Journal of The Korean Society of Clinical Toxicology

A Case of Aconite Poisoning Successfully Recovered after Intravenous Fat Emulsion Therapy: Hee Jun Shin, Hoon Lim; J Korean Soc Clin Toxicol. 2016;14(1):60-65. Published online June 30, 2016

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Abstract PDF: Aconitum is a genus of various species of flowering plants that belongs to the Family Ranunculaceae. Most Aconitum sp. have extremely toxic alkaloid substances such as aconitine, mesaconitine and hypaconitine. Among these substances, aconitine can cause fatal cardiotoxicity by activating sodium channels followed by calcium channels in myocardial cells. Even though there have been various therapeutic plans suggested comprising antidotes based on diverse case reports and studies, there is no confirmatory treatment protocol for aconite poisoning. Here, we report an aconite poisoning patient who had refractory ventricular tachyarrhythmia that did not respond to intravenous amiodarone therapies even though they were sustained for over 2 hours, but showed successful recovery following intravenous fat emulsions (IFE) therapy.

A Case of Successful Resuscitation of 10,150 J Shocks and Therapeutic Hypothermia on Aconitine-induced Cardiovascular Collapse: Hyung Jun Moon, Jung Won Lee, Ki Hwan Kim, Dong Kil Jeong, Jong Ho Kim, Young Ki Kim, Hyun Jung Lee; J Korean Soc Clin Toxicol. 2014;12(2):97-101. Published online December 31, 2014

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Abstract PDF: Aconitine, found in the Aconitum species, is highly extremely toxic, and has been known to cause fatal cardiac arrhythmias and cardiovascular collapse. Although several reports have described treatment of aconitine intoxication, management strategy for the patient in a hemodynamically compromised state who experienced cardiopulmonary collapse is unknown. We report here on a case of a successful cardiopulmonary resuscitation and therapeutic hypothermia in an aconitine-induced cardiovascular collapsed patient. A 73-year-old male who presented with nausea, vomiting, chest discomfort, and drowsy mental state after eating an herbal decoction made from aconite roots was admitted to the emergency department. He showed hemodynamic compromise with monomorphic ventricular tachycardia resistant to amiodarone and lidocaine. After 3 minutes on admission, he collapsed, and cardiopulmonary resuscitation was initiated. We treated him with repeated cardioversion/defibrillation of 51 times, 10,150 joules and cardiopulmonary resuscitation of 12 times, 69 minutes for 14 hours and therapeutic hypothermia for 36 hours. He recovered fully in 7 days.

A Case of Severe Aconitine Intoxication with Ventricular Tachycardia, Successfully Treated by a Combination of Two Anti-arrhythmic Drugs: Seung-Mok Ryoo, Chang-Hwan Sohn, Bum-Jin Oh, Won Kim, Kyoung-Soo Lim; J Korean Soc Clin Toxicol. 2011;9(2):105-108. Published online December 31, 2011

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Abstract PDF: Aconitine is an anti-inflammatory agent with therapeutic uses in oriental medicine as an analgesic and for treatment of stroke. Because of its sodium channel effect, aconitine can promote undesirable, wide complex tachyarrhythmia. If tachycardia develops during use of aconitine, class Ia and class III anti arrhythmic drugs can be utilized for treatment. However there are no single anti-arrhythmia agents which are uniformly effective. We report a case, characterized by wide complex tachyarrhythmia and severe hypotension, which was successfully treated by simultaneous injections of amiodarone and lidocaine. A 59-year-old woman exhibiting clinical signs of drowsiness as a result of ingesting 6 g of aconitine, was admitted to the emergency department. Initially, wide complex tachyarrhythmia (ventricular tachycardia and pulse rate of 180 beats/min) and severe hypotension (blood pressure of 53/26 mmHg) was observed. After simultaneous injection of amiodarone and lidocaine, the patient's rhythm pattern changed to an accelerated junctional rhythm with ventricular premature complex. Two hours later, the patient's heart pattern became a sinus rhythm. As demonstrated by this case, simultaneous injections of amiodarone and lidocaine can be useful in treating ventricular arrhythmia induced by aconitine.

Toxicologic Features and Management in Aconitine Intoxication Following Ingestion of Herbal Tablets Containing Aconitum Species: Wool-Lim Cho, Young-Ho Jin, Tae-Oh Jeong, Jae-Baek Lee, Ji-Hun Kang; J Korean Soc Clin Toxicol. 2008;6(2):104-109. Published online December 31, 2008

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Abstract PDF: Purpose: Unrefined tablets prepared from Aconitum tubers are occasionally used in Korean folk medicine. This study defines the potential sources, clinical toxicology, and treatment of aconitine poisoning. Methods: A retrospective survey was conducted in 63 patients in the ED of a tertiary University Hospital with suspected toxicity from an unrefined tablet prepared from Aconitum tubers from 1999 to 2007. Results: A total of 63 cases enrolled included 26 men and 37 women, aged 30 to 86 years. Forty-eight patients ingested aconitine tablets as digestives, 26 tablets on average. After a latent period of 30 to 450 minutes, patients developed a combination of neurologic (87.3%), gastrointestinal (82.5%), cardiopulmonary (41.3%), and other (28.6%) features typical of aconitine poisoning. Initial ECG abnormalities revealed dysrhythmia (61.9%), conduction disturbance (42.9%), and abnormal waveforms (39.7%), with 28.6% of patients having normal ECGs. All patients received supportive treatment or close observation regardless of ingestion amounts. Patients with hypotension or ventricular arrhythmia were treated with inotropic agents or amiodarone. Conclusion: Toxicologic signs and symptoms can occur after the consumption of aconitine tablets, regardless of ingestion amount. The risk occurs because of inadequately processed aconitine roots. This study will provide important data for public education and distribution regulations for Aconitum sp. in Korea.

Prolonged Cardiopulmonary Resuscitation in a Cardiac Arrest Patient with Aconitine Intoxication: In-Woo Hwang, Tae-O Jeong, Jae-Baek Lee, Youn-Ho Jin; J Korean Soc Clin Toxicol. 2007;5(1):67-70. Published online June 30, 2007

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Abstract PDF: Aconitum is an extremely dangerous plant that contains various toxic diterpenoid alkaloids, primarily concentrated in the roots. We report a case of acute intoxication of a 60-year-old man admitted to our emergency department after ingestion of a large amount of homemade aconitine decoction. At presentation about one hour after intake, the patient was unconscious and electrocardiographic analysis showed a ventricular tachycardia/fibrillation. Several times defibrillation was applied and antiarrhythmic agents were administered, but the patient still exhibited a refractory ventricular fibrillation and failed to return to spontaneous circulation. Sustained cardiopulmonary resuscitation finally produced a pulsatile cardiac rhythm at two hours after intake. The patient was discharged from our hospital on day 8. The authors stress that clinicians must be aware of the possible occurrence of life-threatening ventricular arrhythmia in cases of aconitine intoxication and be prepared to persist with prolonged CPR as necessary.

Ventricular Arrhythmia Following Aconitine-Ingestion - 2 Case Reports -: Mi-Ran Kim; J Korean Soc Clin Toxicol. 2006;4(2):180-186. Published online December 31, 2006

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Abstract PDF: The various species of aconitum contain diterpene (C-20) and norditerpene (C-19) forms of the natural alkaloid aconitine that cause neurologic, gastrointestinal, cardiovascular symptoms. In chinese medicine, these plants has been used as drugs to treat pain, dyspepsia, cerebrovascular disease, and so on. Because the therapeutic window is narrow, poisoning may occur from unintentional exposure, with a variety of toxic effects such as arrhythmia, hypotension, paresthesia, paralysis, nausea, vomiting, and abdominal pain. Aconitine-containing folk remedies are widely used in Korea. We encountered two cases of ventricular arrhythmia in patients who ingested tablets, known as 'Wha-Pung-Dan' made with aconitine extracts and were subsequently admitted to the ED. A 42 year-old man who took 35 tablets presented with ventricualr tarchycardia, and 40 year-old woman who took 40 tablets showed premature ventricular contractions. Both patients were discharged normally without any complications after three days.

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