Cardiac Glycoside Plant Poisoning Follow-up
- Author: Raffi Kapitanyan, MD; Chief Editor: Asim Tarabar, MD more...
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:
- Hypoxic seizures
- Encephalopathy or ischemic stroke
- Myocardial ischemia
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
- For excellent patient education resources, visit eMedicine's Drug Overdose Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning, Drug Overdose, and Activated Charcoal.
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