What is the management for a child who has ingested yew berries?

Management of Yew Berry Ingestion in Children

A child who has ingested yew berries requires immediate emergency department evaluation and treatment due to the potentially fatal cardiotoxic effects of taxine alkaloids contained in the plant.

Immediate Assessment and Management

Initial Evaluation

• Assess vital signs with particular attention to heart rate and rhythm
• Evaluate level of consciousness and neurological status
• Determine time of ingestion and approximate quantity consumed
• Check for signs of cardiotoxicity (arrhythmias, hypotension)

Emergency Interventions

1. Establish IV access immediately for administration of fluids and medications
2. Place on continuous cardiac monitoring to detect arrhythmias
3. Obtain 12-lead ECG to assess for conduction abnormalities and arrhythmias
4. Administer IV fluids - normal saline bolus 20 mL/kg rapidly for signs of hypotension 1

Specific Treatment Measures

Gastrointestinal Decontamination

• Consider activated charcoal if patient presents within 1 hour of ingestion and is alert with protected airway
• Gastric lavage may be considered in severe cases if presenting early after ingestion

Cardiac Management

• For ventricular arrhythmias or conduction disturbances:
  • Administer sodium bicarbonate 1-2 mEq/kg IV bolus, followed by infusion (37.5 mEq/hr) 1
  • Consider amiodarone 5 mg/kg IV for persistent ventricular arrhythmias
  • For severe bradycardia, prepare for transcutaneous pacing 2
  • In refractory cases, consider digoxin-specific Fab fragments (though efficacy is uncertain) 2

Supportive Care

• Correct electrolyte abnormalities, particularly potassium
• Monitor acid-base status and correct as needed
• For seizures, administer benzodiazepines (e.g., diazepam 0.1-0.3 mg/kg IV)
• Prepare for potential need for mechanical ventilation if respiratory depression occurs

Monitoring and Disposition

Continuous Monitoring

• Cardiac monitoring for at least 24 hours after ingestion
• Serial ECGs to monitor for QRS widening or other conduction abnormalities
• Regular vital sign checks and neurological assessments

Criteria for ICU Admission

• Any cardiac arrhythmia or conduction abnormality
• Hypotension requiring vasopressor support
• Altered mental status or seizures
• Respiratory compromise

Disposition

• Discharge after minimum 24 hours observation if:
  • Patient remains asymptomatic
  • Normal cardiac rhythm and conduction
  • Normal vital signs
  • Patient tolerating oral intake

Important Considerations

Toxicity Information

• All parts of the yew plant contain taxine alkaloids, with highest concentrations in leaves and seeds
• Berries have a fleshy red aril surrounding a toxic seed
• Toxicity mechanism: Taxines block cardiac sodium and calcium channels, causing conduction abnormalities 3
• Symptoms typically begin within 1 hour of ingestion and may include nausea, vomiting, abdominal pain, dizziness, and progress to life-threatening arrhythmias 3

Pitfalls to Avoid

• Do not delay treatment while awaiting confirmation of yew berry ingestion - treat based on history and symptoms
• Do not rely solely on conventional antiarrhythmics - sodium bicarbonate appears more effective for taxine-induced arrhythmias 1
• Do not discharge too early - cardiac effects may be delayed and monitoring for at least 24 hours is essential
• Do not underestimate toxicity - even small amounts can be fatal, particularly in children 4

Prognosis

• Mortality is high in untreated cases due to refractory arrhythmias and cardiogenic shock 5
• Early and aggressive intervention improves outcomes
• Most deaths occur within 5 hours of ingestion 4

Follow-up

• Cardiology follow-up with ECG within 1-2 weeks after discharge
• Education for caregivers about plant toxicity and prevention of future exposures