Plants
Most dangerous Oleander, Jimson Weed, Jequirty Pea, Water Hemlock, Poison Hemlock, Monkshood
Ackee Fruit
Jamaica and southern US. Poisonous when unripe (must be splitting open to be ripe) Jamaican vomiting sickness, hypoglycemia, or hepatotoxicity Toxin impairs hepatic gluconeogenesis and fatty acid metab in liver Give glucose, possibly L-Carnitine
Chili Pepper
Capsaicin exposure Vinegar Coca Cola 50 % Sucrose/50%Fructose dissolved in Milk Baby Shampoo Works by nerve stimulation, not direct damage
Dumbcane
Mother-in-laws tongue, poisonous arum, dieffenbachia Calcium oxalate crystals If eaten, immediate pharyngeal reaction Ocular exposure results in immense pain, conjunctivitis, abrasions If resp compromise will develop, it will be in the first 6 hours
Devils Ivy
Calcium oxalate in plant parts Gi and ocular exposure similar to dumbcane exposure Contact dermatitis
Hemlocks
People think poison hemlock is wild carrot or use water hemlock as a pea shooter or straw Cicutoxin causing cns stimulation, seizures, tachycardia then bradycardia and paralysis AC, Benzos, Supportive care
Holly
Gi sx Supportive care
Jade Plant
No toxin
Jimsonweed
Devils apple, stinkweed Tropane alkaloids (atropine, scopolamine, etc.), aka belladonna Also contained in henbane, nightshade, belladonna, mandrake ACh poisoning Activated charcoal, benzos, consider physiostigmine
Oleander
Cardiac glycosides (like dig) Others that contain same: dogbane, foxglove, lily of the valley
Dysrhythmias AC, Consider Digibind,
Poison Ivy
Can get same sx from mango rind or cashew nut shells Must have prior sensitization Topical steroids, if severe systemic steroids
Rosary Pea and Castor Bean
Ricinus seeds are brown and speckled, rosary peas are bright red Abrin and ricin respectively, toxalbumins, inhibit cellular protein synthesis
Mushrooms
Group I
Cyclopeptide Containing Species (Amanita, Galerina, and Lepiota) Potent inhibitors of protein synthesis, lead to hepatorenal failure Onset 6-24 hours If high suspicion, AC, PCN 1 million U/kg/day, Hemoperfusion ? Thioctic acid, cimetidine, IV NAC (Unpublished report in Italy of 11 patients, none died, 1 needed transplant), Silibinin Cr > 1.2 on postingestion day 2=large mortality and probable need for liver transplant
Group VI
Psilocybin Onset 30-60 minutes
LSD like effects
Group IX
Allenic Norleucine, (Pacific Northwest) Amanita Smithiana Causes GI sx in ~30 minutes but can be lethal, the exception to the rule of 6 hour observation Renal failure Unlike other toxic mushrooms, sx may begin immediately
Coprine Containing Mushrooms
C. atramentarius causes a disulfuram-like effect
Muscarine
The non-lethal mushrooms usually cause gi effects in 30-60 minutes. Their effects are sometimes from muscarine, therefore atropine can be used in severe cases. Other times non-specific gi toxins.
Empirical Management
Gauge toxicity by time to emesis. Less than 6 hours is good, usually not toxic. Consult if mixed ingestion or late onset of symptoms
Herbal Remedies
EM Practice Herbal Supplements Table 1. Marketing Of Common Herbal Supplements. Herbal agent Marketed as/also called Claimed benefits Components Comfrey Marketed for treatment of fractures, tendon injuries, gastrointestinal tract ulcerations, and lung congestion Pyrrolizidine alkaloids Ephedra Ma huang; brand names include Metabolife®, Ripped Fuel®, Ultimate Orange, Purple Blast, and Yellow Jackets Marketed as weight loss aids, stimulants, energy boosters, and exercise enhancers Up to 90% ephedrine, also pseudoephedrine and norephedrine (some preparations may include other herbal additives, caffeine, and various stimulants) Ginkgo biloba Marketed to boost cognitive abilities (especially in Alzheimers disease and other dementias), treat peripheral vascular disease, vertigo, tinnitus, altitude sickness, erectile dysfunction, and age-related macular degeneration. Flavonoids which resemble folic acid and possess free radical scavenging properties, and terpenoids Ginseng Panax Marketed to treat sexual dysfunction, cardiovascular disease, immune suppression, and cancer, in addition to enhancing cognitive and physical performance Kava kava Kava, ava, kawa Marketed to relieve insomnia, induce deep sleep, enhance psychic powers, and promote a sense of sociability Kavalactones St. Johns wort Hypericum perforatum Marketed to relieve depression/anxiety, occasionally to promote wound healing Hyperforin, hypericin, a broad range of flavonoids, and tannins Valerian Valerian officinalis Marketed as a sleep aid Volatile oils and valepotriates Table 2. Possible Adverse Effects Of Some Specific Herbal Supplements. Herbal agent Most frequently reported adverse effects Possible/more dangerous complications Comfrey Hepatotoxicity Hepatic insufficiency or fulminant hepatic failure Ephedra Headache, nausea, vomiting, diaphoresis, insomnia, vertigo, agitation, psychosis, hypertension, tachycardia, palpitations, seizures, tremors, and rhabdomyolysis Sudden death, myocardial infarction, stroke, myocarditis, acute hepatitis Ginkgo biloba Gastric upset, headache, dermatitis; sometimes erythema, edema, papules, vesicles complicated by pruritus Seizures, temporally related hemorrhages, hemorrhagic strokes Ginseng Mania/euphoria; also diarrhea, skin eruptions, nervousness, hypertension, edema, vaginal bleeding, falsely elevated digoxin levels Kava kava Dermatologic (kava dermopathy), neurologic, and liver dysfunction Hepatitis, cirrhosis, and liver failure St. Johns wort Photosensitivity, gastrointestinal complaints, dizziness, and headache Serotonin syndrome Valerian CNS sedation Hepatotoxicity Ephedra Mostly ephedrine or precursors of ephedrine Aka ma huang cardiac toxicity Ginkgo Biloba Flavonoids Gi upset, Headache, and Dermatitis May cause seizures Bleeding disorders secondary to inhibition of platelet activating factor Kava Kava advertised to treat insomnia, serotonin and nor-epi uptake blockade, weak gaba, sodium channels, MAOI, and dopamine receptor blockade scaling white rash spreading from head to feet rarely can cause severe liver damage St. Johns Wort Hypericum perforatum for sleep, anxiety, and depression Probably has MAOI and gaba effects May be associated with serotonin syndrome Also hypomanic and manic episodes Ginseng For sexual dysfunction and to enhance physical performance Drug-drug interactions with dig Valerian For insominia and agitation Liver toxicity Comfey Hepatotoxin Table 5. Heavy Metal Adulterants Found In Some Herbal Supplements. Agent Type Contaminant Alarcon Traditional/folk remedy Lead Alkohl Traditional/folk remedy Lead Ayurvedic metal-mineral tonics Traditional/folk remedy Lead Azarcon Traditional/folk remedy Lead Bali goli Traditional/folk remedy Lead Coral, coral calcium Traditional/folk remedy Lead Crocodile Bile Pills for Asthma Asian remedy Arsenic, lead Crude Red Pills Asian remedy Arsenic, lead Crude Tan Pills Asian remedy Arsenic, lead Deshi Dewa (fertility drug) Traditional/folk remedy Lead Gliasard Traditional/folk remedy Lead Greta Traditional/folk remedy Lead Hai ge fen (clamshell powder) Traditional/folk remedy Lead Kohl Traditional/folk remedy Lead Liga Traditional/folk remedy Lead Paylooah Traditional/folk remedy Lead Pilulae Corticis Eucommiae et Ossis Tigris Asian remedy Lead, mercury Precious Pills for Women Asian remedy Lead, mercury Reinforce Sex Pill Asian remedy Lead, mercury Rueda Traditional/folk remedy Lead Surma Traditional/folk remedy Lead Wuchi Chi Pai Feng Wan Asian remedy Lead, mercury Yang Chun Yu Ye Kou Fu Ye Asian remedy Lead, mercury | | |