdomen Diminished bowel soundsDistended urinary bladder

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

TREATMENT

Principles: 1.Control of Agitation2. Protection from self harm

EMERGENCY DEPARTMENT CARE

Follow ABCDE of Emergency Medicine

Consider GI Decontamination foremost1.Emesis by Ipecac- contraindicated2.Gastric Lavage-controversial (increased risk of aspiration!)

24-32 F tube in children36-42 F tube in adult

3. Activated Charcoal- useful1-2g/kg po or via nasogastric/orogastric tubeCan be repeated after 4-6 hrs

Treatment is largely SUPPORTIVE!Agitation/Hallucination:

ReassuranceDark roomChemical 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

SeizuresDiazepamPhenobarbitone

Urinary retention Foley catheterisation

Urine output should be maintained at 1-2ml/kg/hr

Use of Specific Antidote – PHYSOSTIGMINE- is controversial (risk of cholinergic crisis)

Indications: 1. Unresponsive to supportive treatment2. Tachyarrhythmias with hemodynamic

compromise3. Intractable seizures unresponsive to

benzodiazepine4. Extremely sever agitation or psychosis

Hemodialysis and Hemoperfusion is not useful because of high lipid solubility of tropane alkaloids

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)

Beauty lies in the eyes of the Beauty lies in the eyes of the beholder.beholder.