What is the treatment for yellow oleander poisoning?

Treatment for Yellow Oleander Poisoning

Digoxin-specific antibody fragments (digoxin-Fab) are the first-line treatment for yellow oleander poisoning with life-threatening cardiac arrhythmias, as they are the only proven therapy to reduce mortality. 1

Immediate Management

Definitive Antidote Therapy

• Administer digoxin-specific antibody fragments (digoxin-Fab) for life-threatening cardiac arrhythmias, including severe bradydysrhythmias (second-degree AV block type II, third-degree heart block) and ventricular dysrhythmias 1, 2
• Digoxin-Fab effectively reverses cardiac arrhythmias caused by cardiac glycosides (thevetins A and B, neriifolin) in yellow oleander seeds, with prospective observational studies demonstrating mortality benefit 2
• Contact regional poison centers (US: 1-800-222-1222) for expert guidance on dosing and management 1

Supportive Cardiac Management

• Atropine is reasonable for bradydysrhythmias while awaiting digoxin-Fab or in resource-limited settings, though theoretical concerns exist about precipitating tachyarrhythmias 1, 3
• Temporary cardiac pacing is reasonable for bradydysrhythmias not responding to medical therapy 1, 3
• Lidocaine or phenytoin may be used for ventricular dysrhythmias until digoxin-Fab can be administered 1, 2

Clinical Pitfall: While atropine and isoprenaline were used successfully in 80 of 90 patients requiring treatment in one Sri Lankan study 3, some experts caution that accelerating heart rate may increase tachyarrhythmic risk 2. Digoxin-Fab remains the only proven therapy with mortality benefit.

Electrolyte Management

Potassium Abnormalities

• Correct hyperkalemia with insulin-dextrose infusion, as hyperkalemia results from extracellular potassium shift rather than total body excess 2
• Avoid intravenous calcium for hyperkalemia, as it increases the risk of cardiac arrhythmias in cardiac glycoside toxicity 2
• Avoid sodium polystyrene sulfonate resin if digoxin-Fab will be used, as it may cause dangerous hypokalemia 2
• Hyperkalemia correlates with cardiac glycoside concentration and serious dysrhythmias, though it is not an independent predictor of mortality 4

Other Electrolytes

• Correct hypomagnesemia if present, as it can worsen cardiac glycoside toxicity 2
• Provide normal saline for dehydration correction 2

Monitoring Requirements

Cardiac Monitoring

• Continuous ECG monitoring for at least 24 hours is necessary to detect arrhythmias; extend monitoring in severe poisoning 2
• Serial ECGs should assess for PR interval prolongation and digoxin effect, which significantly predict serious dysrhythmias 4
• Most common arrhythmias include sinus bradycardia (27-49%), followed by second-degree AV block (17%) 4, 5

Laboratory Monitoring

• Measure serum potassium, sodium, magnesium, and calcium at presentation 2, 4
• Cardiac glycoside concentration measurement has modest clinical utility (AUC: 0.719) for discriminating serious dysrhythmias at presentation, but better predicts new-onset serious arrhythmias 4

Gastric Decontamination

• Single-dose activated charcoal is probably beneficial and clearly safe 2
• Multiple-dose activated charcoal remains controversial due to contradictory trial results; no firm recommendation can be made 2
• Gastric lavage and emesis induction have not been adequately studied 2

Treatments to Avoid

• Do not use extracorporeal removal methods (hemodialysis, hemofiltration, hemoperfusion, or plasmapheresis), as they are not effective for yellow oleander poisoning 1

Prognostic Indicators

• Number of seeds ingested and hypotension at admission are independent determinants of mortality 4
• Each 0.4 seed increase in consumption increases mortality odds by 1.5 times 4
• Mortality rates range from 2.4-5% with appropriate treatment 3, 4
• Life-threatening arrhythmias develop in approximately 15-17% of admitted patients 3