新光医院肾脏科主治医师(附件)

PLANTPOISONING

inCriticalCare林秉熙醫師新光醫院腎臟科主治醫師國立陽明大學醫學系講師LinB.S.1KeyPoints(1)Therearealargevarietyofplantpoisonsinnaturewithonlyfewspecificantidotes.Acutegastroenteritisisafeatureofmostplantpoisonings.Organicbrainsyndromesarecommon.Supportivecareanddecontamination(gastro-intestinaltractandothers)arethemainstaysoftreatment.LinB.S.2KeyPoints(2)Identificationoftheplantisimportantforanticipatingclinicalevents.Inplant-relatedcardiacglycosidetoxicity,antidigoxinFabfragmentsmaybeofuse.Mucosalirritation,renalfailure,andhypo-calcemiacharacterizeplant-relatedoxalatetoxicity.LinB.S.3KeyPoints(3)Life-threateningmushroompoisoningstendtohaveadelayofatleast6hpriortotheonsetofsymptoms.Hepatic,renal,orcentralnervoussystemcomplicationsmaydevelop,dependingonthetypeofmushroomingestedLinB.S.4HinderedplanttoxicologyPaucityofacutelyillpatients,prospectiveclinicaltrials,andgoodclinicalseriesinplanttoxicologyImmensenumberofuncharacterizedpotentialtoxinsintheplantkingdomImpreciseidentificationoftheoffendingspeciesIdentificationofthetoxinorquantitativebloodlevelsrarelyobtainedLinB.S.5BenignplantswithacuteillnessSimultaneousingestionofpesticidesAllergicresponseLinB.S.6CommonclinicalsyndromesAcutegastroenteritisAlmostuniversal,eventheonlyfeatureofpoisoningsOrganicbrainsyndromethesecondmostcommonmanifestationoftenseenalongwith,orfollowingthegastroenteritisalterationinmentalstatusmanifestedbydelirium,coma,orseizuresLinB.S.7GeneralManagementStablizedairway,breathing&circulationNaloxone&dextroseforalteredmentationGastrointestinaldecontaminationwithlavageandactivatedcharcoalIdentifyingtheplantConsultationwithregionalpoisoncontrolcenterSpecificantidoteifavailableLinB.S.8SpecificPlantSyndromes(1)ANTICHOLINERGICSYNDROMEPYRROLIZIDINEALKALOIDSCARDIACGLYCOSIDEOXALATESYNDROMESOLANINEALKALOIDSNICOTINEALKALOIDCYANOGENICPLANTSLinB.S.9SpecificPlantSyndromes(2)TOXALBUMIN-CONTAININGPLANTSCOLCHINEPOISONINGMISTLETOE(槲寄生)

TOXICOLOGYPODOPHYLLUM(鬼臼樹脂)POISONINGPENNYROYAL(薄荷)OILEUCALYPTUS(桉樹)OILHALLUCINOGENICPLANTSLinB.S.10SpecificPlantSyndromes(3)AKEEFRUITPOISONINGTAXINE(YEW)POISONINGFAVABEANPOISONINGWATERHEMLOCK(毒水芹)POISONINGRHODODENDRON(杜鵑花)POISONINGDAPHNE(月桂)POISONINGGASTROENTERITISSYNDROMEMUSHROOMPOISONINGLinB.S.11AnticholinergicSyndromeDeadlynightshade(Atropabelladonna顛茄)Angel’strumpet(Daturasuaveolens

曼陀羅)Jimsonweed(D.stramonium)Matrimonyvine(Lyciumhalimifolium)Henbane(Hyoscyamusniger茛菪)LinB.S.12Anticholinergicsyndrome(ACS)Tropanealkaloidsatropine(顛茄鹼)scopolamine(茛菪鹼)ThemostcommonplantcausesDaturastramonium

(jimsonweed,曼陀羅)Atropabelladonna(deadlynightshade,茛菪)LinB.S.13Anticholinergicsyndrome(ACS)Themostfrequentcauseofintoxicationbytheseplantsisfromteas.

Anticholinergicplantpoisoningisoccasionallyinducedpurposefullyinanattempttocapturethehallucinogenicanticholinergiceffects.LinB.S.14Anticholinergicsyndrome(ACS)Toxicities:competitiveantagonistatthecholinergic-muscarinicreceptor.Crosstheblood-brainbarrier,causecentraleffectsClinicalpictures:"madasahatter,hotasabare,dryasabone,redasabeet,andblindasabat"LinB.S.15Anticholinergicsyndrome(ACS)Tachycardia:usuallysinussupraventricularaswellasventriculararrhythmiasmayoccur.Profoundalterationinmentation:includingconfusion,agitation,disorientation,hallucinations,andseizures.

LinB.S.16PhysicalexaminationMydriasis,absenceofperspiration,andrelativelyparchedmucousmembranesFlushedduetoperipheralcutaneousdilationFeveriscommon.LinB.S.17TreatmentofACSObservedforcardiacdysrhythmias,hemodynamicinstability,agitation,andseizures.BenzodiazepinesforsignificantagitationPotentialantagonist:Physostigminemayresultinbradydysrhythmias,asystole,orseizuresrestrictedtopatientswithlife-threateningACS,ordiagnosticdilemmasLinB.S.18AdministerationofphysostigmineUsualdoseofphysostigmine:2mg(0.5mgforpediatricpatients)intravenouslyoveratleast2min.AsyringecontainingatropinestandbyContraindications:asthma,peripheralvasculardisease,bowelobstruction,urinarytractobstruction,organgrene.LinB.S.19CARDIACGLYCOSIDESChristmasrose(Helleborusniger

黑藜蘆)

LilyoftheValley(Convallariamajalis

歐鈴蘭)

Foxglove(Digitalispurpurea

毛地黃)

Commonoleander(Neriumoleander夾竹桃)Yellowoleander(Thevetiasp.)LinB.S.20Cardiacglycosides(1)Thepresentationofplantcardiacglycosidepoisoningissimilartomedicinalglycosides.Thereisaninitialperiodofgastrointestinaldiscomfortfollowedbymultiplecardiacconductionabnormalitiesandhyperkalemia.

LinB.S.21Cardiacglycosides(2)Foxgloveplant(Digitalispurpurea

毛地黃)containspredominantlydigitoxinlonghalf-lifeandprolongedclinicalsyndromeEuropeansnapdragon金魚藻(Digitalislanata)containsmostlydigoxincausesamoreabbreviatedsyndromeLinB.S.22Cardiacglycosides(3)Variabledegreeofcross-reactivityDigoxinlevelsunreliableBindtoactivatedcharcoal:MultipledosesofactivatedcharcoalindicatedDigitoxin:atrueenterohepaticcirculationEfficacyofantidigoxinFabfragments:Controversy

LinB.S.23PyrrolizidineAlkaloidSyndromeThreadleaf

(Seneciolongilobus

劉寄奴草)Heliotrope(Heliotropiumeuropaeum

天芥菜)Russiancomfrey

(Symphytumxuplandicum

紫草)Horsefoot

(Tussilagefarfara

款冬)LinB.S.24Pyrrolizidinealkaloids(1)Firstrecognizedin1954inJamaicahepaticveno-occlusivediseaserelatedtodrinkingherbalteasoreatingcontaminatedcereals.Endothelialedemaofsmallandmediumsizehepaticveinsandvenules,resultinsclerosisandocclusion.LinB.S.25Pyrrolizidinealkaloids(2)Congestionofhepaticsinusoidsandcentralveinscentrilobularhemorrhagicnecrosislargehepaticveinsunaffected,distinguishingfromtheBudd-Chiarisyndrome.Typicallpresentation:RUQabdominalpain,nausea,vomiting,diarrhea,hepatomegaly,splenomegaly,ascites,jaundice,hypoglycemia,andextremelyhighGOT/GPTLinB.S.26Pyrrolizidinealkaloids(3)Chronicingestionprogressivehepaticveno-occlusivediseasecorpulmonaleNospecificantidoteTreatment:supportivemanagementofcoagulopathy,hypoglycemia,pulmonaryhypertension,andencephalopathyLinB.S.27OxalateSyndromeDumbcane

(Dieffenbachiasp.)Elephant'sear(Colocasiaantiquorum)Rhubarb(Rheumsp.大黃)Jack-in-the-pulpit(Arisaemaatrorubens

美國黃花菖蒲)Skunkcabbage(Symplocarpusfoetidus

臭菘)Swisscheeseplant(Monsterasp.)Philodendron(Philodendronsp.黃蘗)Caladium(Caladiumbicolor貝母)LinB.S.28Oxalatesyndrome(1)Primarysyndrome:mucosalirritationMostcommoncause:Dieffenbachia

Chronicingestionofrhubarbleaves(大黃)Solublevs.insoluble(rhaphides)formLinB.S.29Oxalatesyndrome(2)Rhaphides:severemucosalirritation,evenlaryngealedemaSolubleoxalate:systemic&diffuseeffectMucosalirritationgastroenteritisrenalfailurehypocalcemiaLinB.S.30Oxalatesyndrome(3)TreatmentMaintainairwayOralfluid,preferablymilkfordilutionECG&serumcalciummonitoringHemodynamicmonitoringAdequatefluidsupply&monitorrenalfunctionLinB.S.31SolanineAlkaloidSyndromeJerusalemcherry(Solanumpseudo-capsicum)Commonpotato(S.tuberosum馬鈴薯)Eggplant(S.melongena

茄子)Woodynightshade(S.

dulcamara)Horsenettle(S.carolinense

針茄)

Commonnightshade(S.nigrum)Tomato(Lycopersiconesculentum)Trumpetflower(Solandrasp.)LinB.S.32Solaninealkaloid(1)MostplantsoftheSolanaceaefamily(nightshade茄屬

orpotatoplants馬鈴薯)

containthesolaninealkaloidsinnontoxicamounts.Severesolaninealkaloidpoisoningcanoccurwhenpotatoesareharvestedwhilestillgreen,areimproperlystored,oraretraumatized.LinB.S.33Solaninealkaloid(2)Toxicities:GastrointestinaltractirritationGastricjuicehydrolyzesolanine

alglycon&sugarAglycone:hypotension&organicbrainsyndromeSolanocapsinetoxicity:cardioinhibitorysyndrome,withbothnegativeinotrophic/chronotrophiceffectSuperimposedACSLinB.S.34Solaninealkaloid(3)TreatmentSupportivemeasuresGastrointestinaldecontamination:activatedcharcoalTreatsuperimposedACSLinB.S.35NicotineSyndromeTobacco(Nicotianasp.菸草)Poisonhemlock(Coniummaculatum

毒人蔘)Indiantobacco(Lobeliainflata

半邊蓮)LinB.S.36Nicotinealkaloid-containingplantsPoisoningwhenusedaspurgativesandenemasHemlock(毒芹)root:confusedwithwildcarrotsLeaves:similarinappearancetoparsley(荷蘭芹)LinB.S.37Nicotinealkaloid-containingplantsToxicityRapidemesisduetodirecteffectandstimulationofmedullarychemoreceptortriggerzoneStimulatepostsynapticreceptorsofautonomicneuronsandmotorendplatesInitialstimulationfollowedbydepression,eithersympathomimeticorcholinergicDeathwithinanhourofingestion(respiratoryfailure)LinB.S.38Nicotinealkaloid-containingplantsTreatmentThoroughskindecontaminationActivatedcharcoalinmultidosefashionRespiratoryandhemodynamicmonitoringLinB.S.39CyanogenicGlycosidesSyndromeCommonfruitpits(Rosaceaefamily)Cherrylaurel(Prunuslaurocerasus月桂櫻桃)Cassava(Manihotesculenta

樹薯)Bamboo(Phytostachysaurea

竹子)Elderberry(Sambcucussp.接骨木)Bitteralmonds(Prunusdulcis

苦杏)Hydrangea(Saxifragaceaefamily繡球花)Limabeans(Phaseoluslunatus

青豆)Chokecherry(Prunesairginiana

苦櫻桃)LinB.S.40Cyanogenicplants(1)Cyanide:OneofthemostpotentandrapidactingpoisonsWidelydistributedintheplantworldintheformofcyanogenicglycosides(sugarcompoundsofcyanide)GlycosidesmaybehydrolyzedbyeitherplantenzymessimultaneouslyingestedorendogenousenzymestoliberatehydrogencyanideLinB.S.41Cyanogenicplants(2)Amygdalin(苦杏仁素)Themostcommonglycoside,alsofoundinplum,peach,apricot,bitteralmond,cherry,pear,andappleThemajorglycosideintheproductsoldasLaetrileThesepitscontainacomplexofenzymesknownasemulsinintheircoats.Whenthepitsarechewed,emulsinisliberatedandmetabolizesthenontoxicamygdalintofreehydrogencyanide.LinB.S.42Cyanogenicplants(3)Linamarin:anothercommoncyanogenicglycosidefoundinlimaandcassavabeansTropicalorNigerianataxicneuropathy:Chroniccassavaconsumptionintropicalareas,particularlyNigeria,associatingwithchroniccyanidepoisoningLinB.S.43Cyanogenicplants(4)Diagnosis:BasedprimarilyonahighindexofsuspicionHypotension,seizures,analteredmentalstatus,orapersistentmetabolicacidosisinthesettingofthepotentialingestionofcyanogenicplantsOdorofbitteralmondsisafurthercluebutunreliable;cannotbedetectedbyupto40%ofthepopulation.

LinB.S.44Cyanogenicplants(5)TreatmentofcyanidepoisoningPromptresuscitationVentilationwith100%oxygenSodiumthiosulfate,25%solution,150mg/kgivGastricdecontamination(larvage)ActivatedcharcoaladministrationLinB.S.45ToxalbuminSyndromeCastorbean(Ricinuscommunis

蓖麻子)Jequiritybean(Abrusprecatorius相思子)Sandboxtree(Huracrepitans)Bellyachebush(Jatrophagossipifolia麻風樹屬)Blacklocust(Robiniapseudoacacia北美刺槐樹)Desertpotato(J.macrorhiza)LinB.S.46Toxalbumin-containingplantsAbrin,theactivetoxininthejequiritybean,andricin,foundinthecastorbean,areamongthemostpotentnaturaltoxinsknownwhenadministeredparenterally.Ingestionofthesebeansisusuallynotassociatedwithtoxicityunlesstheyarechewed.Extremelyantigenic,causingahypersensitivityreaction

LinB.S.47Toxalbumin-containingplantsCastorbeantoxicity:acute,severe,gastroenteritisJequiritybeancontainsglycyrrhizin,whichmaycausehyperaldosteronism.Abrinismoretoxicthanwithricin“aslittleasonejequiritybeanwhenchewedcanbelethaltoachild”LinB.S.48Toxalbumin-containingplantsToxiceffectsoftoxalbuminingesion:acute,persistentandseveregastroenteritisencephalopathy:stupor,seizures,andcomamultipleorgansystemfailureinsomecases,withpancreatitis,hepatotoxicity,hemolysis,renalfailure.Inaddition,aprimaryirritantdermatisLinB.S.49Toxalbumin-containingplantsTreatment:StandardsupportivecareActivatedcharcoaladministrationTreatseverehemorrhagicgastroenteritisNospecificantidoteavailableLinB.S.50ColchicineSyndromeAutumncrocus(Colchicumautuminate)Glorylily(Gloriosasuperba)LinB.S.51ColchicinepoisoningTruebotanicalcolchicinepoisoningisunusual.Theclinicalsyndrome:a