Cardiac Glycoside containing plants : Foxglove, Lilly of the Valley, Oleander, Squill

  • Contain cardiac glycosides, which act as a negative chronotrope as well as a positive inotrope.
  • Patients present with nausea, vomiting, visual changes, bradycardia/arrhythmia, and may develop hyperkalemia – a poor prognostic factor
  • Treatment is Digibind/DigiFAB – look out for the side effects of hypokalemia as well as anaphylaxis.

Anticholinergic Alkaloid containing plants: Jimson Weed, Angels Trumpet, Deadly Nightshade

  • Contain alkaloids that act as anticholinergics ; often used recreationally
  • Patients present with delirium/hallucinations, pupillary dilation, anhydrosis, hyperthermia, skin flushing, urinary retention
  • Treatment is support care, with physostigmine for severe cases – remember to go low and slow!

Toxic Mushrooms

  • Important to distinguish between acute onset symptoms (<6hours) or delayed onset (6-24 hours)
  • Inocybe : acute onset ; cholinergic crisis; treat with atropine
  • Amanita Muscarina: acute onset; CNS toxicity – delrium, myoclonus, seizures ; supportive care and benzos as needed
  • Amanita Phalloides: delayed onset ; treat with NAC and maybe Silibinin
    • Phase 1: 6-24 hrs after ingestion, nausea vomiting diarrhea
    • Phase 2: transient recovery, 24-60 hours after ingestion
    • Phase 3: Hepatic / multisystem organ failure
  • Gyromitra: delayed onset; causes acute B6 deficiency leading to refractory seizures, treat with pyridoxine (vitamin B6) as well as usual seizure care.

Further Reading:

Stone Heart Syndrome – LITFL

Gyromitra – Indiana Poison Center

Anticholinergic Intoxication – EMCrit