What is the treatment for aconite poisoning?

Treatment of Aconite Poisoning

Immediate aggressive supportive care with close hemodynamic monitoring is the cornerstone of aconite poisoning management, as there is no specific antidote, and early initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) should be considered for refractory ventricular arrhythmias and cardiogenic shock. 1, 2

Immediate Supportive Care

The priority in aconite poisoning is stabilization of vital functions before the specific toxin is identified, as timely supportive care takes precedence over antidotal therapy 3. This includes:

• Airway management and hemodynamic support with correction of critical vital sign abnormalities 3
• Close continuous monitoring of blood pressure and cardiac rhythm, as cardiovascular collapse can develop rapidly 4, 2
• 100% oxygen administration to maintain tissue oxygenation 3

Pathophysiology and Clinical Presentation

Aconitine and related alkaloids (mesaconitine, hypaconitine) cause persistent activation of voltage-sensitive sodium channels, leading to severe cardiotoxicity and neurotoxicity 2. Patients typically present with:

• Neurological features: Paresthesia and numbness of face, perioral area, and extremities; muscle weakness 4, 5, 2
• Cardiovascular features: Hypotension, bradycardia, ventricular ectopics, ventricular tachycardia, and ventricular fibrillation 4, 5, 2
• Gastrointestinal features: Nausea, vomiting, abdominal pain, and diarrhea 4, 2

The lethal dose in adults is 3-6 mg, and the overall in-hospital mortality is 5.5%, with death primarily from refractory ventricular arrhythmias and asystole 6, 2.

Specific Management Strategies

Hypotension and Bradycardia

• Intravenous fluid resuscitation with 0.9% saline should be initiated immediately 4
• Inotropic support with dopamine (3 mcg/kg/min) for persistent hypotension despite fluid resuscitation 4
• Atropine 0.6 mg intravenously for symptomatic bradycardia 4, 2

Note that hypotension and bradycardia can persist for 31-36 hours after ingestion, requiring prolonged supportive therapy 4.

Ventricular Arrhythmias

Aconite-induced ventricular arrhythmias are notoriously refractory to direct current cardioversion and standard antiarrhythmic drugs 2. The treatment approach should be:

• Amiodarone or flecainide as reasonable first-line antiarrhythmic agents based on available clinical evidence 2
• Lidocaine infusion has been successfully used in case reports 6

Refractory Cases: VA-ECMO

For ventricular arrhythmias and cardiogenic shock refractory to first-line treatment, early initiation of VA-ECMO is critical to maintain systemic blood flow, blood pressure, and tissue oxygenation 1, 2.

• VA-ECMO should be initiated as soon as possible when circulatory collapse becomes refractory to antiarrhythmics and vasopressors 1
• In one successful case, VA-ECMO was initiated 2 hours after arrival, with return to sinus rhythm after 9 hours and weaning from ECMO by hospital day 3 1
• The key to survival in severe aconite poisoning is early VA-ECMO introduction 1

Extracorporeal Toxin Removal

The role of charcoal hemoperfusion to remove circulating aconitine alkaloids is not established 2. Unlike other poisonings where extracorporeal treatment has clear indications 3, there is insufficient evidence to recommend routine extracorporeal removal for aconite poisoning.

Monitoring and Duration

• Continuous cardiac monitoring is essential, as arrhythmias can develop hours after ingestion 4, 5
• ICU admission is required for all symptomatic patients 5
• Serum aconitine levels decrease rapidly, with detection becoming negative after hospital day 2 in biological samples 1
• Patients can typically be discharged after 24-48 hours if hemodynamically stable without arrhythmias 6, 5

Critical Pitfalls to Avoid

• Do not delay VA-ECMO in patients with refractory ventricular arrhythmias—early initiation is the key to survival 1
• Do not rely solely on electrical cardioversion for ventricular arrhythmias, as they are often refractory 2
• Do not underestimate the duration of toxicity—hypotension and bradycardia can persist for over 30 hours 4
• Contact regional poison control centers (1-800-222-1222 in the US) for expert guidance, as board-certified toxicologists can provide specialized treatment recommendations 3