Cardiac Glycoside Plant Poisoning Workup

  • Author: Raffi Kapitanyan, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 10, 2011
 

Laboratory Studies

Fingerstick glucose determination

Assess for hypoglycemia as a possible cause of altered mental status.

Complete blood count (CBC)

Determine if anemia is a cause or potential complicating factor of dysrhythmia or hypotension.

Electrolytes

Hyperkalemia is a primary manifestation of acute cardiac glycoside toxicity and an early predictor of need for antidotal therapy.

Hypokalemia exacerbates cardiac glycoside toxicity, and it is more typical in chronic toxicity. It is usually secondary to the use of loop diuretics, poor dietary intake, diarrhea, and administration of potassium-binding resins.

Hypercalcemia and hypomagnesemia exacerbate cardiac glycoside toxicity. Magnesium and ionized calcium levels may be helpful, but serum magnesium levels do not reflect total body load of magnesium.

BUN and creatinine

Renal impairment negatively impairs elimination of glycosides and may exacerbate hyperkalemia.

In addition to certain medical conditions (eg, pregnancy, liver disease, subarachnoid hemorrhage, CHF, IDDM, stress, hypothermia), renal insufficiency is associated with elevated endogenous digoxinlike immunoreactive factors that can give false-positive digoxin assay results.

Cardiac glycoside level

Some plant glycosides cross-react with commonly used digoxin radioimmunoassays (RIAs) and digoxin fluorescence polarization immunoassays. Detectable levels of cardiac glycosides have been associated with ingestion of foxglove and oleander; however, levels do not correlate with severity of illness.

Negative digoxin RIA does not rule out a plant glycoside exposure.

Consider other tests, such as cardiac enzymes, thyroid function tests (TFTs), arterial blood gasses (ABGs), or urine drug screens, depending on the patient's presentation.

Consider checking acetaminophen (APAP), salicylate (ASA), and ethanol (ETOH) levels, especially if overdose is suspected.

Pregnancy test

Consider a pregnancy test for women with intentional ingestions or suicidal ideation.

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Imaging Studies

Chest x-ray (CXR) may be indicated for patients with severely toxic reactions or patients with pulmonary findings on physical examination.

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Other Tests

  • Electrocardiogram (ECG) and continuous cardiac monitoring: Assess cardiac rhythm and look for signs of ischemia or infarction. Nonspecific ST segment and T wave abnormalities, consistent with "dig effect," (ST "scooping" or "strain"-like pattern) may be noted. This does not signify toxicity merely the presence of cardiac glycoside. Peaked T waves may occur in hyperkalemia.
  • Pulse oximetry to monitor oxygen saturation and heart rate
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Contributor Information and Disclosures
Author

Raffi Kapitanyan, MD  Assistant Professor of Emergency Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School

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.

Specialty Editor Board

B Zane Horowitz, MD, FACMT  Professor, 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.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and 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.

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.

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, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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].

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  6. Roberts DM, Buckley NA. Antidotes for acute cardenolide (cardiac glycoside) poisoning. Cochrane Database Syst Rev. Oct 18 2006;CD005490. [Medline].

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

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

  10. 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].

  11. 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].

  12. Furbee B, Wermuth M. Life-threatening plant poisoning. Crit Care Clin. Oct 1997;13(4):849-88. [Medline].

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

  14. 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].

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

  16. 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].

  17. 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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The plant shown is foxglove (Digitalis purpura), which contains cardiac glycosides, not tropane alkaloids. © 2000 Richard Wagner
 
 
 
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