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Plant Poisoning, Glycosides - Cardiac: Follow-up

Author: Raffi Kapitanyan, MD, Assistant Professor, Assistant Professor of Emergency Medicine, Emergency Medicine, Robert Wood Johnson University Hospital/UMDNJ
Coauthor(s): Mark Su, MD, FACEP, FACMT, Consulting Staff and Director of Fellowship in Medical Toxicology, Department of Emergency Medicine, North Shore University Hospital; Consulting Staff, North Shore University Hospital; Douglas R Landry, MD, Consulting Staff, Department of Emergency Medicine, Sentara Bayside Hospital
Contributor Information and Disclosures

Updated: Jan 27, 2009

Follow-up

Further Inpatient Care

  • Admit patients who show any signs of cardiac glycoside toxicity to a monitored setting for observation and further care.
  • Admit to ICU/CCU patients with severe signs of toxicity or in whom Fab fragments were used without resolution of symptoms.
  • Patients treated with Fab fragments and with complete resolution of symptoms may be admitted to a monitored setting. Clinicians should be aware of possibility of delayed toxicity if GI decontamination was not completed (especially for the leaves in the GI tract).

Further Outpatient Care

  • Patients meeting the following criteria (measured serially over time) may be discharged:
    • Asymptomatic throughout the course of an ED observation period (12 h postingestion)
    • Normal vital signs
    • Baseline mental status
    • Baseline cardiac rate and rhythm; unchanged ECG
    • Electrolytes within reference range
    • Negative cardiac glycoside assay for any patient not regularly taking a digoxin preparation
    • Unintentional ingestion or clearance by psychiatry in a case of intentional ingestion
  • Follow-up with primary care provider should be arranged within 1-2 days following unintentional ingestions of cardiac glycosides.
  • Close follow-up is mandatory if psychiatry recommends discharge of a patient after intentional ingestion of cardiac glycosides or for any patient with underlying cardiac disease.

Transfer

  • Arrange transfer to another facility with sufficient resources and expertise to care for patient under the following circumstances:
    • Lack of Fab fragments or lack of expertise in their use. However, with the assistance of local poison control center, toxicologist, or cardiologist, administration of Fab fragments should be performed prior to the transfer of symptomatic patient.
    • Lack of personnel experienced in management of cardiac glycoside toxicity
    • Lack of facilities or equipment to manage severe glycoside poisoning
  • Transfer is usually to a tertiary care center with a toxicologist. In the United States, follow all applicable COBRA transfer regulations.

Complications

  • Complications of herbal cardiac glycoside toxicity are secondary to inadequate tissue perfusion caused by dysrhythmia-induced hypotension and include the following:

Prognosis

  • Unintentional ingestion of plants containing cardiac glycosides rarely results in death. However, other plants capable of inducing a similar syndrome of cardiac toxicity (eg, aconite) have been responsible for deaths after ingestion. When death occurs, it generally is due to lethal dysrhythmias and refractory hyperkalemia.
  • Severity of hyperkalemia is predictive of outcome.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider diagnosis because presentation was soon after ingestion when only nonspecific GI symptoms exist
  • Failure to consider diagnosis because incomplete history was obtained (eg, use of alternative medications, plants)
  • Failure to diagnose or correct electrolyte abnormalities, especially hypokalemia or hyperkalemia
  • Using calcium to treat hyperkalemia induced by cardiac glycoside exposure
  • Failure or delay to give digoxin Fab fragments to treat life-threatening dysrhythmias or hyperkalemia after other methods have failed to quickly correct the abnormality
  • Failure to use reduced power settings for cardioversion of ventricular tachycardia or other tachydysrhythmias
  • Failure to consult psychiatry for all intentional ingestions
  • Failure to appreciate that a negative cardiac glycoside assay result does not exclude severe herbal cardiac glycoside toxicity
  • Use of overdrive pacing for the control of ventricular dysrhythmias
  • Use of transvenous pacer for the control of bradycardia prior to administration of Fab fragments resulting in cardiac excitation and consequent ventricular dysrhythmias
 


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References
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References

  1. Bessen HA. Therapeutic and toxic effects of digitalis: William Withering, 1785. J Emerg Med. 1986;4(3):243-8. [Medline].

  2. Bronstein, AC, Spyker, DA, Cantilena Jr., LR, et al. 2006 annual report of the American Association of Poison Control Centers National Poison Data System. Clinical Toxicology. Dec 2007;45(8):815-917.

  3. Eddleston M, Ariaratnam CA, Sjostrom L, Jayalath S, Rajakanthan K, Rajapakse S. Acute yellow oleander (Thevetia peruviana) poisoning: cardiac arrhythmias, electrolyte disturbances, and serum cardiac glycoside concentrations on presentation to hospital. Heart. Mar 2000;83(3):301-6. [Medline].

  4. Gowda RM, Cohen RA, Khan IA. Toad venom poisoning: resemblance to digoxin toxicity and therapeutic implications. Heart. Apr 2003;89(4):e14. [Medline].

  5. Hack JB, Woody JH, Lewis DE, et al. The effect of calcium chloride in treating hyperkalemia due to acute digoxin toxicity in a porcine model. J Toxicol Clin Toxicol. 2004;42(4):337-42. [Medline].

  6. Bain RJ. Accidental digitalis poisoning due to drinking herbal tea. Br Med J (Clin Res Ed). Jun 1 1985;290(6482):1624. [Medline].

  7. Cheung K, Urech R, Taylor L. Plant cardiac glycosides and digoxin Fab antibody. J Paediatr Child Health. Oct 1991;27(5):312-3. [Medline].

  8. Dickstein ES, Kunkel FW. Foxglove tea poisoning. Am J Med. Jul 1980;69(1):167-9. [Medline].

  9. Eddleston M, Rajapakse S, Rajakanthan, Jayalath S, Sjostrom L, Santharaj W. Anti-digoxin Fab fragments in cardiotoxicity induced by ingestion of yellow oleander: a randomised controlled trial. Lancet. Mar 18 2000;355(9208):967-72. [Medline].

  10. el Bahri L, Djegham M, Makhlouf M. Urginea maritima L (Squill): a poisonous plant of North Africa. Vet Hum Toxicol. Apr 2000;42(2):108-10. [Medline].

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  12. Goldfrank, Flomenbaum, Lewin, et al. Cardiac glycosides. In: Goldfrank's Toxicologic Emergencies. 7th ed. 2002:724-734.

  13. Rich SA, Libera JM, Locke RJ. Treatment of foxglove extract poisoning with digoxin-specific Fab fragments. Ann Emerg Med. Dec 1993;22(12):1904-7. [Medline].

  14. Plants - cardiac glycosides. In: Rumack BH, ed. Poisondex. 1997:94.

  15. Slifman NR, Obermeyer WR, Aloi BK, Musser SM, Correll WA Jr, Cichowicz SM. Contamination of botanical dietary supplements by Digitalis lanata. N Engl J Med. Sep 17 1998;339(12):806-11. [Medline].

  16. Van Deusen SK, Birkhahn RH, Gaeta TJ. Treatment of hyperkalemia in a patient with unrecognized digitalis toxicity. J Toxicol Clin Toxicol. 2003;41(4):373-6. [Medline].

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Further Reading

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Keywords

cardiac glycosides, cardiac glycoside toxicity, cardiac glycoside poisoning, treatment of glycoside poisoning, symptoms of glycoside poisoning, glycoside toxicity, glycoside poisoning, plant poisoning, glycoside,  Digitalis purpurea, Digitalis lanata, foxglove, Nerium oleander, common oleander, Thevetia peruviana, yellow oleander, Convallaria majalis, lily of the valley, Urginea maritima, Urginea indica, squill, Strophanthus gratus, ouabain, herbal cardiac glycosides

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Contributor Information and Disclosures

Author

Raffi Kapitanyan, MD, Assistant Professor, Assistant Professor of Emergency Medicine, Emergency Medicine, Robert Wood Johnson University Hospital/UMDNJ
Raffi Kapitanyan, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Mark Su, MD, FACEP, FACMT, Consulting Staff and Director of Fellowship in Medical Toxicology, Department of Emergency Medicine, North Shore University Hospital; Consulting Staff, North Shore University Hospital
Mark Su, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Douglas R Landry, MD, Consulting Staff, Department of Emergency Medicine, Sentara Bayside Hospital
Douglas R Landry, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

B Zane Horowitz, MD, FACMT, Professor, Fellowship Director, Department of Emergency Medicine, Oregon Health and Sciences University; Medical Director, Oregon Poison Center; Medical Director, Alaska Poison Control System
B Zane Horowitz, MD, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Medical Toxicology
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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