What is the management of oleander seed poisoning?

Management of Oleander Seed Poisoning

The management of oleander seed poisoning should focus on administering digoxin-specific antibody fragments (digoxin-Fab), which is reasonable for treating yellow oleander poisoning according to the 2023 American Heart Association guidelines. 1

Initial Assessment and Stabilization

• Recognize symptoms: Look for gastrointestinal symptoms, confusion, hyperkalemia, and cardiac conduction abnormalities including:

  • Bradyarrhythmias
  • Atrioventricular nodal block
  • Ventricular tachycardia/fibrillation
  • Asystole

• Continuous ECG monitoring: Monitor for at least 24 hours to detect arrhythmias; longer monitoring for severe cases 2

• Laboratory evaluation:

  • Serum potassium levels (both hypokalemia and hyperkalemia can occur)
  • Serum digoxin levels (can cross-react with oleander cardiac glycosides)
  • Renal function tests

Specific Treatment Algorithm

1. Digoxin-specific antibody fragments (digoxin-Fab):

   • First-line treatment for life-threatening oleander poisoning 1
   • Dosing: For yellow oleander, 1200 mg (30 vials) has been used in clinical studies 1
   • Expect dysrhythmia resolution within 30-45 minutes in most cases

2. Cardiac management:

   • For bradydysrhythmias:

     • Atropine may be reasonable (Class 2b recommendation, Level C-LD evidence) 1
     • Electrical pacing may be considered if atropine fails (Class 2b recommendation) 1

   • For ventricular dysrhythmias:

     • Lidocaine or phenytoin may be reasonable until digoxin-Fab can be administered (Class 2b recommendation) 1

3. Electrolyte management:

   • Correct hyperkalemia with insulin-dextrose infusion
   • Avoid calcium administration for hyperkalemia as it increases risk of cardiac arrhythmias 2
   • Correct hypokalemia if present as it can worsen cardiac glycoside toxicity

4. Gastrointestinal decontamination:

   • Single-dose activated charcoal is likely beneficial if administered early 2
   • The role of multiple-dose activated charcoal remains controversial 2

Special Considerations

• Oxygen therapy: Provide supportive oxygen as needed, but be aware that excessive oxygen may not be beneficial in cellular toxins

• Fluid management: Correct dehydration with normal saline and maintain adequate renal perfusion 2

• Antiemetics: Control severe vomiting as needed 2

• Avoid hemodialysis: Extracorporeal removal methods including hemodialysis, hemofiltration, hemoperfusion, or plasmapheresis are not recommended (Class 3: No Benefit) 1

Prognosis and Monitoring

• Mortality rates vary but can be significantly reduced with proper treatment
• In a study of 300 patients with yellow oleander seed ingestion, 46% developed arrhythmias with sinus bradycardia being the most common (49.27%) 3
• Median hospital stay is approximately 5 days, with most patients (85.33%) having normal ECG at discharge 3

Pitfalls to Avoid

1. Delaying digoxin-Fab administration: Early administration is critical for severe poisoning

2. Calcium administration: Avoid intravenous calcium for hyperkalemia as it may precipitate life-threatening arrhythmias 2

3. Inadequate monitoring: Patients may develop delayed cardiac toxicity; continuous monitoring for at least 24 hours is essential

4. Underestimating severity: The number of seeds ingested does not reliably predict ECG changes or clinical severity 3

5. Premature discharge: Ensure cardiac rhythm has stabilized before discharge

The evidence strongly supports the use of digoxin-Fab as the cornerstone of treatment for oleander poisoning, with supportive measures for cardiac arrhythmias and electrolyte abnormalities as needed.