1. Cardiac toxins- Plants Dr Julian Johny Thottian

2. Case 18 yr old unmarried pregnant Tamilian female brought to the casualty with giddiness and vomiting PR – 38/mt irregular BP – 90/60mmHg No focal deficits Toxic look CVS- S1 varying S2 with normal split Chest – NVBS Alleged consumption of Nerium Seeds from work site

3. Investigations Hb -11.2gm%, TC-11220/cm3, PLT – 220000/cm3 ESR- 16mm/1 st hr DAYNa( meq/l)K(meq/l)Bld UreaS creat 11424.1180.6 21363.6220.6 31383.9190.8 41404.5290.6 51364.5260.9 61384.2260.8

4. ECG before pacing – 24hrs after consumption

5. Paced

6. Day 7- when pacing was removed

7. Patient stay in hospital was uneventful and treated with orciprenaline, electrolyte correction & antibiotic. Patient removed from temporary pacing Discharged on the 8 th day.

8. Cardiac Glycosides

9. Nerium- white oleander (kaner)

10. Dogbane family Ornamental shrub with white & pink flowers All parts are poisonous including the smoke while burning Used as an abortifacient, homicide and suicide Fatal dose – 15-20 gms of root Fatal period – 24 to 36 hrs

11. Cerebra thevetia- yellow oleander ( pila kaner)

12. Fatal dose : 8-10 seeds, 15-20gms of root, 5- 10 leaves Fatal period 2-3hrs

13. Cerebera odallam (pili kirbir)

14. Fatal dose – kernel of one fruit Fatal period -1-2 days

15. Aconite (mitha zeher- monk`s hood) All parts are poisonous especially the root Clinical features- nausea, vomiting, profuse sweating Hippus Hypotension, AV BLOCK Fatal dose – 1gm of root Fatal period – 1-8 hrs Treatment –Gastric lavage, atropine

16. Cleistanthus collinus (oduvan) Closely related- it is a glucoside Blocks cardiac conductive system Conduction defects Fatal dose – 200-400gms of leaves Fatal period – 1-3 days

17. POPULARITY AS A POISON In Sri Lanka, cases of attempted suicide with yellow oleander were extremely rare before 1980. During that year, the deaths of two girls who intentionally ate yellow oleander seeds was widely reported in local newspapers. The practice suddenly became so popular that the number of cases admitted to Jaffna hospital increased from zero in 1979 to 103 in 1983. QJM (1999) 92 (9): 483-485. doi: 10.1093/qjmed/92.9.483

18. Studies across the world Dept of internal medicine, Colombo- a study on 300 patients -Ventricular ectopics and tachycardias are common in digoxin-poisoned patients, but are less common in oleander-poisoned patients 53% had AV node conduction block, while 62% had sinus node block; 30% had conduction block affecting both nodes. Only 1% had ventricular tachycardias and 8% had ventricular ectopics They report that most of the deaths are due to ventricular arrhythmia Mortality is 20% in their study.

19. Electrocardiography Increased PR interval, T wave flattening or inversion Tachyarrhythmias Bradycardia & heart block – SA block and AV Block

20. Management Induction of emesis & activated charcoal Administering Atropine for severe bradycardia Using Phenytoin or Lidocaine hydrochloride to control arrhythmia. Placing a temporary venous pacemaker Electrical counter shock Digoxin-specific Fab antibody fragments (Digibind).

21. Osterloh et al calculated the lethal oleander leaf dose of their patient to be approximately 4 gm.

22. THANK YOU