Oleander Poisoning 2i4o72

Oleander Poisoning

Dr. Shatdal Chaudhary MD Assistant Professor Department of Internal Medicine, BPKIHS, Dharan

case

• 32 yr female came to ER on 14/2/2066 – Multiple episodes of vomiting – H/o ingestion of 4 oleander seed after family dispute

• itted in CCU • Developed sinus bradycardia and first degree heart block • Treated with atropine infusion and discharged on day 7

Oleander • Also known as Kaner • Wide spread in Nepal and India. • Flowers are used as offerings in the temples

• Can be used for – Suicide – Accidental poisoning especially in children – Abortion – Cattle poison

• In Sri Lanka– In some areas up to 40% of suicidal poisoning cases are now linked to oleander seeds. – annual incidence of >150 per 100 000. – mortality rate of about 10%. – results in about 2000 deaths each year.

• Accidental oleander poisoning occurs throughout the tropics and subtropics • oleander caused 27%of the paediatric plant poisonings in Australia

• There are two varieties – Nerium oleander- Common, pink or white Oleander – Thevetia peruviana- Yellow Oleander All the parts are poisonous

White Oleander (Nerium oleander) • The active principle is nerin • It consisting of three glycosides – Neriodorin: Acts on heart similar to digitalis – Neriodorein: cause muscular twitching and tetanic spasms – Karabin: Affect heart as well as cause muscular spasms. Toxic effects last for 3-6 days.

Cl ini cal Featu res Local, Gastrointestinal, Cardiac, Neurological • Vomiting, Pain abdomen, salivation and restlessness. • Difficulty in swallowing and lock jaw • Muscular twitching, tetanic spasm • Pulse- slow various Brady arrhythmias, SVT with various degree of AV block. • Heart failure, coma Fatal Dose: • about 15 grams of roots, 5-15 leaves – can kill an adults in about 24 hrs

Yellow Oleander (Cerbera Thevetia) • Contains at least eight different cardiac glycosides, including Thevetin A, Thevetin B, thevetoxin, neriifolin, peruvoside and ruvoside. – Thevetin B- Acts like strychnine – Thevetin A- acts like digitalis – Thevotoxin• acts like digitalis • Less toxic than thevetin • Presents in kernels of the seeds

Cl ini cal Featu res • seeds are usually eaten as whole or in chunks . • Large variation in the amount of absorption of cardio active toxins from a seed • the number of seeds ingested does not always correlate with the degree of toxicity • Burning sensation in the mouth, dryness of the throat, vomiting, diarrhoea • Fragments of seeds can be seen in the stomach contents

• Dizziness, tetanic convulsions • Various Brady arrhythemia are can be seen ranging sinus bradycardia to various degree heart block. • sudden cardiac death can occur due to ventricular fibrillation or cardiac asystole

Fatal dose: 8-10 seeds 15-20 grams of roots 5-15 leaves

Treatment • Continuous ECG monitoring for at least 24 h is necessary to detect arrhythmias • longer monitoring in patients with severe poisoning. • Correct dehydration with iv fluids • Correct electrolyte imbalance – Hypokalemia / hyperkalemia both must be corrected.

• Hyperkalemia is best treated with insulin-dextrose infusion. • Antiemetics to control severe vomiting. • Gastric decontamination by the use of single dose and multiple doses of activated charcoal

Activated Charcoal Rationale • activated charcoal prevent the initial absorption of the toxic glycosides, but also prevent toxin reabsorption • After absorption into the systemic circulation, cardiac glycosides are secreted into the gut lumen from the systemic circulation. • In the gut, activated charcoal binds the secreted glycoside and encourages further secretion, and helps in glycoside excretion.

Activated Charcoal  50 g of activated charcoal every 6 h for 3 days or sterile water as placebo.  201 patients received multiple-dose activated charcoal and 200 placebo.  There were fewer deaths in the treatment group (five [2·5%] vs 16 [8%]; percentage difference 5·5%; 95% CI 0·6–10·3; p=0·025),  Multiple-dose activated charcoal is effective in reducing deaths and life-threatening cardiac arrhythmias after yellow oleander poisoning and should be considered in all patients.  Treatment of patients who had yellow oleander poisoning with multiple doses of activated charcoal over 72 h reduced the death rate by 69%. M Eddleston et al. Lancet 2003; 361: 1935–38

Atropine • IV Atropine three 2 mg intravenous boluses at 5–10 min intervals, or infusions of 12 mg/h for: a) sinus bradycardia <50 per min b) sinus bradycardia <60 per min and low systolic blood pressure c) All other bradyarrhythmias

Bradyarrhythmias. • Adrenaline, Noradrenaline, isoprenaline • Tachyarrhythmias- iv lignocaine • Temporary cardiac pacing

Digoxin-specific Fab antibody Fragments • 66 patients who presented to hospital with a serious cardiac arrhythmia were randomised to receive either 1200 mg of anti-digoxin Fab or placebo. • 34 patients received anti-digoxin Fab and 32 • received placebo. • The presenting arrhythmia had resolved completely after 2 h in 15 antibody-treated patients and two controls (p<0·001); 24 patients and five controls, respectively, were in sinus rhythm at 8 h (p<0·001). M Eddleston and D A Warrell et al. Lancet 2000; 355: 967–72

The End