Transcript Cardiac toxins - DR Julian.ppsx

Cardiac toxins- Plants
Dr Julian Johny Thottian
Case
• 18 yr old unmarried pregnant Tamilian female brought
to the casualty with giddiness and vomiting
• PR – 38/mt irregular BP – 90/60mmHg
• No focal deficits
• Toxic look
• CVS- S1 varying S2 with normal split
• Chest – NVBS
• Alleged consumption of Nerium Seeds from work site
Investigations
Hb -11.2gm%, TC-11220/cm3 , PLT –
220000/cm3 ESR- 16mm/1st hr
DAY
Na( meq/l) K(meq/l)
Bld Urea
S creat
1
142
4.1
18
0.6
2
136
3.6
22
0.6
3
138
3.9
19
0.8
4
140
4.5
29
0.6
5
136
4.5
26
0.9
6
138
4.2
26
0.8
ECG before pacing – 24hrs after
consumption
Paced
Day 7- when pacing was removed
Patient stay in hospital was uneventful and
treated with orciprenaline , electrolyte
correction & antibiotic.
Patient removed from temporary pacing
• Discharged on the 8th day.
Cardiac Glycosides
Nerium- white oleander (kaner)
• Dogbane family
• Ornamental shrub with white & pink flowers
• All parts are poisonous including the smoke
while burning
• Used as an abortifacient, homicide and suicide
• Fatal dose – 15-20 gms of root
• Fatal period – 24 to 36 hrs
Cerebra thevetia- yellow oleander
( pila kaner)
• Fatal dose : 8-10 seeds, 15-20gms of root, 510 leaves
• Fatal period 2-3hrs
Cerebera odallam (pili kirbir)
• Fatal dose – kernel of one fruit
• Fatal period -1-2 days
Aconite (mitha zeher- monk`s hood)
• All parts are poisonous especially the root
• Clinical features- nausea , vomiting , profuse
sweating
• Hippus
• Hypotension, AV BLOCK
• Fatal dose – 1gm of root
• Fatal period – 1-8 hrs
• Treatment –Gastric lavage , atropine
Cleistanthus collinus (oduvan)
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Closely related- it is a glucoside
Blocks cardiac conductive system
Conduction defects
Fatal dose – 200-400gms of leaves
Fatal period – 1-3 days
POPULARITY AS A POISON
• In Sri Lanka, cases of attempted suicide with
yellow oleander were extremely rare before
1980.
During that year, the deaths of two girls who
intentionally ate yellow oleander seeds was
widely reported in local newspapers.
The practice suddenly became so popular that
the number of cases admitted to Jaffna
hospital increased from zero in 1979 to 103 in
1983.
QJM (1999) 92 (9): 483-485. doi: 10.1093/qjmed/92.9.483
Studies across the world
• Dept of internal medicine, Colombo- a study on 300
patients -Ventricular ectopics and tachycardias are
common in digoxin-poisoned patients, but are less
common in oleander-poisoned patients
• 53% had AV node conduction block, while 62% had
sinus node block; 30% had conduction block affecting
both nodes. Only 1% had ventricular tachycardias and
8% had ventricular ectopics
• They report that most of the deaths are due to
ventricular arrhythmia
• Mortality is 20% in their study.
Electrocardiography
Increased PR interval,
T wave flattening or inversion
Tachyarrhythmias
Bradycardia & heart block – SA block and AV
Block
Management
•
Induction of emesis & activated charcoal
Administering Atropine for severe bradycardia
Using Phenytoin or Lidocaine hydrochloride to
control arrhythmia.
Placing a temporary venous pacemaker
Electrical counter shock
Digoxin-specific Fab antibody fragments
(Digibind).
• Osterloh et al calculated the lethal oleander
leaf dose of their patient to be approximately
4 gm.
THANK YOU