a) HEMLOCK WATER DROPWORT: Tachycardia (eg, cicuta, oenanthe and conium species) may be noted (Downs et al, 2002; no authors listed, 1994; Knutsen & Paszkowski, 1984).

a) Hypertension may be noted rarely (Knutsen & Paszkowski, 1984).

a) HEMLOCK WATER DROPWORT: Orthostatic hypotension may occur, secondary to fluid loss (ie, emesis and/or diarrhea) (Downs et al, 2002; Applefeld & Caplan, 1979; Landers et al, 1985; Mutter, 1976).

a) SUMMARY: Abrupt cardiac arrest may develop, sometimes within minutes after ingestion (Heath, 2001).
b) CICUTA SPECIES: From 1985 to 1994 only 19 plant-related fatalities were reported in the AAPCC TESS database; 5 of these involved the ingestion of water hemlock (Cicuta) (Krenzelok et al, 1996).

a) CORIARIA MYRTIFOLIA: In one study, 7% of 83 (58 children and 25 adults) patients developed apnea after ingesting Coriaria myrtifolia berries or leaves (80 patients ingested berries; 3 patients ingested leaves) (de Haro et al, 2005).

a) CICUTA SPECIES: Patients with serious poisonings may develop bronchorrhea or excessive bronchial secretions. Symptoms can progress to include respiratory distress and cyanosis (no authors listed, 1994; Landers et al, 1985).

a) Seizures following the ingestion of these plants may occur within 5 minutes to 1 to 2 hours (Robson, 1965; Ball et al, 1987; Heath, 2001). Seizures are often recurrent and status epilepticus can develop (Carlton et al, 1979).
b) CHINESE STAR ANISE (ILLICIUM VERUM): A 3-month-old infant developed an episode of vomiting followed by "twitching" of her extremities and "rolling" eye movement approximately 3 to 4 hours after being given formula containing a tea brewed from star anise (the dried fruit is a spice used in teas) for colic. These symptoms were followed by lethargy. Upon admission the patient appeared gray and ashen with normal vital signs and pulse oximetry (100% on room air). Her skin color and activity level improved with stimulation and oxygen therapy. Laboratory studies, a toxicology screen and a head CT were normal. She was admitted for observation and discharged the following day alert with no sequelae; follow-up at one month was normal (Madden et al, 2012).
c) CORIARIA MYRTIFOLIA: CASE REPORT: An 8-year-old boy presented with a drunken-like state, vomiting, loss of consciousness, and generalized recurrent seizures after ingesting an unknown quantity of Coriaria myrtifolia berries. Following supportive therapy and treatment with benzodiazepines, he recovered and was discharged the next day (de Haro et al, 2005).
d) WATER HEMLOCK: A 16-year-old boy mistook water hemlock for wild carrots while spending a night camping in the woods. Within an hour of ingestion, nausea and vomiting developed. He also had diaphoresis and reported a feeling of confusion. A short time later the patient experienced a 1-minute tonic-clonic seizure that was witnessed by his friend. Three hours after exposure, the teen arrived at an Emergency Department after walking with his friend to get medical help. He recovered completely following supportive care and was discharged to home within 48 hours (French & Hendrickson, 2010).
e) CICUTA VIROSA: A 23-year-old man developed grand mal seizures after ingesting water hemlock and he subsequently died (no authors listed, 1994).
f) OENANTHE CROCATA: After mistakenly ingesting hemlock water dropwort instead of water parsnips, two young adults had generalized tonic-clonic seizures (Downs et al, 2002). In another case series, 2 of 4 adults having eaten a soup made with hemlock water dropwort suffered seizures (O'Mahony et al, 1987).
g) CORIARIA ARBOREA: Of 3 young adults, 2 developed seizures following the ingestion of the berries from the C arborea plant. The first patient was a 26-year-old man who had a tonic-clonic seizure 5.5 hours after ingestion. Onset was sudden and unexpected. The patient was treated with diazepam but a second seizure occurred approximately 4 hours later. He was monitored overnight with no further seizure activity. The second patient was a 21-year-old woman who had a self-resolving tonic-clonic seizure approximately 6.5 hours after exposure. She developed anxiety and slight tachycardia prior to the seizure. All 3 adults were monitored overnight, and had normal ECGs; the third patient remained well except for nausea. All 3 were discharged the following day with no further symptoms (Belcher & Morton, 2013).

a) CASE REPORT: An 11-year-old boy ingested an unknown amount of the root of Hemlock Water Dropwort mistaking the root for wild carrots and developed confusion, drowsiness, headache, as well as GI symptoms an hour after ingestion. Upon admission, clinical signs and symptoms included myosis and ophthalmoplegia along with laboratory evidence of moderate rhabdomyolysis (creatinine kinase 464 International Units/L). Following supportive care, symptoms resolved completely (Durand et al, 2008).

a) WATER HEMLOCK: A 16-year-old boy mistook water hemlock for wild carrots while spending a night camping in the woods. Within an hour of ingestion, nausea and vomiting developed. He also had diaphoresis and reported a feeling of confusion. A short time later the patient experienced a 1-minute tonic-clonic seizure that was witnessed by his friend. Three hours after exposure, the teen arrived at an Emergency Department after walking with his friend to get medical help. He recovered completely following supportive care and was discharged to home within 48 hours (French & Hendrickson, 2010).

a) Hallucinations and amnesia may occur. During the convalescent period, patients may complain of nightmares and anxiety.

a) Paresthesias were reported after ingestion of the root of Oenanthe crocata (Ball et al, 1987).

a) CORIARIA MYRTIFOLIA: In one study, 83 cases (58 children and 25 adults) of Coriaria myrtifolia poisoning (80 cases of berries ingestion; 3 cases of leaves) were identified. The interval between ingestion and onset of manifestations were obtained in 27 symptomatic cases; the mean delay was 150 minutes (range, 10 to 360 minutes). The following neurological symptoms were reported (de Haro et al, 2005):

a) SUMMARY: Salivation may occur with Cicuta, Oenanthe, and Conium poisoning.
b) CICUTA MACULATA (Water Hemlock): A severe intoxication can result in profuse salivation, perspiration, bronchial secretions and respiratory distress that may lead to cyanosis (no authors listed, 1994).

a) SUMMARY: Vomiting and abdominal pain may occur (de Haro et al, 2005; Ball et al, 1987; Carlton et al, 1979). Vomiting is an early symptom of exposure (no authors listed, 1994).
b) CICUTA MACULATA: Mild symptoms of Cicuta maculata exposure can include abdominal pain, nausea, and epigastric pain within 15 to 90 minutes (no authors listed, 1994).
c) CORIARIA MYRTIFOLIA: In one study, 63% of 83 (58 children and 25 adults) patients developed digestive signs (eg; abdominal pain, vomiting) after ingesting Coriaria myrtifolia berries or leaves (80 patients ingested berries; 3 patients ingested leaves) (de Haro et al, 2005).
d) WATER HEMLOCK: A 16-year-old boy mistook water hemlock for wild carrots while spending a night camping in the woods. Within an hour of ingestion, nausea and vomiting developed. He also had diaphoresis and reported a feeling of confusion. A short time later the patient experienced a 1-minute tonic-clonic seizure that was witnessed by his friend. Three hours after exposure, the teen arrived at an Emergency Department after walking with his friend to get medical help. He recovered completely following supportive care and was discharged to home within 48 hours (French & Hendrickson, 2010).
e) OENANTHE CROCATA: In 8 patients, nausea and vomiting developed after eating a curry made with the roots of hemlock water dropwort (Downs et al, 2002).
f) OEANTHE CROCATA: An 11-year-old boy ingested an unknown amount of the root of Hemlock Water Dropwort mistaking the root for wild carrots and developed confusion, drowsiness, headache, as well as abdominal pain, vomiting and diarrhea an hour after ingestion. Upon admission, clinical signs and symptoms included myosis and ophthalmoplegia along with laboratory evidence of moderate rhabdomyolysis. Following supportive care, all symptoms resolved completely (Durand et al, 2008).
g) CICUTA MACULATA: Six patients experienced nausea and vomiting after eating water hemlock mistaken as wild parsnips during a rafting trip (Landers et al, 1985).
h) CORIARIA ARBOREA: Two hours after ingestion of Coriaria arborea berries, 3 young adults developed nausea. Two reported moderate nausea and one had mild symptoms (Belcher & Morton, 2013).

a) SUMMARY: Diarrhea may occur following ingestion.
b) OEANTHE CROCATA: An 11-year-old boy ingested an unknown amount of the root of Hemlock Water Dropwort mistaking the root for wild carrots and he developed confusion, drowsiness, headache, as well as abdominal pain, vomiting and diarrhea an hour after ingestion. Upon admission, clinical signs and symptoms included myosis, ophthalmoplegia along with laboratory evidence of moderate rhabdomyolysis. Following supportive care, all symptoms resolved completely (Durand et al, 2008).

a) CICUTA MACULATA: Acute oliguric renal failure secondary to rhabdomyolysis was reported in a 26-year-old man who ingested a thumb-sized piece of a Cicuta root (Carlton et al, 1979).
b) WATER HEMLOCK: Elevated serum creatinine was reported in a 14-year-old who developed seizures and cardiac arrest after ingesting presumed water hemlock. The patient developed multi-organ system failure (ie. acute lung injury, hypotension, and DIC) and died 20 hours after ingestion (Heath, 2001).

a) CICUTA MACULATA (Water Hemlock): A severe intoxication can result in profuse salivation, perspiration, bronchial secretions and respiratory distress that may lead to cyanosis (no authors listed, 1994).

a) Muscular rigidity may be noted. Fasciculations and increased muscle tone may be seen with ingestion of Conium species due to its nicotinic effects.
b) CORIARIA MYRTIFOLIA: In one study, 12% of 83 (58 children and 25 adults) patients developed hypertonia and muscle cramping after ingesting Coriaria myrtifolia berries or leaves (80 patients ingested berries; 3 patients ingested leaves) (de Haro et al, 2005).

a) Rhabdomyolysis has been reported (Carlton et al, 1979).
b) OEANTHE CROCATA: An 11-year-old boy ingested an unknown amount of the root of Hemlock Water Dropwort mistaking the root for wild carrots and developed confusion, drowsiness, headache, as well as abdominal pain, vomiting and diarrhea an hour after ingestion. Upon admission, clinical signs and symptoms included myosis and ophthalmoplegia along with laboratory evidence of moderate rhabdomyolysis (creatinine kinase 464 International Units/L). Following supportive care, all symptoms resolved completely (Durand et al, 2008)

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) 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 symptomatic and supportive; patients may only require observation. Monitor vital signs and mental status. Tachycardia may be observed. Monitor fluid status and electrolytes in patients that develop significant vomiting. Intravenous fluids may be indicated, if the patient develops significant nausea and vomiting. Reassure the patient.

a) Seizures following the ingestion of these plants may occur within 5 minutes to 1 to 2 hours. Seizures are often recurrent and status epilepticus can develop. Treat seizures with IV benzodiazepines; barbiturates or propofol may be needed if seizures persist or recur. Benzodiazepines (first-line therapy) are indicated to treat seizure activity or control agitation. Provide a supportive environment. Orotracheal intubation is indicated for airway protection in cases of severe agitation, coma or seizure activity.

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

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, 2010; 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):