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
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