Acute oleander poisoning treated successfully without Fab fragments- a case series and literature review

Abstract

ABSTRACT Background- Nerium oleander (common oleander grown as an ornamental plant) and Cerbera Thevetia (yellow oleander grows wildly on the roadside). All parts of these plants, including nectar, are potentially lethal. Suicidal poisoning by the products of these plants is a toxicologic emergency in tropical and subtropical regions. They contain cardiac glycosides, namely Oleandrin, Oleandrigenin, Nerifolin, ThevetinA, and ThevetinB, which act like digoxin in addition to gastrointestinal symptoms. Ingestion of oleander results in nausea, vomiting, abdominal pain, diarrhoea, dysrhythmias, and hyperkalemia. Cardiac toxicity includes a variety of ventricular dysrhythmias and A-V Blocks, muscular twitching, tetanic spasms, lockjaw, coma and respiratory paralysis. The cause of death is usually cardiogenic shock and respiratory arrest. Some cases have been reported with acute kidney injury and hepatic damage. Case report – We have successfully managed 3 cases of acute oleander poisoning. All three patients were young and did not have comorbid conditions. 2 patients presented with mainly abdominal pain and vomiting and had hyperkalemia. The third patient had symptomatic bradycardia and several episodes of vomiting. Most cases can be managed by Multidose activated charcoal and supportive care with IV fluids and symptomatic treatment. Some patients require respiratory support, atropine and pacing for symptomatic bradycardia. Insulin-dextrose is the most effective method of treating hyperkalemia. Calcium chloride is contraindicated in this instance. Specific management is digoxin specific Fab fragments. As emergency physicians may encounter these cases, they should have sound knowledge about symptoms and management. Oleander poisoning should be considered in the differential for any young patient presenting with bradycardia.