Chinese Herbal Medicine (CHM)

Poisoning

AUTHORDr Tse Man LiAugust, 2013

HKCEM College Tutorial

Presentation

• A 55 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., SpO2 98% (Rm Air)

• H’stix 7 mmol/L

Hyperventilation?

Hyperventilation Unlikely

▪ Hypotension, bradycardia

▪ RR18 without respiratory complain

▪ Precipitating factor present?

What will you do?

▪Manage in resuscitation room

▪ IV fluid

▪ ECG and electrolytes +/- ABG

What history will you ask?

Food intake Hx

• Puffer fish

• Big coral fishes: Ciguatera poisoning

• Shellfish: neurotoxic, paralytic

• Pesticide contaminationOthers•Mad honey (Grayanotoxin)•Sodium monoglutamate

Herb Intake Hx

Others (less likely)

•Gelsemium elegans ( 斷腸草 )

•Rhododendron flower ( 鬧羊花 )

•Veratrum spp. root & rhizoma( 黎蘆 )

•Sophora flavescens root ( 苦蔘 )

•Sophora tonkinensis root ( 山頭根 )

• Aconite root ( 烏頭 )

• Natural cardioactive steroid containing herbs

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)

▪ ECG tracing:

▪ Junctional bradycardia

▪ Frequent VEBs

▪ Possible triplet or short run VT?

What will you do?

Management

▪ IV fluid

▪ Anti-arrhythmics: ­ Amiodarone­ Magnesium

▪ Correct any electrolyte abnormalities

What else?

▪ 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

The Formula

熟附子 1 兩半 烏梅 1 兩 雞內金三錢

What is the likely cause of her signs and symptoms?

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 ( 熟 ) 附子 – 一両半 (15 錢 ) = 45g– Recommended dose <15g

What is Aconite ?

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( 炮掣 ):–川烏 , 草烏 , 附子 , 附片 , 雪上一枝蒿

• Aconite poisoning 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

3 commonest causes of poisoning

• The commonest causes are:- Overdose

Suggested ceiling dose in Chinese Pharmacopeia 2010 Ed:•川烏 Radix Aconiti /草烏 Radix Aconiti Kusnezoffii : 一錢(3g)•附子 Radix Aconiti Lateralis : 五錢 (15g)

• Improper curing/boiling

• Contamination of benign herb by plant parts of aconite spp (hidden aconite poisoning)

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

Management

▪ Potential public interest- Call HKPIC / Notify Department of Health- Outbreak control may be needed particularly for

hidden aconite poisoning

Other common acute poisonings associated with CHM

Gelsemium elegans ( 斷腸草 )

• 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. 五指毛桃 fruit of Focus plant- Mis-identfication- Intake of parasitic plant growing on Gelsemium elegans

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 (蟾酥 ), - Tupistra chinensis (川七 or 開口箭 )

▪ Also in toxic plants found in HK: - Nerium orleander ( 紅花甲竹桃 ), Thevetia perviana ( 黃花甲竹桃 ),

Strophanthus divaricatus ( 羊角拗 ), Cerbera manghas ( 海芒果 )

▪ Poisoning resembles digoxin overdose

▪ Cross-react with some digoxin essay in HA Labs

▪ Digoxin antibody is useful

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, GI symptoms

▪ Solanaceae or tropane alkaloids e.g. atropine, hyocyamine, scopolamine

▪ Commonest cause:- Substitution of benign herb by Datura flower( 洋金花 )- Contamination of other benign herb by other unidentified toxic

Solanaceae plants

▪ Physostigmine is a effective antidote

Thank You