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Plant Poisoning, Alkaloids - Quinolizidine and Isoquinoline: Treatment & Medication

Author: David Vearrier, MD, Fellow, Department of Toxicology, Drexel University College of Medicine
Coauthor(s): Richard J Hamilton, MD, FAAEM, FACMT, Chairman, Department of Emergency Medicine, Drexel University College of Medicine
Contributor Information and Disclosures

Updated: Apr 13, 2009

Treatment

Prehospital Care

  • Transport the patient to the nearest emergency facility with advanced life support (ALS) capabilities.
  • Focus assessment and treatment on ABCs.
    • Check serum glucose level and treat if hypoglycemic.
    • Consider naloxone if symptoms suggestive of opioid toxidrome are present.
    • Obtain intravenous access and provide oxygen and cardiac monitoring.
    • Use benzodiazepines to treat seizures.

Emergency Department Care

Emergency care is primarily supportive, focusing in emergency medicine airway, breathing, circulation, disability, and exposure (ABCDEs).

  • Provide supplemental oxygen. If CNS or respiratory depression is present, intubate and provide ventilatory support.
  • Check serum glucose level and treat if hypoglycemic.
  • Consider intravenous naloxone for any patient with altered mental status and an opiate toxidrome.
  • The cornerstone of treatment is GI decontamination with activated charcoal (1 g/kg). A single dose usually is adequate.
    • Induction of emesis with ipecac syrup provides little benefit and is associated with increased risk of aspiration if the patient's mental status declines.
    • Gastric lavage is controversial but may provide maximum benefit when performed within 1 hour of ingestion.
  • Supportive care generally is all that is required postdecontamination. Continuous cardiac monitoring and frequent vital sign determinations are warranted.
  • The use of diuretics has been suggested for diffuse edema from argemone oil poisoning, but evidence of efficacy has not yet been established. Similarly, antioxidant therapy has been suggested though evidence of efficacy has not yet been established.

Consultations

Consulting a medical toxicologist or poison control center may prove helpful in developing differential diagnoses and identifying toxic ingestion.

Medication

The goals of pharmacotherapy are to reduce toxicity, reduce morbidity, and prevent complications.

GI decontaminant

Activated charcoal is the treatment of choice for all quinoline and/or isoquinoline plant ingestions. It is the most effective substance known for adsorbing most poisons. Ipecac syrup administered as a precursor to charcoal is no longer recommended, and gastric lavage has limited use.


Activated charcoal (Actidose-Aqua, Liqui-Char)

Adsorbs toxic alkaloids.

Adult

1 g/kg PO or via NG tube; consider repeat dose 0.5 g/kg 3-4 h after initial dose (usually not indicated in plant toxicity); may administer first dose with sorbitol (cathartic)

Pediatric

<2 years: Not recommended
>2 years: 0.5-1 g/kg PO or via NG tube

Repeat doses may enhance elimination of therapeutic drugs (eg, benzodiazepines)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Intubate patient prn for airway protection

Benzodiazepines

Benzodiazepines are agents of choice for cytisine-induced or other alkaloid-induced seizures.


Lorazepam (Ativan)

Beneficial for sedative and anticonvulsant effects.

Adult

0.05 mg/kg (2-4 mg) IV at 2 mg/min, titrate to effect
Status epilepticus: 4 mg IV over 2-5 min; may repeat second dose in 10-15 min prn

Pediatric

Children: 0.05 mg/kg IV (range 0.02-0.1 mg/kg)
Adolescents: Administer as in adults
Status epilepticus:
Neonates: 0.05 mg/kg over 2-5 min; may repeat in 10-15 min prn
Infants and children: 0.1 mg/kg over 2-5 min; second dose of 0.05 mg/kg IV at 10-15 min prn; single dose not to exceed 4 mg
Adolescents: 0.7 mg/kg IV slowly over 2-5 min; second dose in 10-15 min prn

Toxicity in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs

Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Monitor neurologic status, protect airway, and monitor cardiovascular status; caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease; contains benzyl alcohol, which may be toxic to infants in high doses


Diazepam (Valium)

Also beneficial for sedative and anticonvulsant effects. Half-life relatively long; may give IM if no IV access.

Adult

0.15 mg/kg IV; repeat in 10-15 min prn

Pediatric

0.15 mg/kg IV; may repeat dose in 10-15 min prn; alternatively, 0.3-0.5 mg/kg PR; may repeat in 4-12 h prn

Additive sedative and hypotensive effects with narcotics, psychotropics, and many other drugs

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Monitor neurologic status, protect airway, and monitor cardiovascular status

Antidotes for opiate agonists

These agents are used in patients with altered mental status and opiate toxidrome.


Naloxone (Narcan)

Prevents or reverses opioid effects (hypotension, respiratory depression, sedation), possibly by displacing opiates from their receptors.

Adult

0.4-2 mg IV/IM/SC q2-3min prn; use increments of 0.05-0.1 mg in patients with opioid dependency; may need to repeat dose q20-60min; if no response observed after administering 10 mg, question diagnosis

Pediatric

0.1 mg/kg IV/IM/SC; repeat q2-3min prn

Decreases analgesic effects of narcotics

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease; naloxone may precipitate withdrawal symptoms in patients with opiate addiction

More on Plant Poisoning, Alkaloids - Quinolizidine and Isoquinoline

Overview: Plant Poisoning, Alkaloids - Quinolizidine and Isoquinoline
Differential Diagnoses & Workup: Plant Poisoning, Alkaloids - Quinolizidine and Isoquinoline
Treatment & Medication: Plant Poisoning, Alkaloids - Quinolizidine and Isoquinoline
Follow-up: Plant Poisoning, Alkaloids - Quinolizidine and Isoquinoline
References
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Further Reading

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Keywords

plant poisoning, plant toxicity, alkaloids, quinolizidine, isoquinoline, Baptisia species, false indigo, Cytisus species, scotch broom, Laburnum species, goldenchain, laburnum, Lupinus species, lupine, bluebonnet, Sophora species, mescal bean, frijolito, Argemone species, prickly poppy, Chelidonium species, celandine poppy, Corydalis species, fitweed, Dicentra species, dutchman's breeches, Papaver species, poppy, Sanguinaria species, bloodroot

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Contributor Information and Disclosures

Author

David Vearrier, MD, Fellow, Department of Toxicology, Drexel University College of Medicine
David Vearrier, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and American College of Occupational and Environmental Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard J Hamilton, MD, FAAEM, FACMT, Chairman, Department of Emergency Medicine, Drexel University College of Medicine
Richard J Hamilton, MD, FAAEM, FACMT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael Hodgman, MD, Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare
Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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