Plant Poisoning Dr. Ravi Nanayakkara Objectives • Introduction, classification and identification of poisonous plants. • Circumstances, route of entry, metabolism and excretion of plant poisons. • Mechanism of action, target organs, clinical features(early and late phase) and principles of management. • Autopsy features(external and internal) and sample collection. Plant poisoning More than 300 poisonous plants. Some are edible. Act on more than one organ, but act principally on one organ system. Classification • • • • Neurotoxins Cardiac toxins Gastrointestinal irritants Cellular poisons Neurotoxins • Datura stramonium • Substances of abuse Canabis sativa Erythrocylon coca Papaver somniferum • Strychnos Nux vomika Cardiac toxins • Nerium odorum • Thevetia peruviana Gastro intestinal irritants • Gloria superba • Ricinus communis Cellular poisons • Manihot utilissma • Adenia palmeta Datura stramonium • Attana • CNS Toxic substances Atropine Hyoscine Hyocyamine Scopolamine All are alkaloids Circumstances Accidental –Children eat the seed or fruit Eating the leaves (mistakenly) Intentional – for revenge, confuse an enemy to robbery – mix with thalaguli during long distance bus travels Suicidal ingestion rare. Absorption • GIT • Skin • Mucous membranes Target Organs - Atropine • brain, heart, smooth muscles, glands • Excretion - Kidney Clinical features • Shown in the table. Organs Pathophysiology Clinical Features CNS Stimulation Followed by depression Euphoria, delirium aggression, terrifying hallucinations, bizarre behaviour, confusion, convulsions, increased muscle tone, Unconsciousness Heart Parasympathetic block — > stimulation Tachycardia, hypertension, Tachyarrythmias rarely Skin Inhibition of sweat glands, Dilatation of blood vessels Dry, hot Flushes Eyes Relaxation of radial muscles of pupils, Inhibition of lachrymal glands Mydriasis and blurring of vision, Inhibition of salivary glands ,Inhibition of intestinal musculature leading to relaxation Dry mouth, Reduced gut motility Alimentary tract photophobia, Dry eyes Principles of Management • Eliminate the poison • Phytostigmine to reverse the action • Diazepam to control fits • Manage complications accordingly Mode of death • Respiratory paralysis Asphyxia Postmortem finding • Non specific • Seeds or fragments of the plant may be found in the stomach.stomach may show slight inflmmation. • Lungs : pulmonary oedema. • Other organs will show sings of asphyxia. Specimen collection • Stomach and contents • Intestine • Urine • Blood Canabis sativa • Ganja – flower • Marijuana – flowery tops / cut leaves • Hashish – dried resin • H oil – oily extract Toxic substances • Alkaloids • Cannabinol • Cannabidiol • Cannabidiolic acid Circumstances • Smoking • Beverage • With datura Clinical features • • • • • • • Inhibitions removed – like alcohol Confusion Restlessness Hallucinations Narcosis Nausea Depression Principles of management • Symptomatic Autopsy • Non specific • Features of addiction Erythrocylon coca • Grows in Central/South America • Toxic Substances • Alkaloid – cocaine • Leaves • Synthetic • Action – stimulates CNS and CVS similarly to adrenalin Clinical features Shown in the table. Pathophysiology Clinical features CNS - Initial stimulation Excitement, hallucinations, euphoria, hyperkinesis, headache, nausea, vomiting, twitching of small facial muscles, stereotype behaviour, hypereflexia, tonic-clonic seizures Hyporeflexia, coma, respiratory and cardiovascular depression Late - depression CVS - Initial stimulation – Late – depression Respiratory system - Initial stimulation – Late depression Tachycardia, hypertension, ventricular dysrhythmias Weak, slow pulse; low blood pressure Tachypnoea, slow shallow breathing, cyanosis Vasoconstriction, Hyperactivity (psycho-motor) pallor, hyperthermia Pyrogenic action on thermoregulatory centre Sympathomimetic action on intestinal wall Constriction of radial muscles of the pupil Diarrhoea, abdominal cramps Dilatation of pupil Discussed in drugs of abuse Papaver somniferum (Opium / Heroin) • Unriped capsule of poppy plant • Alkaloids – morphine codeine narcolin papavarin …… Circumstances • Ingestion • Inhalation • Injections Clinical features • Excitement – euphoria • Depression of brain stem • Narcosis and death Discussed in drugs of abuse Strychnos Nux vomika Goda/Divi kaduru • • • • Spinal stimulant Commonly found in Southern costal area. Toxin is mainly found in seeds. Poison – Strychnine ( an alkaloid) Circumstances • • • • Accidental – Children eat fruit Suicidal rare due to bitter Homicidal rare due to bitter Abstract of seeds(strychnine) is used to as a rodenticide, kill stray dogs by injecting with a long stick • Homicidal injection - rare Absorption • All mucosal surfaces • Rapidly absorbed via GIT and spread throughout body Target organ • Spinal cord and brain Action • Strychnine stimulate the brain and spinal cord by inhibiting the inhibitory pathways. • Hyperexcitation of brain stem and spinal cord. • Slightest stimulation can cause convulsions. Clinical features • • • • • • Bitter taste in mouth Muscle stiffness Tremors Twitching Convulsions Concious till death Differential diagnosis Feature Strychnine Tetanus History Of poisoning (may be) Injury (usually available) Onset of symptoms Sudden Gradual Early symptoms Uneasiness, Restlessness Lock jaw Relaxation in between spasms Complete Never complete Fatal period Few hours Several days Chemical analysis Poison + No poison Management • Maintain airway, breathing, circulation • Control fits • Minimum stimulation Gastric lavarge and vomiting can precipitate convulsion. • Management of complications Mode of death • Hypoxia to brain stem Respiratory paralysis Asphyxia Autopsy • Non specific • Asphyxia • Muscle haemorrhages Cardio vascular system • Thevetia peruviana – Yellow oliander • Nerium oleander – Pink oliander Circumstances • Suicide-consume fruits • Accidental – any part of the plant (children) • Homicidal-rare Toxic substance • Cardiac glycosides – digitalis like action • Inhibit Na+/K+ ATPase • Alteration of membrane potential in myocardium and neurones • Increse cardiac Excitability Contractility Automaticity Route of absorption • GIT-injestion Target organs • Heart (mainly) - Arrhythmias • CNS - Neuronal excitability depression • GIT-irritant Clinical features • Faintishness,papitation, irregular pulse,hypotensoin • Yellow vision,blurred vision,dilated pupils, muscular twiching,tetanic spasms,anxiety, confusion • Nausea,vomiting • Pain in throat and numbness in tongue and lips,abdominal pain,profuse salivation Principles of management • Emesis • Activated charcoal • Antidote-Kaneru tab (Antibody against cardiac glycosides) • Management of complications Mode of death • Circulatory failure • Arrhythmias Lethal dose : 8-10 seeds, 15-20g root Autopsy • Non specific • GIT irritation • Fragments of seed in stomach • Poisonous part – Fruit seeds • Poison - Cardiogenic glycosides • Circumstances - Accidental, suicidal • Clinical features - Cardiac arrhythmias Gloriosa superba (Niyangala) • Main suicidal poison before availability of pesticides • Grows throughout the island Toxic substances • Colchicine- Cellular poison • Choline • Salicylic acid Mode of action • Colchicine-cellular poison Mitosis arrested. Cell death. • Choline – action same as acetyl choline • Salicylic acid – Local irritant Circumstances • Accidental-yams • Suicidal • Homicidal Target organs • Gastro intestinal tract • Bone marrow • CNS • Smooth muscles Clinical features • Shown in the table. Patho – physiology Symptoms and signs Time of onset after ingestion Acute inflammation of alimentary tract mucosa due to local actions of salicylic acid and benzoic acid burning pain, numbness, itching and tingling around mouth and throat. Nausea, vomiting, dehydration, thirst, blood and mucus diarrhoea within 6- 12 hrs Augmentation by choline of autonomic contraction of smooth muscles throughout the body. In gastrointestinal tract , bronchi , uterus abdominal colic, ileus, tenesmus, within 6- 12 hrs breathlessness abortion Block of mitosis, by cholchicine in bone marrow→ bone marrow aplasia→ Throinbocytopenia bleeding gums, easy bruising Acute tubular necrosis of the kidney decreased urine output, haematuria Central nervous system stimulation, then depression. Respiratory centre depression Restlessness, confusion, delirium, convulsions, coma Breathlessness after 36 hrs Arrest of cell division in hair follicles Alopecia, generalized depilation after 1-2 weeks within 6 hrs Principles of management • Gastric lavage • Activated charcoal • Management of complications Autopsy • Features of acute dehydration and GI irriration • Features of complication Ricinus communis(Endaru) • Entire plant is poisonous • Seeds most poisonous • Grows throughout the island • Absorption GI mucosa Mode of action Ricin Blockage of protein synthesis Cell death Tissue necrosis Acute inflammation Circumstances • Accidental –Children • Suicidal • Homicidal-rare Clinical features Pathology Clinical features Alimentary tract Acute inflammation Burning, sensation of mouth, throat, chest, abdomen, salivation, nausea, vomiting diarrhoea ↙ ↘ Dehydration electrolyte (thirst) imbalance ↓ ↓ shock muscle cramps (oliguria) (abdomen/calves) drowsiness, delirium, convulsions Haemorrhagic gastroenteritis, erosions abdominal pain,haematemesis,bloody diarrhoea Kidney Nephritis, Acute renal tailure haematuria. albuminuria. oliguria. uraemia Liver Necrosis. Inflammation jaundice Management • Gastric lavarge • Complication Mode of death • Circulatory failure • Renal failure • Respiratory failure Autopsy • GIT irritation • Seeds in stomach • Non specific (Oedema and foci of necrosis) Specimen • Gastric contents • Blood • Histology Liver Kidney Stomach and intestine Manihot utilisma • Cyanogenic glycoside Clinical features • • • • • Nausea Vomiting Abdominal pain Diarrhoea Respiratory failure Management • Complications Autopsy • Contents in stomach • Non specific Poisoning ? • National Poisons Information Centre National Hospital of Sri Lanka Colombo. 0112686143, 0112691111 Ext 430 Summary • • • • CNS GIT CVS Cellular toxic Plants • • • • • • • • Datura stramonium Canabies sativum Erythrocylon cocca Papova somniferum Strichnus nux vomica Nerium odorum Gloriosa superba Ricinus communis For each plant • • • • • • • • • Toxic substance Circumstances Absorption Actions / target organs Clinical features Management Modes of death Post mortem findings Samples Thank You.