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Plant Poisoning, Resins: Treatment & Medication
Updated: Mar 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Plant parts or information regarding surroundings obtained by prehospital providers may be helpful in identifying the suspected toxin.
- Rinse mouth in cases of mucosal irritation to help alleviate symptoms.
- Generally, induced vomiting with ipecac syrup is not encouraged, particularly in cases with potential for altered mental status.
Emergency Department Care
Airway, breathing, and circulation must, above all else, be ensured. Remove any remaining toxin. Ipecac syrup is not recommended. Gastric lavage is unlikely to be effective for removal of plant parts. Activated charcoal may be of benefit, particularly if administered within the first several hours; however, it may be of little benefit with rapidly absorbed substances such as teas.
Hemodialysis has not been proven clinically effective in removing any plant toxin.
Carefully monitor urine output in systemically ill patients because many plant toxins result in GI fluid losses and/or third-spacing of fluid.
Toxicodendron species
An estimated 70% of the population are sensitized to allergens found in the Toxicodendron species, which include poison ivy (see Media files 3-4), poison oak (see Media file 5), and poison sumac (see Media file 6).
Poison ivy. Photo from the Centers for Disease Control and Prevention.
These plants cause potentially severe contact dermatitis. The allergenic substance of Toxicodendron species is found in the milky white sap that is distributed throughout the plant, seed, flowers, and berries. A unique characteristic of the emulsion found in all Toxicodendron species is the color change from milky white to black lacquer upon exposure to air for several minutes. This spot test is not recommended for routine identification because of inherent risk of exposure (see Plant Poisoning, Toxicodendron).
Contact dermatitis develops within 48 hours for most exposures. Highly sensitized individuals develop eruptions within 8 hours. Eruptions often appear in a linear pattern, indicating that a portion of bruised plant was rubbed across the skin when handled or trampled.
Poison oak rash. This photograph depicts an individual's arm with a blistering poison oak rash. Note the linear pattern to the lesions. Hardin Library for the Health Sciences, University of Iowa Public Domain Picture (http://www.lib.uiowa.edu/haRDIN/MD/cdc/4484.html) and Centers for Disease Control and Prevention.
Symptoms at presentation range from mild erythema to papules, vesicles, and bullae. Although once believed to contain the allergen, vesicular fluid cannot transmit contact dermatitis. Systemic distribution of toxin may cause diffuse urticaria or erythema multiforme.
- In mild cases involving only erythema and papules, a topical lotion of calamine or steroid cream and an oral antihistamine may be used.
- Severe cases require more aggressive therapy. Topical therapy for such cases includes the following:
- Aluminum sulfate (1:10 diluted in water) compressed for 30 minutes 3 times a day to dry blisters and relieve itching
- Potassium permanganate soaks to dry blisters (one-half tablespoon in a tub of water for 20 min/d)
- In severe cases, oral corticosteroids may be required and should be tapered over 2-3 weeks. A shorter duration of therapy is associated with rebound dermatitis.
- Symptoms in severe cases should be cleared within 3 weeks; symptoms in milder cases may last only 10 days.
- Possible sequelae include hyperpigmentation over the area of eruption.
- After contact with poison ivy, washing the exposed area as well as hands and clothes with soap and water within 30 minutes of exposure greatly reduces the risk of developing contact dermatitis.
Water hemlock
Cicuta maculate and most other species of Cicuta are similar in appearance and grow to heights of 6 ft. The sap is a yellow oily compound with a parsnip scent and contains cicutoxin, a long chained aliphatic alcohol. Cicutoxin is distributed throughout the plant, with the highest concentration in the tuberous roots. One mouthful of root is sufficient to kill a grown man, and toxicity has been documented after dermal contact. These plants are found in wet swamplands throughout the United States and are the most toxic plants in Alaska (see Media file 1).
Cicutoxin has a parasympathomimetic action when ingested and produces symptoms in 15-60 minutes. Muscarinic actions manifest as abdominal pain, vomiting, diarrhea, trismus, and hypersalivation. More central effects manifest as central nervous system depression, respiratory distress, and possibly tonic-clonic seizures. Death is usually secondary to respiratory arrest.
- Pay particular attention to the patient's airway and respiratory status. Treatment is mostly supportive. Benzodiazepines are recommended for control of seizures. Treatment with anticholinergics has not been proven effective in animal models.
- Consider creatine kinase measurements; the combination of seizures with resultant rhabdomyolysis and gastrointestinal fluid losses place the patient at risk for oliguric renal failure.
- Given the GI losses, closely monitoring the patient's fluid balance is needed.
Chinaberry
Melia azedarach is a tree that may grow to a height of 50 ft. The leaves are serrated with 2-inch long leaflets. The flowers are scented, purplish, and grow in clusters. Chinaberry trees produce yellow berries that persist after the leaves are shed; they contain 3-5 smooth black seeds. Chinaberry trees grow in the South from Virginia to Florida to Texas and Hawaii.
A recently identified neurotoxin (tetranortriterpene) and an unidentified gastroenteric toxin are concentrated in the berry and bark of chinaberry. Ingestion of 6-8 berries has been reported to cause fatality in a young child.
Prolonged latent period is followed by development of mental confusion, ataxia, dizziness, and stupor. Some patients may develop intense vomiting and bloody diarrhea, which results in hypovolemic shock. Reports of respiratory depression, seizures, and paralysis also exist. In some autopsies, fatty degeneration of the liver has been observed.
- Supportive care with fluid and electrolyte replacement is indicated.
- Given the possibility of hepatic fatty degeneration, monitoring liver function is important.
Daphne
Daphne are deciduous round shrubs growing to heights of 4-5 ft. Elliptical leaves with purple or white flowers grow in clusters before the appearance of leaves. Although most exposure is due to the yellow fruit and pits of daphne, the entire plant is poisonous. Ingestion of only a few daphne fruits can be fatal to a young child. Daphne are cultivated throughout the United States and are naturalized to the northeastern United States and Canada (see Media file 2).
Daphne. Photo by Cornell University Poisonous Plants Informational Database.
Ingestion of daphne causes vesication and edema of the mouth, lips, and pharynx with secondary hypersalivation and dysphagia. Subsequent symptoms include extreme thirst, abdominal pain, vomiting, and bloody diarrhea.
Daphnetoxin may cause organ damage, usually due to hypovolemia and electrolyte imbalance; therefore, the kidneys are particularly at risk for damage secondary to acute tubular necrosis.
Fluid and electrolyte balance is critical to prevent a potentially lethal outcome.
Consultations
Consult a medical toxicologist and/or regional poison center for further assistance.
Medication
Medical care of poisoning is primarily symptomatic in nature. Gastric decontamination may benefit by reducing the absorbed dose.
GI decontaminants
These agents are the preferred method when GI decontamination is desired. They are generally mixed and given with a cathartic (eg, 70% sorbitol), except in young pediatric patients in whom electrolyte disturbances may be of concern.
Activated charcoal (Liqui-Char)
Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.
For maximum effect, administer within 30 min of ingesting poison.
Adult
1 g/kg (30-100 g) PO
Pediatric
1-2 g/kg (15-30 g) PO
May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases adsorptive properties)
Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies; unprotected airway with absent gag reflex
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
Not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administering activated charcoal; after emesis with ipecac, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black; monitor for presence of bowel sounds to minimize risk of charcoal ileus
Antihistamines
Competitive histamine antagonists minimize severity of hypersensitivity response.
Diphenhydramine (Benadryl)
For symptomatic relief of symptoms caused by release of histamine in allergic reactions.
Adult
25-50 mg PO q4-6h
Pediatric
5 mg/kg/d PO divided qid
Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions
Documented hypersensitivity; MAOIs; anticholinergic plant toxicity
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
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction; may cause drowsiness
Hydroxyzine (Vistaril, Atarax)
Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS. Sedating, alternative to diphenhydramine.
Adult
25-50 mg PO q4-6h
Pediatric
2-4 mg/kg/d PO divided q6h
CNS depression may increase with alcohol or other CNS depressants
Documented hypersensitivity
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
Associated with clinical exacerbations of porphyria (may not be safe for patients with porphyria); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness
Benzodiazepines
These agents are used to abort seizures, if present.
Diazepam (Valium)
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.
Adult
5-10 mg IV q10-15min until symptoms resolve; not to exceed 30 mg
Pediatric
>30 days to 5 years: 0.2-0.5 mg IV (slowly) q2-5min until symptoms resolve; not to exceed 5 mg
>5 years: 1 mg IV (slowly) q2-5min until symptoms resolve; not to exceed 10 mg
Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs
Documented hypersensitivity; acute narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life.
By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.
Monitoring patient's blood pressure after administering dose is important. Adjust prn.
Adult
2-8 mg IV/IM; titrate to effect
Pediatric
0.05 mg/kg IV/IM
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
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Corticosteroids
These agents are useful for contact dermatitis.
Prednisone (Deltasone)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
40-60 mg PO qd; taper over 2-3 wk
Pediatric
1-2 mg/kg PO qd; taper over 2-3 wk
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Methylprednisolone (Solu-Medrol, Depo-Medrol)
Useful to treat inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, may decrease inflammation.
Multiple corticosteroid preparations are available. Widely available in the ED because of its other uses (ie, acute asthma, spinal cord injury) and is supplied in both parenteral and oral formulations and is therefore discussed here as a typical drug of this class.
Adult
2-60 mg PO qd
40-250 mg IV/IM q6h
Pediatric
1-2 mg/kg PO qd
1-2 mg/kg IV/IM q6h
NSAIDs may cause ulcers when taken concurrently; anticholinesterases may increase weakness in patients with myasthenia gravis when taken concurrently with steroids; risk exists of possible viral dissemination with live-virus vaccines
Documented hypersensitivity; some evidence indicates fetal harm from corticosteroids, so benefits and risks should be considered for use during pregnancy; immunosuppressed patients receiving corticosteroids are at risk for dissemination, activation, or certain infections, and this should be considered when prescribing for these patients
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
Short-term use of corticosteroids, even in large doses, has minimal harmful effects; long-term usage has multiple adverse effects
Possible complications include hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections
More on Plant Poisoning, Resins |
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| Differential Diagnoses & Workup: Plant Poisoning, Resins |
 Treatment & Medication: Plant Poisoning, Resins |
| Follow-up: Plant Poisoning, Resins |
| Multimedia: Plant Poisoning, Resins |
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References
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Further Reading
Keywords
plant poisoning resins, resins, plant resins, poison ivy, poison oak, poison sumac, contact dermatitis, glycoresins, oleoresins, urushiols, poisonous plants, poisonous plant exposures, plant toxin, Toxicodendron species, Cicuta maculata, water hemlock, cicutoxin, chinaberry, Melia azedarach, tetranortriterpene, daphne, daphnetoxin, toxic plant ingestion, resin skin exposure
