cardiac toxins- plants dr julian johny thottian. case 18 yr old unmarried pregnant tamilian female...
TRANSCRIPT
![Page 1: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/1.jpg)
Cardiac toxins- Plants
Dr Julian Johny Thottian
![Page 2: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/2.jpg)
Case
• 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting
• PR – 38/mt irregular BP – 90/60mmHg• No focal deficits• Toxic look• CVS- S1 varying S2 with normal split• Chest – NVBS
• Alleged consumption of Nerium Seeds from work site
![Page 3: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/3.jpg)
Investigations
Hb -11.2gm%, TC-11220/cm3 , PLT – 220000/cm3 ESR- 16mm/1st hr
DAY Na( meq/l)
K(meq/l) Bld Urea S creat
1 142 4.1 18 0.6
2 136 3.6 22 0.6
3 138 3.9 19 0.8
4 140 4.5 29 0.6
5 136 4.5 26 0.9
6 138 4.2 26 0.8
![Page 4: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/4.jpg)
ECG before pacing – 24hrs after consumption
![Page 5: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/5.jpg)
Paced
![Page 6: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/6.jpg)
Day 7- when pacing was removed
![Page 7: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/7.jpg)
Patient stay in hospital was uneventful and treated with orciprenaline , electrolyte correction & antibiotic. Patient removed from temporary pacing
• Discharged on the 8th day.
![Page 8: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/8.jpg)
Cardiac Glycosides
![Page 9: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/9.jpg)
Nerium- white oleander (kaner)
![Page 10: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/10.jpg)
• Dogbane family • Ornamental shrub with white & pink flowers• All parts are poisonous including the smoke
while burning• Used as an abortifacient, homicide and suicide• Fatal dose – 15-20 gms of root• Fatal period – 24 to 36 hrs
![Page 11: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/11.jpg)
Cerebra thevetia- yellow oleander ( pila kaner)
![Page 12: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/12.jpg)
• Fatal dose : 8-10 seeds, 15-20gms of root, 5-10 leaves
• Fatal period 2-3hrs
![Page 13: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/13.jpg)
Cerebera odallam (pili kirbir)
![Page 14: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/14.jpg)
• Fatal dose – kernel of one fruit• Fatal period -1-2 days
![Page 15: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/15.jpg)
Aconite (mitha zeher- monk`s hood)
• All parts are poisonous especially the root• Clinical features- nausea , vomiting , profuse
sweating• Hippus • Hypotension, AV BLOCK• Fatal dose – 1gm of root• Fatal period – 1-8 hrs• Treatment –Gastric lavage , atropine
![Page 16: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/16.jpg)
Cleistanthus collinus (oduvan)
• Closely related- it is a glucoside• Blocks cardiac conductive system• Conduction defects• Fatal dose – 200-400gms of leaves• Fatal period – 1-3 days
![Page 17: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/17.jpg)
POPULARITY AS A POISON
• In Sri Lanka, cases of attempted suicide with yellow oleander were extremely rare before 1980. During that year, the deaths of two girls who intentionally ate yellow oleander seeds was widely reported in local newspapers. The practice suddenly became so popular that the number of cases admitted to Jaffna hospital increased from zero in 1979 to 103 in 1983. QJM (1999) 92 (9): 483-485. doi: 10.1093/qjmed/92.9.483
![Page 18: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/18.jpg)
Studies across the world
• Dept of internal medicine, Colombo- a study on 300 patients -Ventricular ectopics and tachycardias are common in digoxin-poisoned patients, but are less common in oleander-poisoned patients
• 53% had AV node conduction block, while 62% had sinus node block; 30% had conduction block affecting both nodes. Only 1% had ventricular tachycardias and 8% had ventricular ectopics
• They report that most of the deaths are due to ventricular arrhythmia
• Mortality is 20% in their study.
![Page 19: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/19.jpg)
Electrocardiography
Increased PR interval, T wave flattening or inversion
Tachyarrhythmias Bradycardia & heart block – SA block and AV Block
![Page 20: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/20.jpg)
Management
• Induction of emesis & activated charcoal
Administering Atropine for severe bradycardia Using Phenytoin or Lidocaine hydrochloride to control arrhythmia. Placing a temporary venous pacemaker Electrical counter shock Digoxin-specific Fab antibody fragments (Digibind).
![Page 21: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/21.jpg)
• Osterloh et al calculated the lethal oleander leaf dose of their patient to be approximately 4 gm.
![Page 22: Cardiac toxins- Plants Dr Julian Johny Thottian. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting](https://reader037.vdocuments.us/reader037/viewer/2022103122/56649c9a5503460f949577a9/html5/thumbnails/22.jpg)
THANK YOU