Chinese Herbal Medicine Poisoning
اسلاید 1: www.tabaye.ir
اسلاید 2: Chinese Herbal Medicine (CHM) Poisoning AUTHORDr Tse Man LiAugust, 2013HKCEM College Tutorial
اسلاید 3: PresentationA 55 year old lady with no significant past medical health history Complained of numbness first affecting her face then progressed to her hands and feet since 1 hour ago And nausea, vomiting and dizziness Her vitalsGCS 15/15, BP80/50, P45, RR18/min., SpO2 98% (Rm Air)H’stix 7 mmol/L
اسلاید 4: Hyperventilation?
اسلاید 5: Hyperventilation UnlikelyHypotension, bradycardiaRR18 without respiratory complainPrecipitating factor present?
اسلاید 6: What will you do?
اسلاید 7: Manage in resuscitation roomIV fluidECG and electrolytes +/- ABG
اسلاید 8: What history will you ask?
اسلاید 9: Food intake HxPuffer fishBig coral fishes: Ciguatera poisoningShellfish: neurotoxic, paralyticPesticide contaminationOthersMad honey (Grayanotoxin)Sodium monoglutamate
اسلاید 10: Herb Intake HxOthers (less likely)Gelsemium elegans (斷腸草)Rhododendron flower (鬧羊花)Veratrum spp. root & rhizoma(黎蘆)Sophora flavescens root (苦蔘) Sophora tonkinensis root (山頭根)Aconite root (烏頭)Natural cardioactive steroid containing herbs
اسلاید 11: Progress-HxThe patient had taken some Chinese Herbal Medicine (CHM) dispensed from a herb shop 2 hour ago.The numbness and nausea onset 30 minutes after the intake.ECG monitor: (next slide)
اسلاید 12: ECG tracing:Junctional bradycardiaFrequent VEBsPossible triplet or short run VT?
اسلاید 13: What will you do?
اسلاید 14: ManagementIV fluidAnti-arrhythmics: AmiodaroneMagnesiumCorrect any electrolyte abnormalities
اسلاید 15: What else?
اسلاید 16: Collect the following and send to HA Toxicology Reference Lab for analysis if possible:Biological samples (urine and blood)Herb remnants Unused herbsTrace the CHM formula and consult HKPIC for interpretation
اسلاید 17: The Formula熟附子1兩半 烏梅1兩 雞內金三錢
اسلاید 18: What is the likely cause of her signs and symptoms?
اسلاید 19: Clinical Features of Aconite Poisoning Typical clinical triads of GI symptomsNausea, vomiting, abdominal pain, diarrhoeaNumbnessParesthesia, weakness(rarely)Cardiovascular effectHypotension, AV blockage,,ventricular ectopics , ventricular tachycardia, ventricular fibrillationProlong QT, Torsade de pointesOverdose of Fuzi (熟)附子 一両半(15錢) = 45gRecommended dose <15g
اسلاید 20: What is Aconite ?
اسلاید 21: Aconite PoisoningAconite is a plant genus that contain toxic aconite alkaloids e.g. aconitine, mesaconitine, yunaconitine….Aconite alkaloids are sodium channel effectors that are neurotoxic and highly cardiotoxicTheir roots are used in Chinese Herbal Medicine usually after curing(炮掣):川烏 ,草烏,附子,附片,雪上一枝蒿Aconite poisoning is the commonest acute Chinese Herbal Medicine related poisoning in Hong Kong and China. ~10 cases are reported annually.Aconite poisoning is usually severe and can be fatal
اسلاید 22: 3 commonest causes of poisoningThe commonest causes are:OverdoseSuggested ceiling dose in Chinese Pharmacopeia 2010 Ed:川烏Radix Aconiti /草烏Radix Aconiti Kusnezoffii : 一錢(3g)附子Radix Aconiti Lateralis : 五錢(15g)Improper curing/boilingContamination of benign herb by plant parts of aconite spp (hidden aconite poisoning)
اسلاید 23: ManagementActivated Charcoal is presented earlySupportive: IV fluid, atropine for bradycardia, inotroph e.g. dopamineAnti-arrhythmics:Amiodarone, MagnesiumCharcoal haemoperfusion in resistant caseCardiopulmonary bypass
اسلاید 24: ManagementPotential public interestCall HKPIC / Notify Department of HealthOutbreak control may be needed particularly for hidden aconite poisoning
اسلاید 25: Other common acute poisonings associated with CHM
اسلاید 26: Gelsemium elegans (斷腸草)Gelsemine and related toxinsCauses bulbar and extra-ocular muscle weaknessComa and respiratory failure if severeManagement is supportiveCommon Causes Contamination of benign herb e.g.五指毛桃 fruit of Focus plantMis-identficationIntake of parasitic plant growing on Gelsemium elegans
اسلاید 27: Cardioactive Steroid-containing Herbs & PlantsNaturally occurring cardioactive steroids acts on the Na+/K+ ATPase of cardiocyte, e.g. digitotoxin in Digitalis plants. Poisoning resembles Digoxin overdosePresent in Chinese herbs:Toad venom (蟾酥), Tupistra chinensis (川七 or 開口箭)Also in toxic plants found in HK: Nerium orleander (紅花甲竹桃), Thevetia perviana (黃花甲竹桃), Strophanthus divaricatus (羊角拗), Cerbera manghas (海芒果)Poisoning resembles digoxin overdoseCross-react with some digoxin essay in HA LabsDigoxin antibody is useful
اسلاید 28: Anti-cholinergic PoisoningTypically presents as confusion, delirium, visual hallucination within a few hours after CHM useSome presents with partial anti-cholinergic toxidrome:Dilated pupils (blindness)Dry mucous membrane and skin (dryness)Urinary retention (fullness)Red hot skin +/- fever (redness & hotness)Delirium (madness)Tachycardia, GI symptomsSolanaceae or tropane alkaloids e.g. atropine, hyocyamine, scopolamineCommonest cause:Substitution of benign herb by Datura flower(洋金花)Contamination of other benign herb by other unidentified toxic Solanaceae plantsPhysostigmine is a effective antidote
اسلاید 29: Thank You
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