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Cardiac Glycoside Poisoning

Poisoning by Cardiotonic Glycoside


Presentation

  • It is concluded that in patients presenting with gastro-intestinal symptoms, presumably due to poisoning by traditional medicines, cardiac glycoside poisoning should be suspected.[ncbi.nlm.nih.gov]
  • CASE DETAILS: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L).[ncbi.nlm.nih.gov]
  • Improve your interpretation of presenting symptoms with 38 new topics and 40 new images in the Differential Diagnosis section, and optimize patient care with more than 250 new figures and tables.[books.google.com]
  • Underlying cardiac disease, including acute ischemia, can certainly present with acute conduction disturbances and nausea.[clinicaladvisor.com]
  • Two cases of Nerium Oleander poisoning were presented. Clinical picture included gastrointestinal, cardiovascular and central nervous system effects.[degruyter.com]
Congestive Heart Failure
  • Description of the problem Digoxin is commonly used for the treatment of atrial fibrillation, especially with co-existing congestive heart failure.[clinicaladvisor.com]
  • Review Topic QID: 100535 M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M1.CV.111) An 82-year-old male with a history of congestive heart failure presented with new-onset atrial fibrillation.[medbullets.com]
  • Studies have shown Crataegus to be safe when used in tandem with conventional pharmaceutical therapies in the management of congestive heart failure and other cardiac maladies.[restorativemedicine.org]
  • It is used in modern medicine to increase the force of the systolic contractions and prolong duration of the diastolic phase in congestive heart failure.[poisonousplants.ansci.cornell.edu]
  • References: [1] [3] [7] [5] [6] Indications Congestive heart failure (symptomatic patients with NYHA II despite pharmacotherapy) Atrial fibrillation Supraventricular tachycardia References: [4] [8] Contraindications References: [7] [8] We list the most[amboss.com]
Fatigue
  • Neurologic manifestations, such as lethargy, fatigue, confusion, and weakness, are common. Hyperkalemia or hypokalemia can be observed.[clinicaladvisor.com]
  • Symptoms of mild to moderate intoxication of cardiac glycoside poisoning based on the drug Digoxin is fatigue, ventricular ectopic beats, bradycardia, and ventricular tachycardia.[restorativemedicine.org]
Vomiting
  • CASE DETAILS: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L).[ncbi.nlm.nih.gov]
  • 0 Reply is it oleander flower.. toxic effct can be arythmia, vomiting, tremors 2 Reply oleander also causes muscle twitching ,spasm, lock jaw, dysarthria in addition to cardiac effects 5 Reply oleander poisoning..... it's toxic compounds are oleandrin[dailyrounds.org]
  • The clinical symptoms were characterized by nausea, vomiting, salivation, colic, diarrhoea, ventricular tachycardia, dysrhythmia, heart block, ataxia, drowsiness, muscular tremor.[degruyter.com]
  • Acute digoxin toxicity differs significantly from chronic digoxin toxicity Acute digoxin toxicity is likely to cause gastrointestinal symptoms, such as anorexia, nausea, vomiting, and abdominal pain.[clinicaladvisor.com]
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
Nausea
  • CASE DETAILS: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L).[ncbi.nlm.nih.gov]
  • Nausea, malaise, and weakness are common findings in chronic digoxin toxicity.[clinicaladvisor.com]
  • The clinical symptoms were characterized by nausea, vomiting, salivation, colic, diarrhoea, ventricular tachycardia, dysrhythmia, heart block, ataxia, drowsiness, muscular tremor.[degruyter.com]
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
  • Typical symptoms of cardiac glycoside poisoning are nausea, vomiting, blurry vision, and cardiac arrhythmias. Overdose can quickly become life-threatening and swift treatment is vital.[amboss.com]
Diarrhea
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
  • Humans General Symptoms of Poisoning: Abdominal Pains Diarrhea Vomiting Notes on Poisoning: Symptoms can include pain in the mouth cavity, abdominal pains, cramps, diarrhea, and an irregular pulse.[cbif.gc.ca]
  • One observes: digestive disorders: frequently, anorexia, nausea, vomiting, salivation; more rarely, diarrhea or constipation and stomach pains. neurosensory disorders: frequently, headache, insomnia, sometimes confusions, depression, dizziness, visual[pharmacorama.com]
  • […] is for PEAK Premium Subscribers only Sorry, this question is for PEAK Premium Subscribers only (M1.CV.19) A 58-year-old African-American man with a history of congestive heart failure presents to the emergency room with headache, frequent vomiting, diarrhea[medbullets.com]
  • Not unless blurry vision, diarrhea, vomiting and nausea, disorientation, drowsiness, headaches, red skin rashes, excessive salivation, sudden alterations in your cardiac rhythm and possible death sound like your idea of fun. Oh.[mentalfloss.com]
Abdominal Pain
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
  • Humans General Symptoms of Poisoning: Abdominal Pains Diarrhea Vomiting Notes on Poisoning: Symptoms can include pain in the mouth cavity, abdominal pains, cramps, diarrhea, and an irregular pulse.[cbif.gc.ca]
  • Acute digoxin toxicity differs significantly from chronic digoxin toxicity Acute digoxin toxicity is likely to cause gastrointestinal symptoms, such as anorexia, nausea, vomiting, and abdominal pain.[clinicaladvisor.com]
Loss of Appetite
  • Eyes, ears, nose, and throat: Blurred vision Halos around objects (yellow, green, white) * Skin: Allergic reaction (See also: Stevens-Johnson syndrome ) Hives Rash Gastrointestinal: Diarrhea Loss of appetite* Nausea Stomach pain Vomiting Heart and blood[lutheranhealthcare.org]
Tachycardia
  • Death occurs from ventricular fibrillation or tachycardia.[ncbi.nlm.nih.gov]
  • Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL.[ncbi.nlm.nih.gov]
  • The clinical symptoms were characterized by nausea, vomiting, salivation, colic, diarrhoea, ventricular tachycardia, dysrhythmia, heart block, ataxia, drowsiness, muscular tremor.[degruyter.com]
  • References: [1] [3] [7] [5] [6] Indications Congestive heart failure (symptomatic patients with NYHA II despite pharmacotherapy) Atrial fibrillation Supraventricular tachycardia References: [4] [8] Contraindications References: [7] [8] We list the most[amboss.com]
  • Nicotiana spp (tobacco) ingestion, inhalation or transdermal exposure is possible nicotinic syndrome: GI symptoms, sweating, tachycardia, hypotension, tremor, seizures Psychotropic alkaloids, e.g.[lifeinthefastlane.com]
Hypotension
  • […] lanata ) Toxins: digitoxin, digoxin Sign and Symptoms: Nausea, vomiting, diarrhea, salivation Oleander ( Nerium oleander, Thevetia peruviana ) Toxins: oleandrin, folinerin, digitoxigenin, nerium Signs and symptoms: Abdominal pain, visual disturbances, hypotension[sites.google.com]
  • Nicotiana spp (tobacco) ingestion, inhalation or transdermal exposure is possible nicotinic syndrome: GI symptoms, sweating, tachycardia, hypotension, tremor, seizures Psychotropic alkaloids, e.g.[lifeinthefastlane.com]
  • It is also used in the acute setting, particularly where AF occurs in sepsis and is associated with hypotension. The target should be a resting ventricular rate of approximately 90/minute.[patient.info]
  • CRATAEGUS FOR BLOOD PRESSURE CONTROL Crataegus has long been used as a heart tonic for both hyper- and hypotension.[restorativemedicine.org]
Muscle Twitch
  • 0 Reply is it oleander flower.. toxic effct can be arythmia, vomiting, tremors 2 Reply oleander also causes muscle twitching ,spasm, lock jaw, dysarthria in addition to cardiac effects 5 Reply oleander poisoning..... it's toxic compounds are oleandrin[dailyrounds.org]
Blurred Vision
  • Eyes, ears, nose, and throat: Blurred vision Halos around objects (yellow, green, white) * Skin: Allergic reaction (See also: Stevens-Johnson syndrome ) Hives Rash Gastrointestinal: Diarrhea Loss of appetite* Nausea Stomach pain Vomiting Heart and blood[lutheranhealthcare.org]
  • Features suggestive of toxicity include nausea, vomiting, diarrhoea, dyspnoea, confusion, dizziness, headache, blurred vision and diplopia. See the British National Formulary (BNF) for the full list [ 6 ]. U&Es should be monitored.[patient.info]
Diplopia
  • Features suggestive of toxicity include nausea, vomiting, diarrhoea, dyspnoea, confusion, dizziness, headache, blurred vision and diplopia. See the British National Formulary (BNF) for the full list [ 6 ]. U&Es should be monitored.[patient.info]
Confusion
  • Annotation do not confuse with CARDIOTONIC AGENTS History note 2008 Public Note 2008 Record number D054715 Persistent link Allowable qualifiers (subheadings) Browse Medical Subject Headings[medvik.cz]
  • […] vomiting, diarrhea, salivation Oleander ( Nerium oleander, Thevetia peruviana ) Toxins: oleandrin, folinerin, digitoxigenin, nerium Signs and symptoms: Abdominal pain, visual disturbances, hypotension, bradycardia and heart block, tachydysrhythmias, confusion[sites.google.com]
  • Neurologic manifestations, such as lethargy, fatigue, confusion, and weakness, are common. Hyperkalemia or hypokalemia can be observed.[clinicaladvisor.com]
  • One observes: digestive disorders: frequently, anorexia, nausea, vomiting, salivation; more rarely, diarrhea or constipation and stomach pains. neurosensory disorders: frequently, headache, insomnia, sometimes confusions, depression, dizziness, visual[pharmacorama.com]
  • He is started on a medicine and is warned by his physician of the following potential side effects associated with this therapy: nausea, vomiting, confusion, blurry yellow vision, electrolyte abnormalities, and potentially fatal arrhythmia.[medbullets.com]
Headache
  • One observes: digestive disorders: frequently, anorexia, nausea, vomiting, salivation; more rarely, diarrhea or constipation and stomach pains. neurosensory disorders: frequently, headache, insomnia, sometimes confusions, depression, dizziness, visual[pharmacorama.com]
  • Questions (6) Sorry, this question is for PEAK Premium Subscribers only Sorry, this question is for PEAK Premium Subscribers only (M1.CV.19) A 58-year-old African-American man with a history of congestive heart failure presents to the emergency room with headache[medbullets.com]
  • Not unless blurry vision, diarrhea, vomiting and nausea, disorientation, drowsiness, headaches, red skin rashes, excessive salivation, sudden alterations in your cardiac rhythm and possible death sound like your idea of fun. Oh.[mentalfloss.com]
  • […] syndrome ) Hives Rash Gastrointestinal: Diarrhea Loss of appetite* Nausea Stomach pain Vomiting Heart and blood: Irregular heartbeat (or slow heartbeat) Weakness Nervous system: Confusion Depression* Disorientation Drowsiness Fainting Hallucinations* Headache[lutheranhealthcare.org]
  • Features suggestive of toxicity include nausea, vomiting, diarrhoea, dyspnoea, confusion, dizziness, headache, blurred vision and diplopia. See the British National Formulary (BNF) for the full list [ 6 ]. U&Es should be monitored.[patient.info]
Dysarthria
  • 0 Reply is it oleander flower.. toxic effct can be arythmia, vomiting, tremors 2 Reply oleander also causes muscle twitching ,spasm, lock jaw, dysarthria in addition to cardiac effects 5 Reply oleander poisoning..... it's toxic compounds are oleandrin[dailyrounds.org]

Workup

Premature Atrial Contractions
  • Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL.[ncbi.nlm.nih.gov]

Treatment

  • Cheaper and effective medicines are required, in particular for the treatment of yellow oleander poisoning which is problematic in resource poor countries. 2015 The British Pharmacological Society.[ncbi.nlm.nih.gov]
  • Because cardenolides from these plants are structurally similar, acute poisonings are managed using similar treatments.[cochrane.org]
  • Specific Treatment The first priority in treatment is ensuring the patient has an adequate airway and breathing. Patients who are bradycardic can receive atropine 0.5 mg IV, although any response is likely to be transient and minimal.[clinicaladvisor.com]
  • The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).[ncbi.nlm.nih.gov]
  • Treatment included administration of activated charcoal, symptomatic and supportive care. 1. Bessen, H. A. Therapeutic and toxic effects of digitalis: William Withering, 1785. - J. Emerg. Med., 4, 1986, 3, 243. 2. Bourgeois, B., P. Incagnoli, J.[degruyter.com]

Prognosis

  • Prognosis The prognosis for acute digoxin toxicity directly correlates with the mortality.[clinicaladvisor.com]
  • […] tracing) Fluids by IV (through a vein) Medicine (antidote) to reverse the effects of the overdose Medications to correct electrolyte ( potassium , magnesium ) imbalances Tube through the nose into the stomach to empty the stomach (gastric lavage) Outlook (Prognosis[lutheranhealthcare.org]

Etiology

  • Alternative diagnosis If an adequate dose of digoxin immune Fab fragments has been administered and there is no change in the hemodynamics, one should consider searching for alternative etiologies.[clinicaladvisor.com]
  • Cardiac glycoside poisoning Etiology Digoxin overdose ( iatrogenic, by nonadherence to prescribed dosages or by ingestion of plants containing cardiac glycosides) Hypokalemia Renal failure Treatment with verapamil, diltiazem, amiodarone, and/or quinidine[amboss.com]
  • The case can be confirmed if laboratory testing was not performed because either a predominant amount of clinical and nonspecific laboratory evidence of a particular chemical was present or the etiology of the agent is known with 100% certainty.[emergency.cdc.gov]

Epidemiology

  • Epidemiology In the 1780s, the foxglove plant (from which digoxin is derived) was used in the treatment of congestive heart failure.[clinicaladvisor.com]
  • Probable : A clinically compatible case in which a high index of suspicion (credible threat or patient history regarding location and time) exists for digitalis exposure, or an epidemiologic link exists between this case and a laboratory-confirmed case[emergency.cdc.gov]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Digoxin, like other cardiac glycosides, inhibits the sodium-potassium-ATPase. This inhibition results in a rise in extracellular potassium and a rise in intracellular sodium.[clinicaladvisor.com]
  • Pathophysiology Ingested cardioactive steroids (CAS) are approximately 80% bioavailable. However, toxicokinetics depends on multiple factors,... References 1.[link.springer.com]

Prevention

  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • Cardiac glycosides function by inhibiting the intercellular sodium-potassium pumps to prevent the extrusion of sodium. Raised sodium levels derange the action of the sodium-calcium pump leading to an increased intracellular calcium concentration.[sites.google.com]
  • You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week. Take the container with you to the hospital, if possible.[lutheranhealthcare.org]
  • Atrial fibrillation (AF) The principal indication is permanent/persistent AF with a fast ventricular rate - although it it is not the preferred first-line medication (especially as digoxin prevents the normal rise in heart rate associated with exertion[patient.info]
  • Since the breakdown of cAMP is prevented by Crataegus, calcium levels remain high; this leads to sustained myocardial contractility.[restorativemedicine.org]

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