Common poisonous and injurious plants number in the hundreds and have a wide variety of toxicities. This chapter focuses on the most important plant-related exposures clinically relevant to emergency medicine (Tables 220-1 and 220-2).^1,2 Individual plants are discussed in terms of their pathophysiology, clinical features (toxidromes), and treatment.³ Highly poisonous plants (Table 220-1) are highlighted in depth below, and brief reviews are provided for other common poisonous plants. Table 220-2 organizes common poisonous plants according to toxin structure.

In 2012, the American Association of Poison Control Centers received 49,374 reports of plant exposures. Of these cases, 31,920 involved children less than 5 years of age. There were an additional 2918 nonexposure calls that provided information about plants to callers.² The vast majority of exposures (96%) are unintentional ingestions. Cutaneous and ophthalmic exposures are common but generally go unreported. Although inhalational exposures are possible, they are rarely reported.

Unfortunately, obtaining an accurate plant exposure history can be difficult. Most exposures occur in children and are usually unwitnessed. Uncertainty typically surrounds these cases, particularly whether ingestion truly occurred. The timing and amount of exposure is also difficult to quantify in many of these situations. Furthermore, even when a plant is available, identification errors are common and may require a botanist’s expertise. In fact, data from the National Poison Data System demonstrate that medical providers and poison centers are unable to identify plants more than 22% of the time.²

Classification of plants and their toxicities is complex. The most straightforward approach for emergency physicians is to classify toxic plants by the mechanism of action of the toxin and then to further subclassify based on the specific toxin. This will help predict the toxicologic effects. The reverse process can be used if the patient presents with clinical findings (Table 220-2). Unfortunately, attributing one toxicologic syndrome per plant oversimplifies the complexity of plant chemistry, because plants often contain multiple toxic compounds, each of which produces its own toxicologic effects.

Moderate systemic effects as a consequence of plant-related exposures occur in about 1% of patients. Severe life-threatening effects or disabling injuries are extremely uncommon and occur in only about 0.04% of patients. Death occurs in <0.001% of patients.

Dermatitis and GI irritation are the most commonly reported effects of plant toxicity. GI complaints occur commonly following ingestion, and additional toxic symptoms may accompany or follow. Although dermatitis is another commonly reported finding of plant toxicity, systemic toxicity rarely follows (see Table 220-3).

Most plant-related exposures can be managed with supportive care. In patients able to tolerate oral administration and believed to have potentially concerning exposures, administer activated charcoal to prevent absorption of toxin from the GI tract. Because of the uncertainty surrounding plant exposures, observe asymptomatic or minimally symptomatic patients for 4 to 6 hours in the ED. Discharge asymptomatic patients and those with resolved minor toxicity after observation, with strict return precautions if symptoms develop. Admit those with more than minimal findings because toxicity may continue to evolve. This approach is generally applied to all patients with plant exposure because the scientific literature lacks adequate data to provide less conservative recommendations. There are few antidotes available to treat poisonings by plant toxins; none are unique to plant exposures but rather are generalized from use in other poisonings.

Report all exposures to the regional poison control center to obtain assistance with plant identification, to obtain assistance with patient management, and to enable collection of accurate data on toxic plant exposures. Unfortunately, data reported by the National Poison Data System does not require confirmation of exposure, and the incidence of adverse effects is diluted by inconsequential or unconfirmed ingestions.

In Phaedo, Plato details the death of Socrates: after drinking a potion consisting of the extracts of poison hemlock (Conium maculatum

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