What is the treatment for yellow oleander poisoning?

Treatment for Yellow Oleander Poisoning

The primary treatment for yellow oleander poisoning is administration of digoxin-specific antibody fragments (digoxin-Fab), which is reasonable to use for this type of cardiac glycoside toxicity. 1

Pathophysiology and Clinical Presentation

Yellow oleander (Thevetia peruviana) contains cardiac glycosides including thevetins A and B and neriifolin that cause toxicity similar to digoxin poisoning 2:

• Gastrointestinal symptoms: nausea, vomiting, abdominal pain, diarrhea 3
• Cardiovascular effects: various bradyarrhythmias and tachyarrhythmias, including sinus bradycardia, AV blocks, and ventricular dysrhythmias 4
• Electrolyte abnormalities: hyperkalemia is common and potentially life-threatening 3

Treatment Algorithm

First-line Treatment

• Digoxin-specific antibody fragments (digoxin-Fab): The American Heart Association recommends this as reasonable treatment for yellow oleander poisoning 1
  • Effective in reversing life-threatening cardiac arrhythmias 3
  • Shows promising response in hemodynamically stable patients with yellow oleander poisoning 1

Supportive Measures

• Activated charcoal: Single-dose activated charcoal is likely beneficial if administered early 3
• Atropine: May be reasonable for bradydysrhythmias caused by yellow oleander poisoning 1
• Temporary cardiac pacing: May be reasonable for bradydysrhythmias not responding to medical therapy 1, 5
• Antiarrhythmic medications: Lidocaine, phenytoin may be reasonable to treat ventricular dysrhythmias until digoxin-Fab can be administered 1
• Electrolyte management: Correct hypokalemia if present; treat hyperkalemia with insulin-dextrose infusion (avoid calcium which can increase risk of arrhythmias) 3

Ineffective Treatments

• Extracorporeal removal: Hemodialysis, hemofiltration, hemoperfusion, or plasmapheresis are not recommended for treating yellow oleander poisoning 1

Prognostic Factors

• Mortality is higher when:
  • Treatment is delayed 6
  • More seeds are ingested (>4 seeds) 6
  • Life-threatening arrhythmias develop (second-degree heart block type II, third-degree heart block, nodal bradycardia) 5

Clinical Pearls and Pitfalls

• Early recognition is crucial: Yellow oleander poisoning can be fatal if not treated promptly 6
• Continuous cardiac monitoring: All patients should receive continuous ECG monitoring for at least 24 hours to detect arrhythmias 3
• Calcium administration: Avoid intravenous calcium when treating hyperkalemia in yellow oleander poisoning as it may increase the risk of cardiac arrhythmias 3
• Regional poison centers: Contact your regional poison center (1-800-222-1222 in the US) for expert guidance on management 1

Special Considerations

• In resource-limited settings where digoxin-Fab may not be available, management with atropine and isoprenaline can be adequate in most cases, though not optimal 5
• Severity of poisoning does not always correlate with the number of seeds ingested, so all patients should be monitored closely regardless of reported ingestion amount 4