Problems for Discussion - 4 - Plant Poisoning

• Understand the mechanism of toxicity of these plants.
• Discuss the clinical effects of plants with systemic toxicity.
• Detail the assessment of a patient poisoned by a systemically toxic plant.
• Outline the management of gastrointestinal and systemic complications following ingestion of these plants.

A 17-year-old male is brought to hospital by his parents. Whilst intoxicated at a party he ate, for a bet, a whole leaf of dumbcane (Dieffenbachia). Almost immediately he experienced severe pain. He is salivating profusely and is unable to speak.

1. What is the mechanism of toxicity of this exposure?
2. What features will you look for on examination?
3. Could this exposure be life-threatening; if so how?
4. Outline the management that may be required and the indications for each.

An eighteen-month-old girl is brought by her parents to hospital after being observed to eat a small brown mushroom growing in their backyard. Half an hour later she began to vomit profusely. The family present to their local hospital with a sample of one of the mushrooms from the area where she picked the eaten mushroom.

1. Is gastrointestinal decontamination required; if so how?
2. What particular observations do you want to make on examination?
3. Are investigations indicated; if so which?
4. How can the mushroom be identified?
5. How long should the child be observed for?
6. What is the likely prognosis?

• Understand the clinical effects of poisoning by plants containing cardiac glycosides.
• Outline the management of cardiac glycoside plant poisoning.
• Discuss the role of digoxin Fab fragments in the management of cardiac glycoside poisoning.
• Detail the clinical effects of nicotinic alkaloid plant poisoning.
• Discuss the management of nicotinic alkaloid plant poisoning.

A 56-year-old male is brought to hospital by ambulance. Three hours previously he made an infusion using yellow oleander seeds that he then consumed in a suicide attempt. He began vomiting profusely. His heart rate is 50/min and blood pressure 130/80. An ECG shows sinus bradycardia and first degree heart block.

1. What initial treatment is indicated?
2. What investigations should be undertaken and how should they be interpreted?
3. Are digoxin Fab fragments indicated; if so, what dose should be administered?
   Half an hour after arriving he is noted to be more unwell. His heart rate is now 35/min with a blood pressure of 80 systolic. An ECH shows third degree heart block.
4. What treatment is required?
5. Are digoxin Fab fragments indicated; if so, what dose should be administered?

A 13-month-old boy was found eating cigarette butts out of an ashtray. Thirty minutes later he vomited several times and his parents brought him to hospital. On arrival he was noted to be sweaty and salivating. He did not interact with his parents. His pulse rate was 160/min, blood pressure 130/80 and respiratory rate 30/min.

1. What is your risk assessment of this exposure? What further information would assist?
2. What treatment is indicated?
3. Is decontamination indicated; if so how?
   One hour after ingestion the child has a brief grand mal seizure. Over the next 40 minutes he becomes increasingly lethargic. His pulse decreased to 80/min and his blood pressure to 80/40. His respiratory rate decreased to 16/min and was shallow. His skin is mottled and cool.
4. What further treatment is required?
5. What further investigations would assist?
6. What is his prognosis?

A 30 year old girl was brought to the emergency department following ingestion of unknown amount of yellow oleander seeds with sugar.

Questions

1. What additional information in the history would be helpful in making a risk assessment?
2. What investigations will be useful and why?
3. How will you mange this patient?

A 25 year old man was admitted 4 hours following ingestion of 5 yellow oleander seeds. He vomited several times on admission. His Glasgow coma scale was 15/15 and the blood pressure was 100/70 with a pulse rate of 50 beats per minute. The ECG revealed a first degree heart block.

1. What is you risk assessment? Give reasons.
2. What initial investigations are indicated and why?
3. What initial treatment is indicated?
4. How would you monitor this patient?

4 hours later his blood pressure drops to 70mmHg and the ECG showed a third degree heart block.

1. What is your management?
2. A further 2 hours later, he was found to be in Ventricular tachycardia and his blood pressure was unrecordable.
3. What is your management

A 13 year old young boy was admitted with excessive sweating and abdominal pain. He was found to be tachycardic (pulse of 140 beats per minute) and hypertensive (blood pressure was 150/90) He also had dilated pupils, fasciculations and a temperature of 390 C.

1. What is your differential diagnosis?
2. How do you manage this child?

• Understand the mechanisms of hallucinogenic plants.
• Understand the usual patterns of abuse of hallucinogenic plants.
• List the most common clinical manifestations of hallucinogenic plant poisoning.
• Understand how this helps differentiate the likely agent in a suspected hallucinogenic plant ingestion.
• Recognise situations where the use of antidotes may be indicated.
• Know the supportive treatment for anxiety with severe visual hallucinations.

A 15-year-old female is brought in to the emergency department (ED) with an acute confusional state. She has been brought in by her parents who were rung when she was found wandering the streets by passers-by. Nothing can be obtained in the way of history. She had said she was going to a friend’s house six hours previously when she had been completely well. She is on no regular medication. She has previously been suspected to be drunk by her parents.

On examination, she is extremely anxious, distracted by apparent visual hallucinations and incoherent. She has dilated but reactive pupils and is complaining of nausea (the one thing you can understand). Her temperature is 37.5 degrees, her heart rate is 110 beats per minute and blood pressure is 145/90 mmHg.

1. What other clinical features might indicate the nature of the poisoning?
2. What plant/mushroom poisonings are most likely (and what other possibilities are likely)?
3. Do any of these poisonings cause hypertension??
4. What complications might occur?
5. What investigations should be performed?
6. Does she require gastrointestinal decontamination?
7. What other treatment is indicated?

A group of five adolescent males are brought to the Emergency Department of a rural hospital all in a state of delirium. Their ages range from 16 to 19. One of them keeps repeating the phrase ‘magic mushrooms’; the others are incoherent. From one patient driver’s licence his parents are contacted who said the five had left the previous day for a camping trip in the mountains but had been out of mobile phone range since midday yesterday. Nothing of their movements was known until the police were called to a disturbance at the camping grounds. The five were found stumbling around the campsite raving incoherently. Police found no alcohol or medications on searching their campsite but a home-made ‘bong’ and a small amount of what Police thought was cannabis was found in one of the boy’s sleeping bag.

1. What are the potential causes of the patients’ delirium?
2. What investigations are indicated?
3. How should they be managed?
4. Is decontamination required; if so, how?
5. The Police are concerned that the patients have taken an illicit drug and are asking that a drug screen be undertaken on all the boys. How do you approach their request?

A 7 year old boy was brought into the casualty department by her parents in a state of delirium after wondering into the nearby shrub. There was no other available history.
Clinical examination revealed an extremely anxious child who was distracted by visual hallucinations. His pupils were 6mm and reactive. His skin was warm and dry and the axillary temperature was 380C. His pulse was 140 beats per minute and the blood pressure was 100/70mmHg. His bladder was distended.

1. What is the most likely cause of the child’s clinical state
2. What other clinical signs will be of help?
3. What complications may develop?
4. How would you monitor his clinical condition?
5. How would you treat this child?

A 25 year old young man was brought in to the casualty department in a state of delirium. He has been smoking a cigarette presented to him by one of his friends one hour ago. He was agitated and hallucinating. He had dilated pupils. His pulse was 140beats per minute and blood pressure 140/100mmHg.

1. What is your initial management?
2. What is the most likely diagnosis?

A 20 year old girl was brought to the casualty department by the parents after a brief period of colicky abdominal pain, profuse vomiting and bloody diarrhea. She was under the care of the psychiatry team for depression. Her GCS was 13/15. There was no rigidity. His peripheries were cold and a feeble pulse of 140 beats per minute was felt and his blood pressure was 50mmHg.

1. What is your risk assessment
2. What further tests will you arrange
3. What is your initial management

12 hours after admission her urine output has declined to 10ml/hour. Her SGPT was raised at 200iu/L.

1. What has happened?
2. What is your management?