Aconite Poisoning

Aka: Aconite Poisoning, Aconite Toxicity, Aconite, Aconitum Poisoning, Monkshood Poisoning, Wolfsbane Poisoning, Wolfsbane, Aconitum, Aconitum napellus, Monkshood

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II. Definitions

  1. Aconite
    1. Toxic diterpenoid alkaloid root extract from plants in the Aconitum genus (esp. Aconitum napellus)
    2. Aconite contains aconitine, mesaconitine and hypaconitine
  2. Aconitum
    1. Aconitum is a plant genus within the family ranunculaceae
    2. Plants in this genus contain varius diterpenoid alkaloids including aconitans
  3. Diterpenoid Alkaloid
    1. Group of more than 1500 identified complex substances synthesized by plants
    2. Associated with both medicinal and toxic properties

III. Background

  1. Aconite is alkaloid group extracted from Aconitum napellus root (contains aconitine, mesaconitine and hypaconitine)
  2. Aconitum was the first Diterpenoid Alkaloid group to be identified (in early 1800s by Geiger)
  3. Ancient tribes applied Aconitum to arrow tips for hunting and war

IV. Pathophysiology

  1. Accidental or intentional ingestion
    1. Wolfsbane Plant
    2. Monkshood Plant
    3. Aconite root extract (herbal medications)
  2. Aconitite binds voltage-sensitive Sodium channels in their open state
    1. Results in neurovascular and cardiovascular toxicity

V. Pharmacokinetics

  1. Rapid absorption after ingestion
  2. Half-Life: 24 hours
  3. Lethal dose: 2 g Aconite (root extract)

VI. Findings

  1. Cardiovascular
    1. Hypotension
    2. Dysrhythmia
      1. Atrial Fibrillation
      2. Torsades de Pointes
      3. Ventricular Tachycardia
  2. Respiratory
    1. Respiratory Muscle Paralysis with apnea
  3. Gastrointestinal
    1. Nausea or Vomiting
    2. Diarrhea
    3. Abdominal Pain
    4. Hypersalivation
  4. Neurologic
    1. Paresthesias
    2. Numbness (perioral, extremity)
    3. Motor weakness

VII. Labs

  1. See Unknown Ingestion (includes full spectrum toxicology testing)
  2. Bedside Glucose
  3. Basic metabolic panel with Calcium
  4. Serum Magnesium
  5. Aconitine Levels (urine and blood)

VIII. Diagnostics

  1. Electrocardiogram

IX. Management

  1. Gastric Decontamination if within one hour of ingestion and can control airway
    1. Oral Activated Charcoal
  2. Cardiovascular Management
    1. Symptomatic Bradycardia
      1. Atropine
    2. Hypotension
      1. Intravenous Fluids
      2. Vasopressors (e.g. Norepinephrine) for refractory Hypotension
      3. ECMO for Vasopressor refractory Hypotension
    3. Ventricular Tachycardia
      1. Amiodarone or Flecainide are preferred over Lidocaine
      2. May be refractory to Electrical Cardioversion
  3. Replace Electrolytes
    1. Potassium Replacement in Hypokalemia
    2. Magnesium Replacement in Hypomagnesemia
  4. Disposition
    1. Cardiovascular effects require intensive monitoring
    2. Other symptoms (e.g. gastrointestinal) should be medically monitored until resolution
    3. Asymptomatic patients may be discharged to home observation

X. Resources

  1. Aconitum napellus(Monkshood): A Purple Poison (Poison Control)
    1. https://www.poison.org/articles/why-is-monkshood-considered-a-poison--174
  2. Aconitum (Wikipedia)
    1. https://en.wikipedia.org/wiki/Aconitum

XI. References

  1. Tomaszewski (2022) Crit Dec Emerg Med 36(4): 36
  2. Chan (2009) Clin Toxicol 47(4):279-85 +PMID: 19514874 [PubMed]
  3. Thawabteh (2021) Molecules 26(13):4103 +PMID: 34279443 [PubMed]
  4. Wood (2020) J Crit Care Med 6(2):124-129 +PMID: 32426520 [PubMed]

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