新光醫(yī)院腎臟科主治醫(yī)師

1、PLANT POISONINGin Critical Care林秉熙 醫(yī)師新光醫(yī)院腎臟科主治醫(yī)師國立陽明大學醫(yī)學系講師Key Points (1)There are a large variety of plant poisons in nature with only few specific antidotes.Acute gastroenteritis is a feature of most plant poisonings. Organic brain syndromes are common.Supportive care and decontamination (gastro-i

2、ntestinal tract and others) are the mainstays of treatment. Key Points (2)Identification of the plant is important for anticipating clinical events.In plant-related cardiac glycoside toxicity, antidigoxin Fab fragments may be of use.Mucosal irritation, renal failure, and hypo-calcemia characterize p

3、lant-related oxalate toxicity.Key Points (3)Life-threatening mushroom poisonings tend to have a delay of at least 6 h prior to the onset of symptoms. Hepatic, renal, or central nervous system complications may develop, depending on the type of mushroom ingestedHindered plant toxicologyPaucity of acu

4、tely ill patients, prospective clinical trials, and good clinical series in plant toxicology Immense number of uncharacterized potential toxins in the plant kingdom Imprecise identification of the offending speciesIdentification of the toxin or quantitative blood levels rarely obtainedBenign plants

5、with acute illnessSimultaneous ingestion of pesticidesAllergic responseCommon clinical syndromesAcute gastroenteritisAlmost universal, even the only feature of poisonings Organic brain syndromethe second most common manifestationoften seen along with, or following the gastroenteritisalteration in me

6、ntal status manifested by delirium, coma, or seizuresGeneral ManagementStablized airway, breathing & circulationNaloxone & dextrose for altered mentationGastrointestinal decontamination with lavage and activated charcoalIdentifying the plantConsultation with regional poison control centerSpecific an

7、tidote if availableSpecific Plant Syndromes (1)ANTICHOLINERGIC SYNDROMEPYRROLIZIDINE ALKALOIDSCARDIAC GLYCOSIDEOXALATE SYNDROMESOLANINE ALKALOIDSNICOTINE ALKALOIDCYANOGENIC PLANTSSpecific Plant Syndromes (2)TOXALBUMIN-CONTAINING PLANTSCOLCHINE POISONINGMISTLETOE (槲寄生) TOXICOLOGYPODOPHYLLUM (鬼臼樹脂) PO

8、ISONINGPENNYROYAL (薄荷) OILEUCALYPTUS (桉樹) OILHALLUCINOGENIC PLANTSSpecific Plant Syndromes (3)AKEE FRUIT POISONINGTAXINE (YEW) POISONINGFAVA BEAN POISONINGWATER HEMLOCK (毒水芹) POISONINGRHODODENDRON (杜鵑花) POISONINGDAPHNE (月桂) POISONINGGASTROENTERITIS SYNDROMEMUSHROOM POISONINGAnticholinergic SyndromeD

9、eadly nightshade (Atropa belladonna 顛茄)Angels trumpet (Datura suaveolens 曼陀羅)Jimson weed (D. stramonium)Matrimony vine (Lycium halimifolium)Henbane (Hyoscyamus niger 茛菪)Anticholinergic syndrome (ACS)Tropane alkaloidsatropine (顛茄鹼)scopolamine (茛菪鹼)The most common plant causesDatura stramonium (jimson

10、 weed, 曼陀羅)Atropa belladonna (deadly nightshade,茛菪)Anticholinergic syndrome (ACS)The most frequent cause of intoxication by these plants is from teas. Anticholinergic plant poisoning is occasionally induced purposefully in an attempt to capture the hallucinogenic anticholinergic effects.Anticholiner

11、gic syndrome (ACS)Toxicities: competitive antagonist at the cholinergic-muscarinic receptor. Cross the blood-brain barrier, cause central effectsClinical pictures: mad as a hatter, hot as a bare, dry as a bone, red as a beet, and blind as a bat Anticholinergic syndrome (ACS)Tachycardia:usually sinus

12、supraventricular as well as ventricular arrhythmias may occur. Profound alteration in mentation:including confusion, agitation, disorientation, hallucinations, and seizures. Physical examinationMydriasis, absence of perspiration, and relatively parched mucous membranes Flushed due to peripheral cuta

13、neous dilationFever is common.Treatment of ACSObserved for cardiac dysrhythmias, hemodynamic instability, agitation, and seizures. Benzodiazepines for significant agitationPotential antagonist: Physostigminemay result in bradydysrhythmias, asystole, or seizuresrestricted to patients with life-threat

14、ening ACS, or diagnostic dilemmasAdministeration of physostigmineUsual dose of physostigmine: 2 mg (0.5 mg for pediatric patients) intravenously over at least 2 min.A syringe containing atropine standbyContraindications: asthma, peripheral vascular disease, bowel obstruction, urinary tract obstructi

15、on, or gangrene.CARDIAC GLYCOSIDESChristmas rose (Helleborus niger 黑藜蘆) Lily of the Valley (Convallaria majalis 歐鈴蘭) Foxglove (Digitalis purpurea 毛地黃) Common oleander (Nerium oleander 夾竹桃) Yellow oleander (Thevetia sp.)Cardiac glycosides (1)The presentation of plant cardiac glycoside poisoning is si

16、milar to medicinal glycosides.There is an initial period of gastrointestinal discomfort followed by multiple cardiac conduction abnormalities and hyperkalemia. Cardiac glycosides (2)Foxglove plant (Digitalis purpurea 毛地黃)contains predominantly digitoxinlong half-life and prolonged clinical syndromeE

17、uropean snapdragon 金魚藻 (Digitalis lanata)contains mostly digoxincauses a more abbreviated syndromeCardiac glycosides (3)Variable degree of cross-reactivityDigoxin levels unreliable Bind to activated charcoal: Multiple doses of activated charcoal indicated Digitoxin: a true enterohepatic circulation

18、Efficacy of antidigoxin Fab fragments: Controversy Pyrrolizidine Alkaloid SyndromeThreadleaf (Senecio longilobus 劉寄奴草)Heliotrope (Heliotropium europaeum 天芥菜)Russian comfrey (Symphytum xuplandicum 紫草)Horsefoot (Tussilage farfara 款冬)Pyrrolizidine alkaloids (1)First recognized in 1954 in Jamaicahepatic

19、 veno-occlusive disease related to drinking herbal teas or eating contaminated cereals.Endothelial edema of small and medium size hepatic veins and venules, result in sclerosis and occlusion. Pyrrolizidine alkaloids (2)Congestion of hepatic sinusoids and central veinscentrilobular hemorrhagic necros

20、islarge hepatic veins unaffected, distinguishing from the Budd-Chiari syndrome.Typicall presentation:RUQ abdominal pain, nausea, vomiting, diarrhea, hepatomegaly, splenomegaly, ascites, jaundice, hypoglycemia, and extremely high GOT/GPTPyrrolizidine alkaloids (3)Chronic ingestionprogressive hepatic

21、veno-occlusive diseasecor pulmonaleNo specific antidoteTreatment: supportivemanagement of coagulopathy, hypoglycemia, pulmonary hypertension, and encephalopathyOxalate SyndromeDumbcane (Dieffenbachia sp.)Elephants ear (Colocasia antiquorum)Rhubarb (Rheum sp. 大黃)Jack-in-the-pulpit (Arisaema atroruben

22、s 美國黃花菖蒲)Skunk cabbage (Symplocarpus foetidus 臭菘)Swiss cheese plant (Monstera sp.)Philodendron (Philodendron sp. 黃蘗)Caladium (Caladium bicolor 貝母)Oxalate syndrome (1)Primary syndrome: mucosal irritationMost common cause: Dieffenbachia Chronic ingestion of rhubarb leaves (大黃)Soluble vs. insoluble (rh

23、aphides) formOxalate syndrome (2)Rhaphides: severe mucosal irritation, even laryngeal edemaSoluble oxalate: systemic & diffuse effectMucosal irritationgastroenteritisrenal failurehypocalcemiaOxalate syndrome (3)TreatmentMaintain airwayOral fluid, preferably milk for dilutionECG & serum calcium monit

24、oringHemodynamic monitoringAdequate fluid supply & monitor renal functionSolanine Alkaloid SyndromeJerusalem cherry (Solanum pseudo-capsicum)Common potato (S. tuberosum 馬鈴薯) Eggplant (S. melongena 茄子) Woody nightshade (S. dulcamara) Horse nettle (S. carolinense 針茄) Common nightshade (S. nigrum) Toma

25、to (Lycopersicon esculentum) Trumpet flower (Solandra sp.)Solanine alkaloid (1)Most plants of the Solanaceae family (nightshade 茄屬 or potato plants 馬鈴薯) contain the solanine alkaloids in nontoxic amounts.Severe solanine alkaloid poisoning can occur when potatoes are harvested while still green, are

26、improperly stored, or are traumatized.Solanine alkaloid (2)Toxicities:Gastrointestinal tract irritationGastric juice hydrolyze solanine alglycon & sugarAglycone: hypotension & organic brain syndromeSolanocapsine toxicity: cardioinhibitory syndrome, with both negative inotrophic/chronotrophic effectS

27、uperimposed ACSSolanine alkaloid (3)TreatmentSupportive measuresGastrointestinal decontamination: activated charcoalTreat superimposed ACSNicotine SyndromeTobacco (Nicotiana sp. 菸草)Poison hemlock (Conium maculatum 毒人蔘)Indian tobacco (Lobelia inflata 半邊蓮)Nicotine alkaloid-containing plantsPoisoning w

28、hen used as purgatives and enemasHemlock (毒芹)root: confused with wild carrotsLeaves: similar in appearance to parsley (荷蘭芹)Nicotine alkaloid-containing plantsToxicityRapid emesis due to direct effect and stimulation of medullary chemoreceptor trigger zoneStimulate postsynaptic receptors of autonomic

29、 neurons and motor end platesInitial stimulation followed by depression, either sympathomimetic or cholinergicDeath within an hour of ingestion (respiratory failure)Nicotine alkaloid-containing plantsTreatmentThorough skin decontaminationActivated charcoal in multidose fashionRespiratory and hemodyn

30、amic monitoringCyanogenic Glycosides SyndromeCommon fruit pits (Rosaceae family)Cherry laurel (Prunus laurocerasus 月桂櫻桃)Cassava (Manihot esculenta 樹薯)Bamboo (Phytostachys aurea 竹子)Elderberry (Sambcucus sp. 接骨木)Bitter almonds (Prunus dulcis 苦杏)Hydrangea (Saxifragaceae family 繡球花)Lima beans (Phaseolus

31、 lunatus 青豆)Chokecherry (Prunes airginiana 苦櫻桃)Cyanogenic plants (1)Cyanide:One of the most potent and rapid acting poisonsWidely distributed in the plant world in the form of cyanogenic glycosides (sugar compounds of cyanide)Glycosides may be hydrolyzed by either plant enzymes simultaneously ingest

32、ed or endogenous enzymes to liberate hydrogen cyanideCyanogenic plants (2)Amygdalin (苦杏仁素)The most common glycoside, also found in plum, peach, apricot, bitter almond, cherry, pear, and apple The major glycoside in the product sold as LaetrileThese pits contain a complex of enzymes known as emulsin

33、in their coats. When the pits are chewed, emulsin is liberated and metabolizes the nontoxic amygdalin to free hydrogen cyanide.Cyanogenic plants (3)Linamarin: another common cyanogenic glycoside found in lima and cassava beansTropical or Nigerian ataxic neuropathy:Chronic cassava consumption in trop

34、ical areas, particularly Nigeria, associating with chronic cyanide poisoningCyanogenic plants (4)Diagnosis:Based primarily on a high index of suspicionHypotension, seizures, an altered mental status, or a persistent metabolic acidosis in the setting of the potential ingestion of cyanogenic plantsOdo

35、r of bitter almonds is a further clue but unreliable; cannot be detected by up to 40 % of the population. Cyanogenic plants (5)Treatment of cyanide poisoningPrompt resuscitationVentilation with 100 % oxygenSodium thiosulfate, 25 % solution, 150 mg/kg ivGastric decontamination (larvage)Activated char

36、coal administrationToxalbumin SyndromeCastor bean (Ricinus communis 蓖麻子)Jequirity bean (Abrus precatorius 相思子)Sandbox tree (Hura crepitans)Bellyache bush (Jatropha gossipifolia 麻風樹屬)Black locust (Robinia pseudoacacia 北美刺槐樹)Desert potato (J. macrorhiza)Toxalbumin-containing plantsAbrin, the active to

37、xin in the jequirity bean, and ricin, found in the castor bean, are among the most potent natural toxins known when administered parenterally.Ingestion of these beans is usually not associated with toxicity unless they are chewed.Extremely antigenic, causing a hypersensitivity reaction Toxalbumin-co

38、ntaining plantsCastor bean toxicity: acute, severe, gastroenteritisJequirity bean contains glycyrrhizin, which may cause hyperaldosteronism.Abrin is more toxic than with ricin“as little as one jequirity bean when chewed can be lethal to a child” Toxalbumin-containing plantsToxic effects of toxalbumi

39、n ingesion:acute, persistent and severe gastroenteritisencephalopathy: stupor, seizures, and comamultiple organ system failure in some cases, with pancreatitis, hepatotoxicity, hemolysis, renal failure.In addition, a primary irritant dermatisToxalbumin-containing plantsTreatment:Standard supportive careActivated charcoal administrationTreat severe hemorrhagic gastroenteritisNo specific antidote availableColchicine SyndromeAutumn crocus (Colchicum autuminate)Glory lily (Gloriosa superba)Colchicine poisoningTrue botanical colchicine poisoning is unusual.The