• Understand the spectrum of intoxication with common herbal medications.
• List traditional medications susceptible to interact with St John’s wort and the symptoms associated with this poisoning.
• Describe initial evaluation, stabilisation and treatment of common herbal remedies intoxication.
• Discuss the main difficulties in dealing with herbal remedies poisonings.
• Describe the mechanism of toxicity of Ma Huang.
• Describe the mechanism of aconite tachyarrhythmias.
• Discuss steps that would be useful in preventing herbal medication poisoning from a Community Health Perspective.

A 33-year-old female is brought by a neighbour to the Emergency Department. The neighbour became worried when hearing loud noises coming from the patient’s flat on Monday morning. The patient was found in her home confused, agitated, not recognising her friend and talking to herself. Her pulse is 130/min, sinus rhythm; her BP 95/60, respiratory rate 14 and saturation 98% on room air. A bottle of tablets was found at her bedside with only 3 tablets left. The label on the bottle has Asian characters unreadable by any colleagues working in the Department. The neighbour tells you this lady has recently returned from visiting family in China and has been depressed for quite some time. She doesn’t smoke cigarettes but occasionally goes to ‘rave parties’.

1. What are the potential causes of this patient’s delirium?
2. How should this patient be managed at this time?
3. Is decontamination indicated; if so, how?
4. What features on examination will help you distinguish between a serotonergic and a sympathomimetic toxicity responsible for this patient’s symptoms?

A 56-year-old French man is brought in the middle of the night to the resuscitation area of the Emergency Department. He is unwell, nauseated and vomited en route. He has a tachycardia with a heart rate of 160/min and a BP of 95/50. Despite his obvious distress, he is able to explain that he is here visiting old friends who now are running a winery in the Hunter Valley. During the evening, they were reminiscing over their younger days and one of his friend pulled out a bottle of ‘La fée Verte’- (the green fairy) made by a friend of theirs back home. The ECG done on arrival shows a wide complex QRS.

1. What is the most likely toxin responsible for this man’s problem according to the history he gives you?
2. Is the reported ingestion of ‘green fairy’ compatible with the clinical scenario?
3. What do you think might be the ‘real’ culprit in this case? Can you identify other substances susceptible to cause cardiac dysrhythmias?
4. Which antiarrhythmic would you use in this scenario?
5. How could you attempt to identify the substance ingested?
6. How should you address the issue of the other friends with whom he drank?

A 60-year-old lady is brought in by her grand-daughter concerned that she hasn’t been feeling well for a week. The grand-daughter went to her house as there was no answer to her phone calls. A month ago, she went to see a therapist who suggested she take some vitamins to boost her system, help her digestion and some other substance to help her sleep and they seemed to work quite well initially. The grand-daughter is not sure what she has taken or how much but the patient hasn’t been able to tolerate any oral intake over the last 2 days because of nausea, vomiting and diarrhea. Otherwise well, this lady was not taking any medication previously and did not suffer from any chronic illness. On examination, you find her drowsy, mucous membranes are dry, skin turgor is decreased. Her HR is 125/min, sinus tachycardia and her BP 100/65. Her examination is otherwise unremarkable and her neurological exam is without abnormalities.

1. What investigations do you specifically request in this setting?
2. Can you give a differential diagnosis of potential medications involved and how they could lead to this lady’s state?
3. What management is required?