Oleander Poisoning

Dr. Shatdal Chaudhary MDAssistant 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

• Admitted 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.

Clinical Features

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, comaFatal 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

Clinical Features

• 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 CharcoalRationale• 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