ABSTRACT
Background: Vertatrum viride (false hellebore) is a perennial commonly found in eastern North America. The most common cause of exposure is misidentification when foraging for wild onion, or skunk cabbage. One regional poison center saw an increase in foraging-related poisonings during initial COVID-19 restrictions. The case report highlights severe delayed cardiac effects after ingestion of Veratrum viride in an otherwise healthy, young, female athlete. Case report: A 24-year-old female presented to an emergency room alongside family with complaints of nausea and vomiting that started 30 min after a meal consisting of foraged wild onion (Allium triccocum). Five others ate the same meal and noted similar symptoms. Vitals upon arrival (3 h post ingestion) are as described: HR 51, BP 88/52, Temp 36.7, RR 18 and O2 sat 100% on room air. The patient had no previous cardiac history and was athletic. Management included D5LR with K replacement, and dopamine infusion at 10mcg/kg/min. Dopamine was tapered slowly, down to 6 mcg/kg/min at 16.5 h. Vitals continued to be stable at 17.5 h post ingestion and dopamine was discontinued. The patient developed severe bradydysrhythmia 15 min later, consisting of complete heart block leading to prolonged sinus pause. She responded to 10 s of CPR with return of spontaneous circulation with a junctional escape rhythm which reverted back to sinus bradycardia. A repeat EKG was unremarkable. The dopamine infusion was reinstituted at 4 mcg/kg/min and continued until 26.5 h post ingestion. She was monitored an additional 9.5 h, and remained in sinus rhythm with mild complaints of dizziness that resolved before discharge. Discussion(s): Veratrum spp. toxicity is due to alkaloids found throughout the plant which cause sodium channel opening when bound to type 2 sodium channels. By increasing sodium ion influx during the resting potential and delaying inactivation to create a late sodium current, these alkaloids increase automaticity in conductive cells. This mechanism, paired with the Bezold-Jarisch reflex, is likely responsible for increased vagal tone leading to bradycardia, hypotension, sinus arrhythmia, and junctional escape rhythm. It is noteworthy that even 18 h post ingestion in a relatively stable patient with no significant cardiac history, cardiac arrest occurred just after treatment tapering. Clinicians should consider prolonged observation time in the setting of discontinuation of vasopressors. Conclusion(s): Both clinicians and amateur foragers should be aware of the risks associated with ingestion of Veratrum viride, especially during early spring when it more closely resembles wild onion. While uncommon, significant delayed cardiac effects are possible. Mistaking the plant for edible wild onions can be the difference between a delectable dinner, and a night in the ICU.
ABSTRACT
A gap in knowledge exists regarding drug use among drivers and other road users (pedestrians, bicyclists) who are seriously or fatally injured in crashes in the United States. This study examines the prevalence of alcohol as well as selected over-the-counter, prescription, and illegal drugs in the blood of seriously or fatally injured drivers and other crash victims near the time of their crashes before and during the COVID-19 public health emergency. Data was collected at Level 1 trauma centers and medical examiner offices. The 3,003 participants represent a convenience sample of roadway users who were seriously or fatally injured during the study period. Trauma centers and medical examiners made available small volumes of blood for toxicological analyses from the total collected during their normal clinical procedures. The results indicate drug prevalence was high among seriously and fatally injured roadway users before the public health emergency began and was even higher during, especially for alcohol, cannabinoids (active THC), and opioids. Drivers in particular showed significantly higher overall drug prevalence during the public health emergency, with 64.7% testing positive for at least one active drug, compared to 50.8% before. Drivers also showed an increase in testing positive for two or more categories of drugs going from 17.6% before to 25.3% during the public health emergency. Of particular note, active THC was more prevalent among drivers during the public health emergency than alcohol (32.7% versus 28.3%), and opioid use among drivers almost doubled from 7.5% to 13.9%. Overall, the results of this study suggest the highway safety community should be concerned about the impact of other drugs as well as alcohol. In particular, the observed cannabis and opioid prevalence rates before and during the public health emergency could be indicative of a growing problem. These findings are prevalence rates only and cannot be used to determine whether the people were impaired at the time of their crash.