صفحه 1:
www.tabaye.i
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صفحه 2:
۱۱۵۲۱۷۱ 00۱۱69۰ 8
AUTHOR
Dr Tse Man
ا
صفحه 3:
Presentation
* A55 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 vitals
* GCS 15/15, BP80/50, P45, RR18/min., SpO, 98%
(Rm Air)
* H’stix 7 mmol/L
صفحه 4:
Hyperventilation?
صفحه 5:
Hyperventilation Unlikely
= Hypotension, bradycardia
=RR18 without respiratory
complain
«Precipitating factor present?
صفحه 6:
What will you do?
صفحه 7:
= Manage in resuscitation room
IV fluid
ECG and electrolytes +/- ABG
صفحه 8:
What history will you
ask?
صفحه 9:
Food intake Hx
* Puffer fish
* Big coral fishes: Ciguatera
poisoning
* Shellfish: neurotoxic,
paralytic
Others
۰۱۵0 ۷
(Grayanotoxin)
*Sodium monoglutamate
* Pesticide contamination
صفحه 10:
Herb Intake Hx
* Aconite root (00)
* Natural cardioactive
steroid containing
herbs Others (less likely)
*Gelsemium elegans (000)
*Rhododendron flower ([0))
‘Veratrum spp. root & ۴۵۱2۵۳۵) ]0(
“Sophora flavescens root (i)
“Sophora tonkinensis root (100)
صفحه 11:
Progress-Hx
* The 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)
صفحه 12:
+ Ec tracing:
Junctlonal bradycaraa + ان
قل موه
+ Possible ple or short un VI?
صفحه 13:
What will you do?
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صفحه 14:
«IV fluid
« Anti-arrhythmics:
Amiodarone
Magnesium
«Correct any electrolyte
abnormalities
صفحه 15:
What else?
صفحه 16:
= Collect the following and send to
HA Toxicology Reference Lab for
analysis if possible:
- Biological samples (urine and blood)
- Herb remnants
- Unused herbs
= Trace the CHM formula and consult
HKPIC for interpretation
صفحه 17:
SERRE PE
The
Formula
۱۱
صفحه 18:
What is the likely cause
of her signs and
symptoms?
صفحه 19:
Clinical Features of
Aconite Poisoning
* Typical clinical triads of
— GI symptoms
+ Nausea, vomiting, abdominal pain, diarrhoea
— Numbness
» Paresthesia, weakness(rarely)
— Cardiovascular effect
» Hypotension,
* AV blockage,,
+ ventricular ectopics , ventricular tachycardia, ventricular
fibrillation
+ Prolong QT, Torsade de pointes
* Overdose of Fuzi (])) 00
-000 (150) = 45g
— Recommended dose <15g
صفحه 20:
What is Aconite ?
صفحه 21:
Aconite Poisoning
* Aconite 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 cardiotoxic
+ Their roots are used in Chinese Herbal Medicine
usually after curing( 00):
—00 .00,00,00, 00000
0 0 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
صفحه 22:
3 commonest causes of
poisoning
* The commonest causes are:
- Overdose
Suggested ceiling dose in Chinese Pharmacopeia
2010 Ed:
لك Aconiti / J Radix Aconiti Kusnezoffii: ][
0 (39
“00 Radix Aconiti Lateralis : [[] (15g)
+ Improper curing/boiling
+ Contamination of benign herb by plant parts of aconite
spp (hidden aconite poisoning)
صفحه 23:
Management
* Activated Charcoal is presented early
* Supportive:
- IV fluid, atropine for bradycardia, inotroph
e.g. dopamine
* Anti-arrhythmics:
- Amiodarone,
- Magnesium
* Charcoal haemoperfusion in resistant
case
* Cardiopulmonary bypass
صفحه 24:
Management
= Potential public interest
- Call HKPIC / Notify Department of Health
- Outbreak control may be needed
particularly for hidden aconite poisoning
صفحه 25:
Other common acute
poisonings associated
with CHM
صفحه 26:
Gelsemium elegans ( [J
O)
* Gelsemine and related toxins
* Causes bulbar and extra-ocular muscle
weakness
* Coma and respiratory failure if severe
* Management is supportive
* Common Causes
- Contamination of benign herb e.g. (O00 fruit of Focus
plant
- Mis-identfication
- Intake of parasitic plant growing on Gelsemium elegans
صفحه 27:
Cardioactive Steroid-containing
Herbs & Plants
Naturally occurring cardioactive steroids acts on
the Na+/K+ ATPase of cardiocyte, e.g. digitotoxin in
Digitalis plants.
* Poisoning resembles Digoxin overdose
Present in Chinese herbs:
- Toad venom ( (1),
- Tupistra chinensis (QQ or 000)
* Also in toxic plants found in HK:
- Nerium orleander ( 00000 ), Thevetia perviana ( 00000),
Strophanthus divaricatus ( [J ), Cerbera manghas (000) )
= Poisoning resembles digoxin overdose
= Cross-react with some digoxin essay in HA Labs
= Digoxin antibody is useful
صفحه 28:
Anti-cholinergic Poisoning
= Typically presents as confusion, delirium, visual
hallucination within a few hours after CHM use
= Some 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, Gl symptoms
= Solanaceae or tropane alkaloids e.g. atropine,
hyocyamine, scopolamine
= Commonest cause:
- Substitution of benign herb by Datura flower( 000 )
- Contamination of other benign herb by other unidentified
toxic Solanaceae plants
= Physostigmine is a effective antidote
صفحه 29:
Thank You