Extracorporeal life support as bridge to recovery in yew poisoning: case reports and literature review

The dosage makes the poison - ECMO support considerations in poisoning

Acute poisoning may lead to life-threatening conditions that require advanced life support, such as extracorporeal membrane oxygenation (ECMO). Data about the use of ECMO in intoxications and overdose are limited to case reports and case series. This review focuses on the classification of toxic agents, mechanisms of toxicity, treatment strategies, and predictors of mortality among ECMO-supported patients. Cardiogenic shock and arrhythmias can arise from cardiovascular toxins, including β-blockers, calcium channel blockers, and tricyclic antidepressants, while severe respiratory failure can result from respiratory toxins such as opioids and paraquat. ECMO is used as a bridge to recovery, transplantation, or adjunctive therapies, and the survival rates vary widely. Mortality predictors include severe acidosis (pH< 7.1) and the need for renal replacement therapy prior to ECMO. Despite its lifesaving potential, ECMO does not treat the underlying toxicity; it only stabilizes patients during the clearance of toxin or the administration of antidotes. Nevertheless, ECMO is a valuable but underutilized tool in managing severe poisoning that offers nonspecific organ support, particularly in refractory cardiogenic shock and respiratory failure, and it provides critical time for recovery. Future research should address data gaps, including underreporting of non-survivors, to better understand ECMO's role and outcomes in intoxication management.

Pediatric extracorporeal cardiopulmonary resuscitation for yew cardiotoxicity

INTRODUCTION

English yew is an evergreen conifer frequently planted in household gardens and, when ingested in large doses, results in severe cardiotoxicity characterized by difficult to control ventricular arrhythmias with high rates of mortality.

CASE REPORT

A previously healthy teenage female presented as an out-of-hospital cardiac arrest with refractory ventricular arrhythmias and severe biventricular dysfunction. Due to rapid deterioration in her clinical status, she was cannulated onto venoarterial extracorporeal membrane oxygenation (ECMO) which resulted in rapid normalization of her rhythm and ventricular function.

DISCUSSION

Our case highlights the importance of keeping a broad differential diagnosis when considering etiologies of ventricular arrhythmias in the pediatric population. The final diagnosis was not made until after discharge and implantable cardiac defibrillator (ICD) placement.

CONCLUSION

The delayed diagnosis of this intentional English yew ingestion ultimately resulted subsequent ICD removal. Early ECMO activation in cases of English yew toxicity can be essential for patient survival.

[Severe intoxication after yew (Taxus) ingestion-case report and literature review]

BACKGROUND

Severe yew (Taxus) intoxication is a rare condition that can lead to life-threatening cardiac arrhythmia. The survival of patients requires highly specialized emergency and intensive care treatment.

OBJECTIVES

Systematic overview of the clinical picture and important treatment options.

METHODS

Case report of severe yew intoxication with subsequent literature review of comparable case reports. Analysis of 33 case reports with a total of 37 critically intoxicated patients from the years 2000-2024 from Europe and North America.

RESULTS

Severe yew intoxications were almost exclusively the result of suicidal intent. Patients average age was 33 (± 14.5) years. The use of antiarrhythmic drugs and electrical stimulation of the heart often proved to be ineffective or deteriorating in its effect over time. The use of lipid emulsion and/or digoxin-specific Fab fragments has little evidence. The average duration of a clinically relevant arrhythmogenic effect was 22±11.7 h.

CONCLUSIONS

The management of yew intoxication is primarily limited to symptomatic treatment. The availability of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in a "bridge-to-recovery" concept appears to be of utmost importance.

Venoarterial extracorporeal membrane oxygenation in combination with Levosimendan as a bridge to recovery for a case of severe yew intoxication in a 13-year-old patient

In an adolescent patient with severe yew intoxication and consecutive cardiac arrest, non-responsive to conventional resuscitation necessitating extracorporeal life support, Levosimendan has been implemented in the early acute phase of hemodynamic stabilization, without obvious side effects. However, the additive value of this treatment in severe yew intoxication remains speculative.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

[Intoxications in childhood and adolescence]

Poisoning of children requires quick and rational action. It is crucial to recognize a poisoning, to interpret the symptoms correctly, and to assess the severity of the poisoning as precisely as possible. This is the best way to find the optimal therapy for each patient.Cases of suspected poisoning are common in childhood. The risk of a potential poisoning must be recognized and interpreted correctly. Based on this, symptomatic and specific therapy can be carried out. The poisons information centres have a great experience in the diagnosis and treatment of poisonings and can help the attending physicians to plan the further therapeutic steps.Both the hazard of a toxic substance and a realistic exposure assessment must be considered. This is especially crucial in cases of suspected poisoning of (still) mostly asymptomatic patients. This is the way to prevent overtreatment without overlooking dangerous poisonings.

Extracorporeal cardio-pulmonary resuscitation in poisoning: A scoping review article

Background

Extracorporeal cardiopulmonary resuscitation (ECPR) represents last-line salvage therapy for poisoning-induced cardiac arrest but no review has focused on this specific area.

Objective

This scoping review sought to evaluate the survival outcomes and characteristics of published cases of ECPR for toxicological arrest, with the aim of highlighting the potential and limitations of ECPR in toxicology.Eligibility Criteria.We searched PubMed and Cochrane for eligible papers from database inception to October 1, 2022 using the keywords "toxicology", "ECLS" and "CPR". References of included publications were searched to identify additional relevant articles. Qualitative synthesis was used to summarize the evidence.

Results

85 articles were chosen: 15 case series, 58 individual cases and 12 other publications that were analyzed separately due to ambiguity. ECPR may improve survival outcomes in selected poisoned patients, although the extent of benefit is unclear. As ECPR for poisoning-induced arrest may have better prognosis compared to from other aetiologies, it is likely reasonable to apply ELSO ECPR consensus guideline recommendations to toxicological arrest.Out-of-hospital cardiac arrest alone may not be sufficient grounds to deny ECPR if effective resuscitation had been promptly instituted. Poisonings involving membrane-stabilizing agents and cardio-depressive drugs, and cardiac arrests with shockable rhythms appear to have better outcomes. ECPR may permit excellent neurologically-intact recovery despite prolonged low-flow time of up to four hours. Early ECLS activation and pre-emptive catheter placement can significantly shorten time-to-ECPR and possibly improve survival.

Conclusion

As effects of poisoning may be reversible, ECPR can potentially support poisoned patients through the critical peri-arrest state.

Characteristics of emergency department presentations following ingestion of Taxus baccata (yew)

OBJECTIVE

Presentations of Taxus baccata (yew) poisoning can range between asymptomatic cases and life-threatening cardiotoxicity - depending on the amount ingested. This study aimed to describe emergency department (ED) presentations after yew exposure, and covers their clinical presentation, diagnostic and specific treatment, to contribute to optimising intreatment and prophylaxis.

METHODS

Retrospective observational study of cases (≥ 16 years of age) presenting at the ED of the University Hospital of Bern, Switzerland, from 1 May 2012 to 31 May 2020 following reported yew exposure. Cases were retrieved from the electronic patient database using full-text terms.

RESULTS

During the study period, 55 presentations (11 patients) of the 350,381 ED attendances were included. All patients were female and the median age on first presentation was 22 years (range 16-48). All 10 patients with intentional intake had previous diagnoses of psychiatric disorders. Commonly reported symptoms on presentation were gastrointestinal disturbances (31 presentations, 56%), neurological (six presentations, 11%) and subjective cardiovascular symptoms (five presentations, 9%). The most frequent clinical findings on presentation were tachycardia (15 presentations, 27%) and hypotension (11 presentations, 20%). In 52 presentations (95%), gastroscopic extraction of the leaves was performed, activated charcoal was administered in 25 cases (45%), and there were no fatalities. In the majority of the cases (40, 73%), the patient was admitted to psychiatric care and in 10 (18%) the patient was discharged home.

CONCLUSION

ED presentations after yew exposure appear to be rare, but potentially life-threatening and commonly observed in this study in young female patients with underlying psychiatric diseases. In this case series, gastroscopic extraction and activated charcoal application were commonly performed and there were no fatalities.

Cardiogenic shock due to yew poisoning rescued by VA-ECMO: case report and literature review

Ingestion of leaves of the European yew tree (Taxus baccata) can result in fatal cardiac arrhythmias and acute cardiogenic shock. This cardiotoxicity derives from taxine alkaloids that block cardiac voltage-gated sodium and calcium channels. Prompt initiation of venoarterial extracorporeal membrane oxygenation is essential to bridge these critically ill patients to recovery, as there is no antidote available. We here report a 39-year old patient with toxic cardiogenic shock after yew poisoning, who was successfully rescued by venoarterial extracorporeal membrane oxygenation and had a full neurological recovery. This report emphasizes the role of intoxications as reversible causes of cardiac arrest and adds further evidence to the body of existing literature thus encouraging the early use of venoarterial extracorporeal membrane oxygenation in patients with yew poisoning and cardiogenic shock.

Poisoning by Plants

BACKGROUND

Questions on poisoning by plants are a common reason for inquiries to poison information centers (PIC). Over the years 2011-2020, plant poisoning was the subject of 15% of all inquiries to the joint poison information center in Erfurt, Germany (Gemeinsames Giftinformationszentrum Erfurt, GGIZ) that concerned poisoning in children (2.3% in adults). In this patient collective, plant poisoning occupied third place after medical drugs (32%) and chemical substances (24%), and was a more common subject of inquiry than mushroom poisoning (1.5%).

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed/TOXLINE on plant poisoning and on 12 epidemiologically and toxicologically relevant domestic species of poisonous plants in risk categories 2 and 3 (up to 2021).

RESULTS

Medical personnel should have basic toxicological knowledge of the following highly poisonous plants: wolfsbane (aconitum), belladonna, angel's trumpet, cowbane (cicuta virosa), autumn crocus, hemlock, jimson weed, henbane, castor bean (ricinus), false hellebore, foxglove (digitalis), and European yew. The intoxication is evaluated on the basis of a structured history (the "w" questions) and the clinical manifestations (e.g., toxidromes). Special analysis is generally not readily available and often expensive and time-consuming. In case of poisoning, a poison information center should be contacted for plant identification, risk assessment, and treatment recommendations. Specimens of plant components and vomit should be obtained, if possible, for further testing. Measures for the elimination of the poisonous substance may be indicated after a risk-benefit analysis. Specific antidotes are available for only a few types of plant poisoning, e.g., physostigmine for tropane alkaloid poisoning or digitalis antibodies for foxglove poisoning. The treatment is usually symptomatic and only rarely evidence-based. Individualized medical surveillance is recommended after the ingestion of large or unknown quantities of poisonous plant components.

CONCLUSION

The clinician should be able to recognize dangerous domestic species of poisonous plants, take appropriate initial measures, and avoid overdiagnosis and overtreatment. To improve patient care, systematic epidemiological and clinical studies are needed.

Taxine alkaloid poisoning successfully supported with venoarterial extracorporeal membrane oxygenation: a case report

BACKGROUND

Ingestion of the berries of the European yew tree can result in fatal cardiac arrhythmias.

CASE SUMMARY

A 53-year-old female presented to our emergency department following ingestion of ∼200 European yew tree berries. At presentation, she was in cardiogenic shock due to a mixture of tachy- and bradyarrhythmias including ventricular tachycardia, atrial fibrillation with slow ventricular response and prolonged ventricular conduction, and periods of asystole. She was referred to a specialist cardiac centre and promptly established on mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (V-A ECMO) by a retrieval team. Following resolution of her arrhythmias, she was weaned from V-A ECMO after 4 days of support and was discharged home with full neurological recovery on Day 12.

DISCUSSION

Poisoning can lead to acute reversible but potentially fatal cardiogenic shock. We believe that access to prompt initiation of V-A ECMO was key to this patient's survival.

Fatal ingestion of Taxus baccata: English yew

Poisoning from consumption of foraged alternative medicine products is an uncommon yet recognized occurrence. Here, presented is the case of a 40-year-old woman who was witnessed to collapse with labored breathing and subsequently died despite emergency medical personnel attendance and resuscitation efforts. Autopsy revealed the presence of plant matter that was visually identified as leaves from Taxus baccata - the English Yew. Isolation of alkaloids from the plant material and subsequent identification of the same alkaloids in the decedent's blood by liquid chromatography-tandem mass spectrometry indicated a toxicological cause of death. This case illustrates a collaborative team approach among subject matter experts to unexpectedly discover and then confirm the sudden death of this woman from T. baccata toxicity.

[Cardiogenic shock following yew needle poisoning : Digoxin immune fab, va-ECMO and albumin dialysis for the treatment of a suicidal yew leaf poisoning]

We present the case of a 46-year-old male who developed refractory bradycardia with cardiogenic shock after attempting suicide by ingestion of yew leaves. Due to delayed availability of the Digoxin immune fab, a va-ECMO was established to maintain sufficient circulation. Administration of the digoxin fab resulted in recovery of spontaneous circulation. Continuous venovenous hemodiafiltration with hemoadsorption and albumin dialysis were initiated with the intention to remove immune fab-toxin complexes and as organ support in acute kidney and liver failure. Within 5 days the patient was successfully weaned from ECMO, liver support and renal replacement and discharged without physical sequelae.