a) Early effects of cystine toxicity is a rise in blood pressure and heart rate, which can be followed by hypotension (Mitchell, 1951).

a) Bradycardia may occur late in an exposure (Mitchell, 1951).

a) SPANISH BROOM (SPARTIUM JUNCEUM L,): A 72-year-old woman developed tachycardia after ingesting Spanish Broom flowers (Riccardi et al, 2006).

a) Cytisine may act as a respiratory stimulant. The stimulant effects may sometimes be missing depending on the animal intoxicated and the dose (Dale & Laidlaw, 1912).
b) Cheyne-Stokes respiration may develop (Lampe & Fagerstrom, 1968).

a) A dog developed severe dyspnea associated with exercise after chewing and crushing the mescal bean pods from a mountain laurel plant {Sophora secundiflora} (Knauer et al, 1995).

a) Large doses may produce paralysis but cytisine is less active in this regard than nicotine (Lampe & Fagerstrom, 1968).
b) Spinal reflexes are depressed even in mild intoxications (Lampe & Fagerstrom, 1968).
c) BAPTISIA AUSTRALIS: Two adult family members picked what they thought was asparagus from a municipal rain garden. Abdominal pain, nausea, severe vomiting and diarrhea developed in both individuals within 15 to 30 minutes of ingesting 3 to 5 6-inch stalks. Other symptoms included inability to walk and vertigo. Physical examination showed severe truncal ataxia and inability to stand unassisted in both patients. Laboratory studies showed hypokalemia (K 3.1 mEq/L) and hyperglycemia (225 mg/dL). The patients were admitted and provided supportive care. By the next morning, all symptoms had resolved and both women were discharged without complications. The plant material was confirmed by the Horticultural Department of the University of Wisconsin (Anderson et al, 2015).

a) Large doses may produce coma (Lampe & Fagerstrom, 1968).

a) Intoxication may produce headache (Lampe & Fagerstrom, 1968; Furet, 1986).

a) Delirium and hallucinations have also been reported, but these are not well substantiated (Lampe & Fagerstrom, 1968; Hatfield, 1977).

a) SPANISH BROOM (SPARTIUM JUNCEUM L,): Two women (72-year-old and 62-year-old) developed fatigue after ingesting Spanish Broom flowers (Riccardi et al, 2006).

a) SPANISH BROOM (SPARTIUM JUNCEUM L,): Two women (72-year-old and 62-year-old) developed mental confusion and agitation after ingesting Spanish Broom flowers (Riccardi et al, 2006).

a) SPANISH BROOM (SPARTIUM JUNCEUM L,): Two women (72-year-old and 62-year-old) developed tremor after ingesting Spanish Broom flowers (Riccardi et al, 2006).

a) SPANISH BROOM (SPARTIUM JUNCEUM L,): A 72-year-old woman developed vertigo after ingesting Spanish Broom flowers (Riccardi et al, 2006).

a) Other symptoms reported have included brief periods (1 to 2 hours) of sleepiness, dizziness and decreased coordination in a child (Bruneton, 1999).

a) Ataxia, collapse and possible loss of consciousness occurred in a pet dog after exercise which was usually tolerated. The effects were believed to be due to chewing mountain laurel (Sophora secundiflora) mescal bean pods (Knauer et al, 1995).

a) Vomiting is the most common effect reported following ingestion (United State Dispensatory, 1955) (Lampe & Fagerstrom, 1968; Bruneton, 1999).
b) It has been suggested that the early onset of vomiting may limit the amount of cytisine absorbed. Vomiting may be profuse and last several hours after ingestion. Ingestion of the seed may result in a delay of symptoms, unlike exposure to the flower (Bruneton, 1999).
c) SPANISH BROOM (SPARTIUM JUNCEUM L,): Two women (72-year-old and 62-year-old) developed vomiting after ingesting Spanish Broom flowers (Riccardi et al, 2006).
d) BAPTISIA AUSTRALIS: Two adult family members picked what they thought was asparagus from a municipal rain garden. Abdominal pain, nausea, severe vomiting, and diarrhea developed in both individuals within 15 to 30 minutes of ingesting 3 to 5 6-inch stalks. Other symptoms included inability to walk and vertigo. Physical examination showed severe truncal ataxia and inability to stand unassisted in both patients. Laboratory studies showed hypokalemia (K 3.1 mEq/L) and hyperglycemia (225 mg/dL). The patients were admitted and provided supportive care. By the next morning, all symptoms had resolved and both women were discharged without complications. The plant material was confirmed by the Horticultural Department of the University of Wisconsin (Anderson et al, 2015).

a) Abdominal pain may also occur (Bruneton, 1999).
b) SPANISH BROOM (SPARTIUM JUNCEUM L,): Two women (72-year-old and 62-year-old) and one man (67-year-old) developed abdominal pain after ingesting Spanish Broom flowers (Riccardi et al, 2006).
c) BAPTISIA AUSTRALIS: Two adult family members picked what they thought was asparagus from a municipal rain garden. Abdominal pain, nausea, severe vomiting, diarrhea and dizziness developed in both individuals within 15 to 30 minutes of ingesting 3 to 5 6-inch stalks (Anderson et al, 2015).

a) Diarrhea is rare and may be due to other plant constituents (Lampe & Fagerstrom, 1968).
b) BAPTISIA AUSTRALIS: Diarrhea was reported in 2 adults within 30 minutes of ingesting baptisia australis that was mistaken for asparagus (Anderson et al, 2015).

a) Salivation may occur (Lampe & Fagerstrom, 1968).

a) Diuresis uncommonly occurs (Dale & Laidlaw, 1912).

a) Pallor has been reported (Lampe & Fagerstrom, 1968).

a) Numbness of the hands, muscle weakness, and incoordination have also been reported (Dale & Laidlaw, 1912).

a) Joint stiffness, weakness, and collapse in a pet dog following exercise, which was usually tolerated, was believed to be due to chewing mescal bean pods from mountain laurel plant (Sophora secundiflora) (Knauer et al, 1995).

a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.

a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
b) ADVERSE EFFECTS/CONTRAINDICATIONS

a) Treatment is primarily symptomatic and supportive. Due to its similar action to nicotine, vomiting is common following exposure. However, the early onset of vomiting may limit the amount of cytisine absorbed. Vomiting may be profuse and last several hours after ingestion. Ingestion of the seed may result in a delay of symptoms, unlike exposure to the flower. Monitor fluid and electrolyte status in patients that develop significant vomiting. Correct fluid status and replace electrolytes as indicated. Monitor vital signs and neurologic function following an exposure. Assess for hypotension and/or bradycardia. Obtain a baseline ECG as necessary. Persistent vital sign abnormalities, altered mental status, muscle weakness, and possible seizure activity indicate a more severe poisoning.

a) Treat initial hypotension with IV fluids followed by dopamine or norepinephrine as needed. Patients may need airway support and mechanical ventilation for altered mental status, respiratory distress, secretions or respiratory paralysis. Atropine can be given for bradycardia or significant muscarinic signs (ie, bronchorrhea), if present. Benzodiazepines should be used to treat seizures or severe agitation.

a) Seizure activity can indicate a more severe poisoning.

a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).

a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .

a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).

a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2009; Chin et al, 2008).

a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).

a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):

a) Infuse 10 to 20 milliliters/kilogram of isotonic fluid and keep the patient supine. If hypotension persists, administer dopamine or norepinephrine. Consider central venous pressure monitoring to guide further fluid therapy.

a) DOSE: Begin at 5 micrograms per kilogram per minute progressing in 5 micrograms per kilogram per minute increments as needed (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). If hypotension persists, dopamine may need to be discontinued and a more potent vasoconstrictor (eg, norepinephrine) should be considered (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
b) CAUTION: If ventricular dysrhythmias occur, decrease rate of administration (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). Extravasation may cause local tissue necrosis, administration through a central venous catheter is preferred (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).

a) PREPARATION: 4 milligrams (1 amp) added to 1000 milliliters of diluent provides a concentration of 4 micrograms/milliliter of norepinephrine base. Norepinephrine bitartrate should be mixed in dextrose solutions (dextrose 5% in water, dextrose 5% in saline) since dextrose-containing solutions protect against excessive oxidation and subsequent potency loss. Administration in saline alone is not recommended (Prod Info norepinephrine bitartrate injection, 2005).
b) DOSE

1) Thirty-four were asymptomatic, 12 had nausea and vomiting, 7 had abdominal pain, 3 had sore mouths, 2 delirium, 2 drowsiness, and 1 diarrhea.
2) Twelve of the children received no treatment, 2 fluids only, 34 ipecac, 4 lavage, and 3 cathartics.