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toxidrome

Cardiac glycosides toxidrome

botanicals

definition

cardiac glycosides toxidrome

the following toxicity information is largely derived from poisonings, overdoses and research on isolated constituents; used with appropriate clinical judgment and cautious prescribing, herbs are safe and efficacious

plants included:

» Adonis vernalis

» Apocynum spp.

» Asclepias tuberosa

» Convallaria majalis

» Digitalis purpurea

» Helleborus niger

» Polygonatum multiflorum, Polygonatum officinale

» Strophanthus spp.

» Urginea maritima

» Veratrum spp.

treatment of overdose: EDTA, monitor serum potassium levels

(Ellis, p. 18)

• cardiac glycoside toxidrome: oral ingestion or exposure results in irritation of oropharynx and stomach. Severe abdominal pain, nausea, vomiting, and diaphoresis occur. Diuresis, diarrhea follow with a persistent headache, sleepiness or delirium. Visual changes include a yellow-green cast and appearance of geometric patterns around objects. Loss of consciousness may ensue with respiratory failure, leading to death.

lab changes: decreased pulse rate with characteristic EKG changes: atrial fibrillation, premature ventricular contractions, partial or complete A-V block, T wave inversion, often with ST depression (Ellis, p. 18; Felter and Lloyd, p. 227)

» Helleborus niger:

treatment of overdose includes: gastric lavage and emesis; applications of warm towels may relieve spastic colon (Duke, p. 227; Hardin and Arena)

• cardiac glycoside toxidrome: orogastric mucosa irritant due to protoanemonin, possibly augmented by saponins. Initial signs include numbing or prickling sensation of the tongue, a burning of the esophageal and gastric mucosa, and a sense of suffocation. This is followed by nausea, vomiting, diarrhea, severe thirst and abdominal cramps. Gastrointestinal irritation spreads down the rectum; diaphoresis, mydriasis, vertigo, delirium, and then convulsions occur. Digitalis-related EKG changes may be seen (Felter and Lloyd, p. 983; Phillips, p. 12).

• auditory and visual disturbances can also occur, including tinnitus, mydriasis and photophobia (von Oettingen, pp. 372-373)

» Strophanthus spp.:

treatment of overdose: EDTA, monitor serum potassium levels

(Ellis, p. 18)

• cardiac glucoside toxidrome due to strophanthin-K or oubain, the most potent cardiac glycoside: following direct oral exposure or ingestion, irritation of the oropharynx and stomach occurs; severe abdominal pain, nausea, vomiting, and diarrhea ensue, accompanied by a severe headache, vertigo and often delirium; other signs include swollen eyelids, and leg edema, miosis with non-reactive pupils, and Cheyne-Stokes respiration (Ellis, p. 18; von Oettingen, p. 543; Theines and Haley, p. 127; Brundage, p. 140)

• characteristic EKG changes occur: atrial fibrillation, premature ventricular contractions, partial or complete A-V block, and T wave inversion, often with ST segment depression (Brundage, p. 140; Ellis, p. 18)

• blood pressure can drastically increase at times, accompanied by an asystole; death is preceded by a period of apnea; sudden death has occurred from respiratory failure (von Oettingen, p. 543)

» Veratrum spp.:

• produces medullary excitation/cardiovascular depression characterized by bradycardia, hypotension, often lasting 24 hours; initially pruritus, burning and prickling sensations of the mouth, tongue, and throat occur, followed by salivation, gastric inflammation, dysphagia, nausea, vomiting, and diarrhea; muscle cramps, shivering, vertigo, blurred vision, yellow vision, diaphoresis, and general confusion occur; the patient may also experience palpitations, reduced body temperature and reduced urinary output; severe cases develop dysphasia, dysphagia, paresthesias, and a state of generalized motor paralysis, followed by convulsions, and even death, as breathing difficulties lead to respiratory collapse; severe cardiac effects include bradycardia and depressed conductivity; death can occur in 3-12 hours; ingestion is usually non-fatal

• Veratrum viride has been characterized as a hallucinogen (Morton, p. 61)

footnotes

Brundage, A.H. 1929. A Manual of Toxicology, 15th ed. New York: D. Appleton and Co.

Duke, J.A. 1985. C.R.C. Handbook of Medicinal Herbs. Boca Raton, FL: The C.R.C. Press.

Ellis, M.D. 1975. Dangerous Plants, Snakes, Arthropods, And Marine Life. Hamilton, IL: Drug Intelligence Publications, Inc.

Felter, H. W., and Lloyd, J. U. 1983. King's American Dispensatory, Vols. I and II. Portland, OR: Eclectic Medical Publications.

Hardin, J. W.; and Arena, J.M. 1974. Human Poisoning from Native Cultivated Plants, 2nd ed. Durham, NC: Duke University Press.

Morton, J.F. 1977. Major Medicinal Plants: Botany, Culture, Uses. Springfield, IL: Charles C. Thomas.

Phillips, C.D. 1879. Materia Medica and Therapeutics: Vegetable Kingdom. New York: William Wood and Company.

Thienes, C.H., Haley, T.J. 1975. Clinical Toxicology. 5th ed. Philadelphia: Lea and Febiger.

von Oettingen, W.F. 1958. Poisoning: A Guide to Clinical Diagnosis and Treatment. Philadelphia: W.B. Saunders and Company.

ence Publications, Inc.

Felter, H. W., and Lloyd, J. U. 1983. King's American Dispensatory, Vols. I and II. Portland, OR: Eclectic Medical Publications.

Hardin, J. W.; and Arena, J.M. 1974. Human Poisoning from Native Cultivated Plants, 2nd ed. Durham, NC: Duke University Press.

Morton, J.F. 1977. Major Medicinal Plants: Botany, Culture, Uses. Springfield, IL: Charles C. Thomas.

Phillips, C.D. 1879. Materia Medica and Therapeutics: Vegetable Kingdom. New York: William Wood and Company.

Thienes, C.H., Haley, T.J. 1975. Clinical Toxicology. 5th ed. Philadelphia: Lea and Febiger.

von Oettingen, W.F. 1958. Poisoning: A Guide to Clinical Diagnosis and Treatment. Philadelphia: W.B. Saunders and Company.

Poisoning: A Guide to Clinical Diagnosis and Treatment. Philadelphia: W.B. Saunders and Company.