Highly toxic plants

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222, or the nearest international regional poison center.
Common name	Genus and species	Toxicity	Emergency management*
Pokeweed	Phytolacca americana	Severe gastroenteritis, hypovolemic shock, lymphocytosis	Supportive care
Castor bean	Ricinus communis	Severe gastroenteritis, GI hemorrhage, hemolysis, shock	Supportive care
Jequirity bean	Abrus precatorius	Severe gastroenteritis, GI hemorrhage, shock, seizures, demyelinating encephalopathy	Supportive care
Autumn crocus	Colchicum autumnale	Delayed gastroenteritis, multisystem organ failure	Supportive care
May apple	Podophyllum peltatum	GI mucosal necrosis, coma, polyneuropathy	Supportive care
Lily of the valley	Convallaria majalis	Brady- and tachyarrhythmias, gastroenteritis, weakness, hyperkalemia	Digoxin-specific Fab^¶
Foxglove	Digitalis purpurea
Oleander	Nerium oleander
Yellow oleander	Thevetia peruviana
Azalea	Azalea (multiple species)	Bradycardia, hypotension, gastroenteritis, blurred vision, dizziness, altered mental status	Clinically significant bradycardia: Atropine (0.02 mg/kg IV, minimum dose 0.1 mg, maximum dose 1 mg) If unresponsive: Epinephrine (0.01 mg/kg [0.1 mL/kg of 1:10,000 concentration], maximum dose 1 mg) and/or cardiac pacing
Rhododendron	Rhododendron (multiple species)
Death camus	Zigadenus species
Mountain laurel	Kalmia latifolia
Monkshood	Aconitum (multiple species)	Ventricular arrhythmias, gastroenteritis, paresthesias, numbness, weakness, diaphoresis, altered mental status	Ventricular arrhythmias: Amiodarone (5 mg/kg IV, may repeat up to a maximum total daily dose of 15 mg/kg or 2.2 grams) Sodium bicarbonate (1 to 2 mEq/kg IV bolus, maximum single dose 50 mEq) in patients with widened QRS Magnesium sulfate (20 to 50 mg/kg IV, maximum single dose 2 grams) in patients with torsades de pointes ECMO may provide temporary support to patients with refractory arrhythmias or cardiogenic shock until the toxin is metabolized but is rarely needed
False hellebore	Veratrum album	Bradycardia, hypotension, gastroenteritis, paresthesias, syncope, transient blindness, seizures	Clinically significant bradycardia: Atropine (0.02 mg/kg IV, minimum dose 0.1 mg, maximum dose 1 mg) If unresponsive: Epinephrine (0.01 mg/kg [0.1 mL/kg of 1:10,000 concentration], maximum dose 1 mg) and/or cardiac pacing
Yew	Taxus baccata	AV block, ventricular arrhythmias, gastroenteritis, seizures, coma	Clinically significant bradycardia: Atropine (0.02 mg/kg IV, minimum dose 0.1 mg, maximum dose 1 mg) If unresponsive to atropine: Epinephrine (0.01 mg/kg [0.1 mL/kg of 1:10,000 concentration], maximum dose 1 mg) and/or cardiac pacing If bradycardia refractory to the above treatments: Calcium gluconate 10% (60 to 100 mg/kg, maximum single dose 3 grams; may repeat every 10 minutes) Sodium bicarbonate (1 to 2 mEq/kg IV bolus, maximum single dose 50 mEq) in patients with widened QRS ECMO may provide temporary support to patients with refractory arrhythmias or cardiogenic shock until the toxin is metabolized but is rarely needed Treat seizures as for water hemlock (Cicuta species) below
Poison hemlock	Conium maculatum	Nicotinic toxicity: Salivation, lacrimation, vomiting, diarrhea, wheezing, diaphoresis, small pupils, muscle fasciculations, muscle weakness, paralysis, coma, seizures	Atropine for muscarinic effects (0.02 mg/kg IV, minimum initial dose 0.1 mg, maximum dose 1 mg), repeat dose every 5 to 15 minutes as needed to dry bronchial secretions without causing anticholinergic toxicity (eg, delirium or hyperthermia) Treat seizures as for water hemlock (Cicuta species) below Paralysis may require rapid sequence intubation and mechanical ventilation Refer to UpToDate content on nicotine poisoning
Wild tobacco	Nicotiana tabacum
Indian tobacco	Lobelia inflata
Blue wild or blue false indigo	Baptisia australis
Golden chain	Laburnum anagyroides
Golden chain tree	Cytisus laburnum
Jimson weed	Datura stramonium	Anticholinergic toxicity: Tachycardia, flushing, hot and dry skin, dilated pupils and blurry vision, disorientation, bizarre behavior, paranoia, delirium hallucinations, seizures, decreased bowel sounds, urinary retention	Physostigmine (0.01 to 0.03 mg/kg slowly over 5 minutes, maximum single dose 0.5 mg; if no response, may be repeated every 5 to 10 minutes to a maximum total dose of 2 mg)^Δ Benzodiazepines for agitation (eg, lorazepam 0.05 to 1 mg/kg, maximum single dose 2 to 4 mg)
Angel trumpet	Brugmansia (multiple species)
Deadly nightshade	Atropa belladonna
Henbane	Hyoscyamus niger
Bitter lupin or chocho	Lupinus (multiple species)
Water hemlock	Cicuta (multiple species)	Severe and recurrent seizures, vomiting, abdominal pain, diaphoresis, bronchorrhea, salivation, flushing, bradycardia, hypotension, delirium	Benzodiazepines (eg, lorazepam 0.05 to 0.1 mg/kg, maximum single dose 4 mg), repeat up to 0.3 mg/kg If unresponsive: Phenobarbital (15 to 20 mg/kg, may repeat 5 to 10 mg/kg every 15 to 20 minutes as needed up to a maximum total dose of 40 mg/kg) For refractory seizures, continuous infusion of midazolam^◊
Water dropwort	Oenanthe crocata
Morning glory	Ipomea violacea	LSD effects: Visual hallucinations, vomiting, nausea, abdominal pain, flashbacks	Quiet, dim environment and Benzodiazepines for agitation (eg, lorazepam 0.05 to 1 mg/kg, maximum single dose 2 to 4 mg)
Baby or Hawaiian woodrose	Argyreia nervosa
Large woodrose or Spanish morning glory	Merremia tuberosa
Peyote	Lopophora williamsii
Pits or seeds from cherry, apricot, peach, plum, pear, apple	Prunus (multiple species)	Cyanide toxicity: Cherry red skin, tachycardia, tachypnea, ventricular arrhythmias, coma, seizures, vomiting, abdominal pain, severe lactic acidosis	IV hydroxocobalamin (70 mg/kg, maximum dose 5 grams) up to 3 doses For severe poisoning not response to 2 doses of hydroxocobalamin, may also give IV sodium thiosulfate 25% (1.65 mL/kg [412.5 mg/kg]); refer to UpToDate content on cyanide poisoning

This table provides typical clinical features and management for major toxic effects of highly toxic plants. For more detail, refer to UpToDate topics on plant poisoning and nicotine poisoning.

GI: gastrointestinal; Fab: antibody fragments; IV: intravenous; AV: atrioventricular; ECMO: extracorporeal membrane oxygenation; LSD: lysergic acid diethylamide.

* All patients with symptomatic ingestion of highly toxic plants warrant administration of oral activated charcoal, fluid repletion, and supportive care of airway, breathing, and circulation.

¶ Although digoxin-specific Fab fragments will bind plant cardiac glycosides, doses higher than typically given for digoxin poisoning may be necessary. Refer to UpToDate topics on digitalis (cardiac glycoside) poisoning.

Δ Physostigmine may provide diagnostic confirmation of anticholinergic poisoning and is indicated for patients with hyperthermia, life-threatening tachyarrhythmias, or seizures. Physostigmine should not be given to patients with widened QRS on electrocardiogram or those who have co-ingested agents with sodium channel blocking effects (eg, quinidine, cyclic antidepressants).

◊ When giving phenobarbital with benzodiazepines, anticipate apnea and perform emergency endotracheal intubation as needed. Water hemlock and water dropwort may cause seizures that are difficult to control and recur despite treatment with benzodiazepines and phenobarbital. Administration of phenytoin or fosphenytoin should be avoided. (Refer to "Management of status epilepticus in children.")

Reference:

Poison emergency center contact numbers. Liquid Glass Nanotech. Available at: https://www.liquidglassnanotech.com/poison-emergency-center-contact-numbers/ (Accessed on May 25, 2021).

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Highly toxic plants