What is the management for aconite poisoning?

Management of Aconite Poisoning

Immediate treatment with supportive care, antiarrhythmic medications, and consideration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is essential for managing aconite poisoning, which primarily causes life-threatening ventricular arrhythmias. 1

Initial Management

• Contact a poison control center or medical toxicologist immediately for expert guidance on treatment protocol 2
• Remove all contaminated clothing and thoroughly wash exposed skin with soap and water to prevent continued absorption 3
• Avoid inducing vomiting as this may worsen the condition and delay care 3
• Do not administer activated charcoal unless specifically advised by poison control 3

Cardiovascular Management

• Monitor cardiac rhythm continuously as ventricular arrhythmias are the primary life-threatening complication 4
• For ventricular arrhythmias, administer one of the following antiarrhythmic medications:
  • Flecainide (first-line) - associated with successful restoration of sinus rhythm in most cases 4
  • Amiodarone - effective in approximately half of cases 4
  • Mexiletine or procainamide - may be considered as alternatives 4
• For hypotension and bradycardia:
  • Administer intravenous fluids (0.9% saline) 5
  • Consider vasopressors such as dopamine (3 μg/kg/min) 5
  • Administer atropine for significant bradycardia 5
• High-dose magnesium sulfate may be considered for refractory ventricular arrhythmias 6

Advanced Interventions

• For refractory ventricular arrhythmias or cardiovascular collapse:
  • Initiate VA-ECMO early if available, as it has been shown to be lifesaving in severe cases 1
  • Prolonged cardiopulmonary resuscitation may be necessary as a "time-buying" strategy until the body excretes the toxins 4
  • Consider cardiopulmonary bypass for severe cases unresponsive to other treatments 4
• Direct cardioversion has limited effectiveness for aconite-induced arrhythmias but may be attempted 4

Neurological Management

• Administer benzodiazepines for seizures or agitation 2
• Monitor for central nervous system effects including altered mental status and seizures 5

Monitoring and Supportive Care

• Provide airway management if respiratory distress is present 3
• Monitor vital signs, cardiac rhythm, and electrolytes continuously 5
• Continue supportive care until aconite is eliminated from the body (typically 24-48 hours) 5

Common Pitfalls to Avoid

• Do not delay treatment while waiting for confirmation of aconite poisoning; treat based on clinical presentation 2
• Avoid using lidocaine as it has shown limited effectiveness compared to other antiarrhythmics 4
• Do not administer high concentrations of oxygen without specific guidance, as this may worsen certain toxicities 3
• Recognize that standard ACLS protocols may be insufficient; specific antiarrhythmic therapy is required 4

Prognosis

• With prompt and appropriate treatment, complete recovery is possible despite the high mortality risk 7
• Ventricular arrhythmias may persist for 24-48 hours after ingestion, requiring continuous monitoring during this period 5