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2/15/2015 Tintinalli's Emergency Medicine: A Comprehensive Study Guide > Poisonous Plants Mark A. Hostetler; Sandra M. Schneider Poisonous Plants: Introduction Poisonous and injurious plants number in the hundreds and have a wide variety of toxicities. This chapter focuses on the most important plant-related exposures clinically relevant to emergency medicine (Tables 215-1 and 215-2) and those most frequently encountered during the holiday season.1,2 Individual plants are discussed in terms of their pathophysiology, clinical features (toxidromes), and treatment3 (Table 215-3). Table 215-1 Most Highly Poisonous Plants Castor bean (Ricinus communis) Coyotillo (Karwinskia humboldtiana) Foxglove (Digitalis purpurea) Jequirity bean (Abrus precatorius) Oleander (Nerium oleander) Poison hemlock (Conium maculatum) Water hemlock (Cicuta maculata) Yew (Taxus species) Table 215-2 Most Commonly Encountered Poisonous and Nonpoisonous Plants Poisonous/Injurious Nonpoisonous Aloe species African violet (Episcia reptans) Azalea (Rhododendron species) Coleus species Cactus species Dracaena species Caladium species Ficus plant (Ficus species) Colchicum (autumn crocus, meadow saffron) Honeysuckle (Lonicera species) Jade plant (Crassula species) Dumbcane (Dieffenbachia amoena) Pyracantha species http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 1/15 2/15/2015 Fava beans (Vicia faba) Rubber tree plant (Ficus elasticus) Holly (Ilex species) Spider plant (Chlorophytum species) Jimsonweed (Datura species) Umbrella plant (Schefflera species) Lily of the valley (Convallaria majalis) Wandering jew (Tradescantia albiflora) Mistletoe (Phoradendron flavescens) Nightshade (Solanum species) Peppers (Capsicum species) Philodendron species Poinsettia (Euphorbia species) Poison ivy (Toxicodendron species) Pokeweed (Phytolacca species) Pothos (Epipremnum species) Table 215-3 Symptoms and Treatment of Severely Poisonous Plant Ingestions Plant Symptoms Castor bean (Ricinus communis) Delayed gastroenteritis, delirium, seizures, coma, death Coyotillo (Karwinskia humboldtiana) Ascending paralysis Treatment Whole-bowel irrigation Supportive care Supportive care GI decontamination with activated charcoal Foxglove (Digitalis purpurea) Nausea, vomiting, diarrhea, abdominal pain, confusion, cardiac dysrhythmias Monitoring of potassium level Antidysrhythmics Digoxin-specific Fab antibody for dysrhythmias Jequirity bean (Abrus precatorius) Delayed gastroenteritis, delirium, seizures, coma, death http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 Whole-bowel irrigation Supportive care 2/15 2/15/2015 GI decontamination with activated charcoal Oleander (Nerium oleander) Nausea, vomiting, diarrhea, abdominal pain, confusion, cardiac dysrhythmias Monitoring of potassium level Antidysrhythmics Digoxin-specific Fab antibody for dysrhythmias Poison hemlock (Conium maculatum) Tachycardia, tremors, diaphoresis, mydriasis, muscle weakness, seizures, neuromuscular blockade Water hemlock (Cicuta maculata) Nausea, vomiting, abdominal pain, delirium, seizures, death Common: nausea, vomiting, abdominal pain Yew (Taxus species) Rare: seizures, cardiac dysrhythmias, coma GI decontamination with activated charcoal Supportive care GI decontamination Supportive care GI decontamination with activated charcoal Consider whole-bowel irrigation Supportive care Epidemiology According to statistics gathered by the American Association of Poison Control Centers, exposures to plants are the fourth most common reason for poison control center notification and account for 5% to 10% of all calls received.1–3 This is likely a reflection of their wide availability rather than any high level of innate toxicity. Children <6 years of age account for 70% to 80% of all plant-related exposures, the vast majority of which (96%) are unintentional.4 The most common plant-related calls received by poison control centers concern completely nontoxic plants (21%), and on average, <10% of patients require treatment in a health care facility. Clinical Features Dermatitis and GI irritation are the most commonly reported symptoms of plant toxicity. Vomiting is not a common symptom after plant ingestions.5 Moderate systemic effects occur in about 1% of patients. Severe life-threatening effects or disabling injuries are extremely uncommon and occur in only about 0.04% of patients. Death as a consequence of plant-related exposures is rare and occurs in <0.001% of patients. Treatment Most plant-related exposures require no treatment, and those that do often can be managed by simple GI http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 3/15 2/15/2015 decontamination procedures to decrease the absorption of ingested toxins. Activated charcoal can adsorb many toxins and can prevent their absorption into the body. It is the treatment of choice for most patients who require GI decontamination. Whole-bowel irrigation using polyethylene glycol electrolyte solution should be added when a potentially toxic intact seed has been ingested. The theory is that the bowel can be cleansed of plant material prior to toxin release. Patients who have had a potentially serious exposure but who are asymptomatic should be observed in the ED for about 6 hours. If patients remain asymptomatic, they may be discharged with instructions to return to the ED if symptoms develop. Symptomatic patients require ongoing monitoring and care and should be admitted to the hospital, because toxicity may continue to evolve. Few plant toxins have specific antidotes. All exposures should be reported to the regional poison control center to obtain assistance with patient management and to enable collection of accurate data on toxic plant exposures. Severely Poisonous Plants Castor Bean (Ricinus communis) Ricin is a potent toxalbumin that inhibits protein synthesis and causes severe cytotoxic effects on multiple organ systems. It may be one of the most poisonous naturally occurring substances known.6 Although present in all parts of the castor bean plant, ricin is concentrated mostly in the bean. Only 1% to 5% of the bean is ricin. Castor beans are covered by a hard, relatively impervious outer shell that must be chewed or in some way broken in order for the ricin to cause toxicity. Symptoms develop 6 to 8 hours after exposure. Symptoms include gastroenteritis, which may be severe and hemorrhagic, followed by delirium, seizures, coma, and death. Beans are particularly antigenic and may cause severe hypersensitivity and cutaneous and systemic allergic reactions. Recent attempts to use ricin as a weapon for bioterrorism have not been successful, but the possibility of its use remains a serious threat to society. More information about ricin can be found at http://www.bt.cdc.gov/agent/ricin/facts.asp. Whole-bowel irrigation has been advocated to ensure rapid and complete decontamination of the GI tract. Rapid elimination of the bean before erosion of the outer shell occurs may decrease or prevent the release of potent toxins. Beans should be counted to ensure complete recovery. Patients should be observed for at least 12 hours. Once symptoms develop, care is supportive. Coyotillo (Karwinskia Humboldtiana) Ingestion of coyotillo, which is found in Mexico, leads to ascending paralysis and in severe cases may lead to bulbar palsy and death. There is no specific antidote, but mechanical ventilation may be necessary. Foxglove (Digitalis purpurea) Foxglove contains cardiac glycosides similar in structure and action to digitalis. Its toxicity lies somewhere between that of lily of the valley and oleander (see Oleander below). Jequirity Bean (Abrus precatorius) Jequirity beans contain the toxalbumin abrin, one of the most lethal naturally occurring toxins known.7 Children have died as a result of simply chewing the beans (without swallowing). Chewing and swallowing just one bean http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 4/15 2/15/2015 may also be lethal to an adult. Symptoms include delayed gastroenteritis, which may be severe and hemorrhagic, followed by delirium, seizures, coma, demyelinating encephalitis, and death. Recovery of the intact bean by whole-bowel irrigation is recommended. Patients should be observed for at least 12 hours. Treatment is otherwise supportive. Oleander (Nerium oleander) All parts of the oleander plant contain the cardiac glycosides oleandrin, oleandroside, nerioside, and digitoxigenin, which are similar in structure and effect to digitalis. Cardiac glycosides act by inhibiting the sodium- and potassium-activated adenosine triphosphatase pump and lead to hyperkalemia and a variety of dysrhythmias (see Chapter 21, Fluids and Electrolytes; Chapter 22, Cardiac Rhythm Disturbances; and Chapter 23, Pharmacology of Antiarrhythmics). Of all plants containing cardiac glycosides (lily of the valley, foxglove, and oleander), oleander is the most toxic.8 The Cerbera odollam, or suicide tree, found in India and Madagascar also contains cardiac glycosides similar to those in oleander. Plant glycosides cross-react sufficiently so that a positive result on a test of serum digoxin level confirms ingestion. However, quantitative values on the serum digoxin assay do not indicate the amount ingested or predict potential toxicity. Effects include nausea, vomiting, diarrhea, abdominal pain, confusion, and cardiac dysrhythmias. Potassium levels should be closely monitored. Hyperkalemia may be severe, may be refractory to the usual treatments (insulin, glucose, bicarbonate), and may require hemodialysis.9 Calcium administration is generally not recommended, because it may theoretically exacerbate the digitalis toxicity, although there are no published data from human experience. In addition to GI decontamination with activated charcoal and standard antidysrhythmic therapy, administration of digoxin-specific Fab antibody fragments is recommended for patients with ventricular dysrhythmias.10 Poison Hemlock (Conium maculatum) All parts of poison hemlock contain alkaloids that are similar in structure and effect to nicotine and can induce neuromuscular blockade. Symptoms occur rapidly 15 minutes to 1 hour after ingestion and begin with complaints of burning and dryness of the mouth. Tachycardia, tremors, diaphoresis, mydriasis, profound muscle weakness, and seizures may develop. In severe cases, ascending paralysis, rhabdomyolysis, acute renal failure, bradycardia, coma, and death occur. Although most ingestions are unintentional, there are some case reports of toxicity from intentional use by patients for a presumed narcoticlike effect.11 Treatment consists of GI decontamination with activated charcoal and supportive care, which may include administration of IV fluids, antidysrhythmics, and anticonvulsants. Water Hemlock (Cicuta maculata) Cicutoxin, a C17-polyacetylene, is found in highest concentrations in the root of water hemlock, but all parts of the plant contain the poison. Its mechanism of action appears to involve inhibition of noncompetitive γ-aminobutyric acid antagonists of γ-aminobutyric acid receptors. One mouthful may be fatal in as soon as 15 minutes. Initial symptoms include nausea, vomiting, and abdominal pain, followed by delirium, seizures, and death. Seizures may be severe and refractory to conventional anticonvulsant therapy. The mortality rate may be as high as 30%.12 Treatment consists of GI decontamination with activated charcoal and supportive care with IV fluids and anticonvulsants. Yew (Taxus Species) http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 5/15 2/15/2015 Yew contains taxine alkaloids in the leaves and seeds, potent toxins with effects on cardiac myocytes.13 Case reports of near-fatal human ingestions and fatal livestock ingestions have created the impression that yew berry ingestions are highly toxic. This is not true, however. Although GI symptoms are common, moderate to lifethreatening complications are rare (<1%), and human fatalities have not been reported.14 Symptoms after ingestion include nausea, vomiting, and abdominal pain. Rarely, seizures, cardiac dysrhythmias, and coma occur. Treatment consists of GI decontamination, with activated charcoal, fluids, anticonvulsants, and antidysrhythmics given as necessary. Whole-bowel irrigation may be considered. Common Poisonous and Injurious Plants See Table 215-4. Table 215-4 Symptoms and Treatment of Common Poisonous Plant Ingestions or Exposures Plant Symptoms Treatment Ackee (Blighia sapida) Hypoglycemia Glucose Aloe (Aloe barbadensis) Abdominal pain, diarrhea, red urine, nephritis Supportive care Usually minor symptoms GI decontamination with activated charcoal Azalea (Rhododendron species) Cactus Severe intoxication: salivation, lacrimation, bradycardia, hypotension, progressive paralysis Pain and irritation from embedded spines Atropine for symptomatic bradycardia Fluids or vasopressors for hypotension Removal of spines Rubber cement peel Usually minor symptoms Caladium species Colchicum (autumn crocus, meadow saffron, glory lily) Severe intoxication: burning and irritation of oral mucosa, swelling, drooling, dysphagia, respiratory compromise Delayed and severe gastroenteritis→severe multisystem organ failure http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 Ingest cold milk or ice cream for oral burning Analgesics Consider steroids if severe symptoms GI decontamination with activated charcoal Aggressive fluid resuscitation 6/15 2/15/2015 Usually minor symptoms Dumbcane (Dieffenbachia amoena) Severe intoxication: burning and irritation of oral mucosa, swelling, drooling, dysphagia, respiratory compromise Ingest cold milk or ice cream for oral burning Analgesics Consider steroids if severe symptoms Fava beans (Vicia faba) In persons with glucose-6-phosphate dehydrogenase deficiency: GI upset, fever, headache, hemolytic anemia, hemoglobinuria, jaundice Treatment varies depending on degree of hemolysis seen Henbane (Hyoscyamus niger) Anticholinergic symptoms: hallucinations, mydriasis, tachycardia, agitation, seizures, coma Consider physostigmine in severe cases Jimsonweed (Datura species) Anticholinergic symptoms: hallucinations, mydriasis, tachycardia, agitation, seizures, coma GI decontamination with activated charcoal Consider wholebowel irrigation Supportive care GI decontamination with activated charcoal Lily of the valley (Convallaria majalis) Nausea, vomiting, diarrhea, abdominal pain, confusion, cardiac arrhythmias Monitoring of potassium level Antiarrhythmics Digoxin-specific Fab antibody for arrhythmias Monkshood (Aconitum species) Bradycardia, heart block, torsades de pointes, ventricular fibrillation GI decontamination with activated charcoal Supportive care Nettle (stinging nettle, bull nettle) (Urtica species) Localized burning http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 Symptomatic care 7/15 2/15/2015 Nightshade, common or woody (Solanum species) Nightshade, deadly (Atropa belladonna) Nausea, vomiting, diarrhea, abdominal pain With larger doses: delirium, hallucinations, coma Anticholinergic symptoms: hallucinations, mydriasis, tachycardia, agitation, seizures, coma Supportive care GI decontamination with activated charcoal Supportive care Peach, apricot, pear, crab apple, yam bean, and hydrangea (pits or seeds) GI decontamination with activated charcoal Acute cyanide toxicity if large amounts are ingested: diaphoresis, nausea, vomiting, abdominal pain, lethargy Whole-bowel irrigation Cyanide antidote therapy Copious irrigation with water Pepper (Capsicum species) Irritation and pain on contact Milk or ice cream for oral irritation Analgesics Usually minor symptoms Philodendron species Pokeweed (Phytolacca americana) Severe intoxication: burning and irritation of oral mucosa, swelling, drooling, dysphagia, respiratory compromise Mucosal irritation, abdominal pain, nausea, vomiting, profuse diarrhea Cold milk or ice cream for oral irritation Analgesics Consider steroids GI decontamination with activated charcoal Supportive care Severe intoxication: coma, death Potato, eggplant (raw) (Solanum species) Nausea, vomiting, diarrhea, abdominal pain With larger doses: delirium, hallucinations, coma Supportive care Cold milk or ice http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 8/15 2/15/2015 Pothos (devil’s ivy, Epipremnum species) Yellow sage (Lantana camara) Usually minor symptoms cream for oral irritation Severe intoxication: burning and irritation of oral mucosa, swelling, drooling, dysphagia, respiratory compromise Analgesics Dilated pupils, vomiting, diarrhea, weakness, coma Consider steroids GI decontamination with activated charcoal Fluids Skin protection Toxicodendron species (poison ivy, oak, and sumac) Holly (Ilex species) Poinsettia (Euphorbia pulcherrima) American mistletoe (Phoradendron flavescens) Dermatitis Antipruritic and topical therapies Systemic steroids for facial, genital, or widespread involvement Gastroenteritis GI decontamination with activated charcoal Can be fatal if significant ingestion Supportive care Occasional local irritation — Gastroenteritis GI decontamination with activated charcoal Supportive care Easter lily (Lilium longiflorum) Toxicity has not been reported in humans No treatment necessary Ackee (Fruit of Blighia sapida) Ingestion of unripened ackee fruit leads to hypoglycemia and encephalopathy. Treatment with glucose prevents serious consequences. If hypoglycemia is present, administration of 50% dextrose in water IV immediately is indicated, followed by continuous infusion with 10% dextrose in water IV to maintain euglycemia. Symptomatic patients should be admitted for treatment of hypoglycemia. Aloe (Aloe barbadensis) Sap from the common succulent houseplant Aloe barbadensis contains an anthraquinone that acts as a cathartic. http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 9/15 2/15/2015 Symptoms include abdominal pain and diarrhea within 6 to 12 hours of ingestion. The substance may occasionally turn the urine red, and large doses may cause nephritis. There is no specific antidote. IV fluid administration may be necessary to support GI fluid losses. Azalea (Rhododendron Species) Andromedotoxins are found in the leaves, flowers, and nectar of azaleas. Potential symptoms after ingestion include salivation, lacrimation, bradycardia, hypotension, progressive paralysis, and potentially (but rarely) death. Most cases of ingestion result in minimal toxicity. In addition to GI decontamination, treatment consists of administration of atropine for symptomatic bradycardia and fluids or vasopressors for hypotension. Cactus Cactus needles or spines may embed in the skin and cause direct mechanical injury. Patients typically complain of pain and irritation at the site. Unlike other foreign bodies such as glass that are inert, spines contain proteinaceous material and should be removed if possible. Multiple small cactus spines may be removed by applying a thin layer of rubber cement or other similar substance over area, allowing the material to dry, and then gently peeling it off, removing the spines that have become embedded in the adhesive. Complications such as infection and granuloma formation occur, but are uncommon. Prickly pear cactus causes a dermatitis that can be confused with scabies. Caladium Species Toxicity of Caladium species is similar to that of dumbcane due to raphides but is less severe [see Dumbcane (Dieffenbachia amoena) below]. Colchicaceae (Autumn Crocus, Meadow Saffron, Glory Lily) Colchicine is contained in all parts of the autumn crocus, meadow saffron, and glory lily. Colchicine causes a gastroenteritis that is severe and delayed (2 to 24 hours), followed by severe multisystem organ failure.15 Mild toxicity is expected if GI symptoms begin >9 hours after ingestion. Common effects include coagulopathy, bone marrow suppression with granulocytopenia and thrombocytopenia, cardiac dysrhythmias, cardiogenic shock, adult respiratory distress syndrome, hepatic failure, delirium, seizures, coma, and death. If patients survive, alopecia may develop. In addition to GI decontamination with activated charcoal, treatment usually requires aggressive fluid resuscitation. Colchicine-specific Fab fragments have been used with some success experimentally but are not commercially available for severe poisonings. Dumbcane (Dieffenbachia amoena) Dumbcane plants contain calcium oxalate crystals packaged into bundles known as raphides. The plants also contain proteolytic enzymes that have antitrypsinlike activity and stimulate histamine and bradykinin release. Children who chew the leaves develop immediate burning and irritation of the oral mucosa. Cases of severe swelling, drooling, dysphagia, and respiratory compromise have been reported, but are rare.16 Most cases of human ingestion result in minor symptoms that resolve with little or no treatment. Demulsifying agents, such as cold milk or ice cream, may help relieve oral symptoms, and analgesics may be necessary. Steroids are considered beneficial for severe cases, although there have been no controlled trials of this therapy. Fava Beans (Vicia faba) http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 10/15 2/15/2015 An estimated 10% to 20% of persons with glucose-6-phosphate dehydrogenase deficiency develop favism after consuming fava beans. Symptoms include GI upset, fever, and headache, and patients may develop hemolytic anemia with hemoglobinuria and jaundice (see Chapter 232, Acquired Hemolytic Anemia). Henbane (Hyoscyamus niger) Ingestion of henbane causes anticholinergic symptoms, with hallucinations, mydriasis, tachycardia, agitation, seizures, and coma. Treatment with physostigmine may be useful in severe cases. Jimsonweed (Datura Species) Jimsonweed (also known as thorn apple, devil’s trumpet, or locoweed) is infamous for its hallucinogenic properties. Exposures most commonly are intentional and occur through experimentation.17 All parts of the plant are toxic and contain atropinelike alkaloids (hyoscyamine, atropine, and scopolamine) capable of precipitating acute anticholinergic crises by competitive inhibition of cholinergic muscarinic receptors. Symptoms occur within 30 to 60 minutes and may last for up to 48 hours because of anticholinergic-induced delayed gastric motility. Symptoms include hyperthermia (“hot as a hare”), flushed skin (“red as a beet”), dry skin and mucous membranes (“dry as a bone”), mydriasis (“blind as a bat”), and hallucinations or delirium (“mad as a hatter”). Tachycardia and urinary retention are also common. Treatment includes GI decontamination with activated charcoal and supportive care, including IV fluids, external cooling, and restraints for patient protection. GI decontamination using whole-bowel irrigation may be useful for up to 48 hours after ingestion if the patient remains symptomatic. Physostigmine, a cholinesterase inhibitor, antagonizes both the central and peripheral effects and may be considered in patients with severe toxicity exhibiting hyperthermia, seizures, or psychosis.17 An initial dose of 0.5 milligram for children or 1.0 to 2.0 milligrams for adults is given slowly IV over 5 minutes. Repeat doses may be required (see Chapter 182, Hallucinogens, and Chapter 196, Anticholinergics). Lily of the Valley (Convallaria majalis) In addition to toxicity from ingesting the lily of the valley plant itself, which contains cardiac glycosides, toxicity has been reported from drinking water in which the freshly cut flowers were kept [see Oleander (Nerium oleander) above]. Marijuana (Cannabis sativa) Ingestion of marijuana by children may lead to ataxia, seizures, hallucinations, psychosis and coma. Monkshood (Aconitum Species) Monkshood contains a sodium channel blocker, aconitine, that if ingested leads to bradycardia and heart block, torsades de pointes, and ventricular fibrillation. Nettle (Stinging Nettle, Bull Nettle) (Urtica Species) Nettles contain a specialized system for injecting their toxins. Stinging hairs are connected to a bladder filled with various irritants (histamine, acetylcholine, 5-hydroxytryptamine). Handling of the plant stimulates the injection of these substances via the hair tube. An immediate burning response occurs that may last for hours. Treatment is symptomatic. http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 11/15 2/15/2015 Nightshade, Common or Woody (Solanum Species) The glycoalkaloid solanine is present in all parts of the common or woody nightshade. Ingestion results in nausea, vomiting, diarrhea, and abdominal pain. Delirium, hallucinations, and coma may also occur with larger doses. There is no specific treatment. Nightshade, Deadly (Atropa belladonna) Deadly nightshade contains atropinelike substances with anticholinergic properties [see Jimsonweed (Datura Species)]. Peach, Apricot, Pear, Crab Apple, Yam Bean, and Hydrangea Amygdalin, a cyanogenic glycoside found in the pits or seeds of the peach, apricot, pear, crab apple, yam bean, and hydrangea, is metabolized by the enzyme emulsin to hydrocyanic acid. If large quantities are ingested, the hydrocyanic acid created may lead to acute cyanide toxicity. Emulsin is also present in the pits or seeds of the aforementioned plants and may be present to some degree in intestinal bacteria. Ingestion of large amounts of seeds or pits results in diaphoresis, nausea, vomiting, abdominal pain, and lethargy that develop over hours. GI decontamination using activated charcoal and whole-bowel irrigation is needed. Symptomatic patients should be treated as for cyanide poisoning (see Chapter 198, Industrial Toxins). Pepper (Capsicum Species) Some species of Capsicum cause irritation, burning, and pain upon contact with mucous membranes as a result of depletion of substance P from terminal nerve endings. Contact typically occurs as a result of self-inoculation while preparing peppers or exposure to spraying of pepper extracts by police. Corneal abrasion may result if the substance is sprayed in the eye. Decontaminate affected areas by irrigation with copious amounts of water and gentle hand soap. For oral irritation, demulsifying agents, such as cold milk or ice cream, may help. Analgesics may be necessary. Philodendron Species All parts of some Philodendron species contain oxalate raphides and may produce symptoms similar to those caused by dumbcane, although less severe. Pokeweed (Phytolacca americana) All parts of the pokeweed plant are toxic, especially the roots, unripe berries, and seeds. Phytotoxins (phytolaccotoxin and phytolaccine) cause direct mucosal irritation and GI symptoms. Patients complain of burning in the mouth and throat, with abdominal pain, nausea, vomiting, and profuse diarrhea that may be foamy.18 Severe intoxications may result in coma and death. Treatment is GI decontamination with activated charcoal and supportive care consisting of fluid and electrolyte replacement. Potato, Eggplant (Solanum Species) Solanine is contained in green potatoes and in the sprouts, and is destroyed by cooking. It is also found in unripe eggplant. Ingestion may cause gastroenteritis, with onset up to 12 hours after consumption [see Nightshade, Common or Woody (Solanum Species)]. http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 12/15 2/15/2015 Pothos (Devil’s Ivy, Epipremnum Species) Pothos has toxicity similar to that associated with dumbcane, but less severe. Yellow Sage (Lantana camara) Leaves and unripe fruit of Lantana camara contain the toxin lantadene, which may produce dilated pupils, vomiting, diarrhea, weakness, and coma. Symptoms may be delayed for 2 to 6 hours. Treatment is GI decontamination with activated charcoal and fluids for dehydration. Toxicodendron Species (Poison Ivy, Oak, and Sumac) Poison ivy, poison oak, and poison sumac contain the antigenic resin urushiol. Once exposed, most individuals develop sensitization as the antigenic resin binds with skin proteins and forms a complete antigen. Reexposure then stimulates a T cell–mediated immune response. Reactions begin with itching, burning, and redness that develop over 12 to 48 hours and may progress to varying degrees of vesiculobullous formation. Treatment consists of antipruritic and topical therapies (oatmeal baths and topical steroids). Facial, genital, or widespread involvement requires systemic steroid therapy for at least 10 to 14 days. Patients should be advised to clean under their fingernails and wash all contaminated clothing. IvyBlock contains bentoquatam and binds urushiol to prevent absorption. Zanfel also removes urushiol from the skin. Skin cleansers (such as Tecnu) may be used up to 8 hours after exposure to decontaminate the skin. For further discussion, see Chapter 244, Treatment of Skin Disorders in the Emergency Department. Common Holiday or Seasonal Plants (Poisonous and Nonpoisonous) Holly (Ilex Species) Holly leaves are nontoxic, but the berries contain a variety of toxins known as saponins. Gastroenteritis is the most common effect after ingestion and may occur with consumption of as few as 2 or 3 berries; ingestion of 20 to 30 berries may be fatal. Treatment is GI decontamination with activated charcoal followed by administration of IV fluids to prevent dehydration. Poinsettia (Euphorbia pulcherrima) Poinsettia is not toxic. It occasionally causes local irritation to the skin, mouth, or conjunctiva.19 American Mistletoe (Phoradendron flavescens) All parts of American mistletoe are poisonous and contain phoratoxin, a toxalbumin. Gastroenteritis may occur following ingestion of a large number of berries, but significant morbidity is rare.20 Treatment is GI decontamination with activated charcoal accompanied by fluid and electrolyte monitoring. Easter Lily (Lilium longiflorum) Toxicity from ingestion of Easter lily has not been reported in humans. Special Considerations Toddlers experience the world by first putting it into their mouths. Because 80% of the exposures occur among children <6 years of age and most occur within the home, prevention is paramount. All poisonous and injurious plants should be kept out the reach of toddlers and preschoolers. Homes should be purged of all potentially toxic http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 13/15 2/15/2015 plants, just as they are of medications and cleaning supplies, and children should be specifically instructed never to eat plants or wild berries.4,21 References 1. Krenzelok EP, Jacobsen TD: Plant exposures: a national profile of the most common plant genera. Vet Hum Toxicol 39: 248, 1997. [PubMed: 9251180] 2. Watson WA, Litovitz TL, Klein-Schwartz W, et al: 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 22: 335, 2005. 3. Mrvos R, Krenzelok EP, Jacobsen TD: Toxidromes associated with the most common plant ingestions. Vet Hum Toxicol 43: 366, 2001. [PubMed: 11757998] 4. Lawrence RA: Poisonous plants: when they are a threat to children. Pediatr Rev 18: 162, 1997. [PubMed: 9114716] 5. Krenzelok EP, Mrvos R, Jacobsen TD: Contrary to the literature, vomiting is not a common manifestation associated with plant exposures. Vet Hum Toxicol 44: 298, 2002. [PubMed: 12361120] 6. Audi J, Belson M, Patel M, et al: Ricin poisoning: a comprehensive review. JAMA 294: 2342, 2005. [PubMed: 16278363] 7. Kinamore PA, Jaeger RW, Castro FJ: Abrus and ricinus ingestion. Clin Toxicol 17: 401, 1980. [PubMed: 6108823] 8. Bose TK, Basu RK, Biswas B, et al: Cardiovascular effects of yellow oleander ingestion. J Indian Med Assoc 97: 407, 1999. [PubMed: 10638101] 9. Eddleston M, Persson H: Acute plant poisoning and antitoxin antibodies. J Toxicol Clin Toxicol 41: 309, 2003. [PubMed: 12807314] 10. Shumaik GM, Wu AW, Ping AC: Oleander poisoning: treatment with digoxin-specific Fab antibody fragments. Ann Emerg Med 17: 732, 1988. [PubMed: 3382077] 11. Drummer OH, Roberts AN, Bedford PJ, et al: Three deaths from hemlock poisoning. Med J Aust 162: 592, 1995. [PubMed: 7791646] 12. Centers for Disease Control and Prevention: Water hemlock poisoning—Maine, 1992. MMWR Morb Mortal Wkly Rep 43: 229, 1994. 13. Wilson CR, Sauer J, Hooser SB: Taxanes: a review of the mechanism and toxicity of yew (Taxus spp.). Toxicon 39: 175, 2001. [PubMed: 10978734] 14. Krenzelok EP, Jacobsen TD, Aronis J: Is the yew really poisonous to you? J Toxicol Clin Toxicol 36: 219, 1998. [PubMed: 9656977] 15. Gabrscek L, Lesnicar G, Krivec B, et al: Accidental poisoning with autumn crocus. J Toxicol Clin Toxicol 42: 85, 2004. [PubMed: 15083942] 16. Pedaci L, Krenzelok EP, Jacobsen TD, Aronis J: Dieffenbachia species exposures: an evidence-based assessment of symptom presentation. Vet Hum Toxicol 41: 335, 1999. [PubMed: 10509443] 17. Forrester MB: Jimsonweed (Datura stramonium) exposures in Texas 1998–2004. J Toxicol Environ Health 69: 1757, 2006. [PubMed: 16905506] 18. Roberge R, Brader E, Martin ML, et al: The root of evil: pokeweed intoxication. Ann Emerg Med 15: 470, 1986. [PubMed: 3954185] 19. Krenzelok EP, Jacobsen TD, Aronis JM: Poinsettia exposures have good outcomes: just as we thought. Am J Emerg Med 14: 671, 1996. [PubMed: 8906768] 20. Krenzelok EP, Jacobsen TD, Aronis J: American mistletoe exposures. Am J Emerg Med 15: 516, 1997. [PubMed: 9270395] 21. Krenzelok EP, Jacobsen TD, Aronis J: Those pesky berries: are they a source of concern? Vet Hum Toxicol 40: 101, 1998. [PubMed: 9554066] http://accessemergencymedicine.mhmedical.com.ezproxy.uky.edu/content.aspx?bookid=693§ionid=45915562 14/15 2/15/2015 Useful Web Resources U.S. Food and Drug Administration, Poisonous Plant Database —http://www.accessdata.fda.gov/scripts/plantox/index.cfm U.S. Department of Agriculture, Agricultural Research Service, Poisonous Plant Research Laboratory —http://www.ars.usda.gov/Main/docs.htm?docid=3496 American Association of Poison Control Centers—http://www.aapcc.org Canadian Poisonous Plants Information System—http://www.cbif.gc.ca/pls/pp/poison?p_x=px Poisonous plants informational database (Cornell University)—http://www.ansci.cornell.edu/plants/ Poisonous Plants Homepage (University of Pennsylvania)—http://cal.vet.upenn.edu/projects/poison/index.html Plants Toxic to Animals (University of Illinois)—http://library.illinois.edu/vex/toxic Updated bibliography of research and articles related to plant toxicity (Jean Bruneton, Université d’Angers) —http://ead.univ-angers.fr/~pharma/bruneton/main.php?nom=0&langue=0 Emergency Preparedness and Response: Facts about Ricin, Centers for Disease Control and Prevention —http://www.bt.cdc.gov/agent/ricin/facts.asp Copyright © McGraw-Hill Global Education Holdings, LLC. 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