Thanks to Nick for discussing the case of a young man with no known medical history who presented with altered mental status and ventricular tachycardia after ingestion of a Chinese herb product called aconitum (aka wolfsbane or monkshood)! Thankfully he did well with supportive care. Pearls below:
- In a recent survey, 17.7% of U.S. adults used natural products in the past year.
- Aconitum (aka wolfsbane or monkshood) is a highly toxic plant product used in herbal medicine that can lead to fatal cardiac arrhythmias.
- Activated charcoal does not have strong evidence to support its use but is recommended for most toxic ingestions if given within one hour following the ingestion.
For those who want more info:
Commonly used natural products: In the 2012 National Health Interview Survey, 17.7% of U.S. adults used natural products in the previous year. Here are the 10 most common natural products used by U.S. adults:
Fish oil (7.8%)
Glucosamine or chondroitin (2.6%)
Probiotics or prebiotics (1.6%)
Coenzyme Q-10 (1.3%)
Ginkgo biloba (0.7%)
It’s important to keep in mind not only direct toxic effects of natural products, but also their interactions with medications (e.g. St. John’s wort and warfarin, ginkgo biloba and warfarin/NSAIDs, grapefruit and calcium channel blockers).
Check out the Natural Medicines Comprehensive Database (http://naturaldatabase.therapeuticresearch.com) for scientific and clinical information on safety and efficacy of natural products. Seriously, check it out. It has a lot of good info.
The NIH also has resources on herbs and supplements:
Aconitum/Aconite: aka wolfsbane or monkshood.
- Plant product widely used in Chinese and Indian herbal medicine.
- All parts of the plant contain high levels of toxin, especially the root.
- Processing into tincture of aconite reduces toxicity by 90%, but still associated with morbidity and mortality even with small ingestions.
- Mechanism: Binds and maintains sodium channels in the open position.
- Cardiotoxicity includes ventricular arrhythmias (VT, Torsades, VF), bradycardia, hypotension, and asystole.
- Other toxicities include neurologic (paresthesias, weakness, altered mental status) and GI (vomiting and diarrhea).
- Safety and Efficacy: From the Nature Medicines Comprehensive Database (above), this product is “unsafe” when used in any fashion, and there is “insufficient reliable evidence” for its efficacy. It has no known interactions with medications or other herbs/supplements.
- Absorbent powder made from superheated organic material.
- Surface area is covered with functional groups that adsorb chemicals within minutes of contact, preventing GI absorption.
- Most useful within 1 hour of ingestion, while toxin remains in the stomach.
- Contraindications include depressed mental status with poor airway protection, late presentation, need for endoscopy if ingestion is caustic (impairs visualization), and intestinal obstruction. Intubation for the purpose of giving activated charcoal is not recommended.
- The usual adult dose is a single dose of 50 g.
- It is administered by mixing with water to form a gritty slurry.
- Unsurprisingly, this is not palatable, so flavoring with juice or thickening with sorbitol may be helpful if needed.
- Safety: The main complication is aspiration, but this occurs in <1% of poisonings, and the data are not clear whether it is the charcoal or the toxic ingestion that increases aspiration risk.
- Efficacy: There are no clear RCTs showing clinical benefit to activated charcoal.
- Despite this, it is recommended in most ingestions, with exceptions being heavy metals (e.g. iron, lead, mercury), inorganic ions (lithium, potassium, iodide), corrosive acids/alkali, hydrocarbons, and alcohols.
- Gastric lavage and ipecac are no longer recommended for ingestions.
Have a great day everyone!