Method of Participation: To earn AMA PRA Category 1 Credit™
- Complete the post-test and evaluation (Note: A score of at least 80% must be achieved to earn CME credit)
- Participate in the discussion/debate thread about specific articles
- Process your online payment of $10 (fees are non-refundable).
- A certificate of attendance will be forwarded within 4 to 6 weeks of participation
Release Date: December 10, 2012
Expiration Date: December 10, 2013Estimated Time of Completion: 1 hour
Fee: This CME activity costs $10, payable by credit card at the completion of the activity. Fees are non-refundable.
The Center for Emergency Medical Education (CEME) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The Center for Emergency Medical Education (CEME) designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity is designed for emergency medicine physicians and other health care providers interested in the treatment of patients with cardiopulmonary arrest.
The Center for Emergency Medical Education (CEME) offers a one-credit content-specific posttest and evaluation based on an article in the Emergency Physicians Monthly magazine as each issue is published.
Disclosure of Faculty Financial Interests or Relationships:
It is the policy of Center for Emergency Medical Education (CEME) to insure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities, and that all contributors present information in an objective, unbiased manner without endorsement or criticism of specific products or services and that the relationships that contributors disclose will not influence their contributions. In accordance with the Standards for Commercial Support issued by the Accreditation Council for Continuing Medical Education (ACCME), the Center for Emergency Medical Education (CEME) requires resolution of all faculty conflicts of interest to ensure CME activities are free of commercial bias. Those involved in the planning and teaching of this activity are required to disclose to the audience any relevant financial interest or other relationship.
All faculty, planners, and staff in a position to control the content of this CME activity have indicated that he/she has no relationship, which, in the context of the article, could be perceived as a potential conflict of interest:
Kevin M. Klauer, DO, FACEP, Director, CEME
Logan Plaster, Editor/Creative Director, Emergency Physicians Monthly
Ginger Brake, CEME Program Coordinator
Participants must have access to the Internet:
CEME Program Coordinator
Emergency Medicine Physicians
4535 Dressler Road NW
Canton, Ohio 44718
(330) 493-4443 Ext: 1445
The Center for Emergency Medical Education (CEME) is committed to protecting your privacy while using the CEME website. You can, in general, visit our website without identifying yourself or disclosing any personal information. Any personal information you choose to provide will not be shared with third parties without permission.
When you submit online registration, the information you provide is confidential. At no point do we now, or will we ever sell, rent or lease information we collect to any outside individual or organization.
The CEME website contains links to other sites. CEME is not responsible for the privacy practices or the content of such websites.
The materials on this site are protected by copyright laws and may not be reproduced, modified, displayed, transmitted, or otherwise published without the prior written consent of The Center for Emergency Medical Education (CEME). You may access the materials on this website only for your personal, noncommercial use.
The materials on this site are provided for general medical education purposes only and are not meant to be applied rigidly and followed in all cases. Use of this information in a particular situation remains the professional responsibility of the practitioner. In no event will CEME be liable for any decision made or action taken in reliance upon the information provided.
Copyright © 2010 Center for Emergency Medical Education. All Rights Reserved
STEP 2: READ THE ARTICLE
STEP 3: TAKE THE QUIZ
STEP 4: PROCESS PAYMENT
After evaluating this article, participants will be able to:
1. Incorporate strategies into practice for the detection of toxicity associated with mistletoe ingestion
2. Develop an evidence-based approach to the management of mistletoe ingestions
A 2-year-old child is brought to the ED on a cold December evening by frantic parents one hour after swallowing several mistletoe berries at home. The parents had placed the mistletoe plant over the door entryway secured by a piece of scotch tape. During a large family holiday gathering, the mistletoe fell to the floor causing the curious toddler to ingest several of the scattered berries. When discovered by the mother, she gave her daughter a “bottle full” of outdated syrup of ipecac. En route to the ED, the child vomits twice in the family car.
In its natural setting, mistletoe is a semi-parasitic plant that uses its roots to penetrate a branch or trunk of a tree and absorb nutrients from its host. It is also capable of surviving on its own by producing food through photosynthesis. There are over 1000 species of mistletoe, but the species most commonly used for Christmas decoration is the American mistletoe (Phoradendron). It has greenish-yellow leathery leaves and white berries that first appear in the fall. American mistletoe grows on a wide variety of trees and ranges from Florida to New Jersey and as far west as Texas and California. American mistletoe berries are not intended for human consumption, but provide an essential food source for many birds, butterflies, insects, and mammals.
There is a rich heritage of folklore related to mistletoe. Both Norse and Greek mythology documented the plant’s mystical powers. The Celts worshiped mistletoe, especially when it was found on an oak tree. Our custom of decorating homes with mistletoe at Christmas is based on the Druid tradition of ushering in the winter solstice. During the Middle Ages, branches of mistletoe were hung from rafters to ward off evil spirits, and sprigs were placed above doorways to prevent witches from entering. Mistletoe was also believed to bestow fertility, and kissing under the mistletoe was associated with courtship and marriage. According to tradition, one berry should be removed from the sprig of mistletoe after each kiss. When all the berries are gone, the kissing would cease. Mistletoe has long been regarded as an aphrodisiac and fertility herb, which explains its association with uninhibited sexuality.
While kissing under the mistletoe is a longstanding holiday tradition, eating the plant is not recommended because mistletoe has a historic reputation of being poisonous. Eating any part of the plant, particularly the leaves or berries, or drinking a tea made from the plant, can result in clinical side effects. However, more modern studies have documented minimal toxicity.
The American Phoradendron species contains the toxin phoratoxin, which can cause blurred vision, nausea, abdominal pain, and diarrhea. The European Viscum species of mistletoe contains the alkaloid tyramine, which produces more pronounced symptoms than the American version including potential cardiotoxicity and hypotension following large exposures. Viscum album has some therapeutic uses including breast cancer treatment with Iscador, a drug made from mistletoe extract.
According to national poison control data, 1-2 berries or leaves eaten by a child will not result in serious toxicity. In studies with cases documenting accidental ingestion, there were no fatalities and very few symptomatic cases. One study published in 1996 reviewed 92 cases of mistletoe ingestion and found that only a small fraction of patients showed any signs or symptoms of toxicity. Eight of 10 people who consumed 5 or more berries had no symptoms, and 3 of the 11 people who consumed only leaves had self-limited GI symptoms. Another retrospective study reviewed over 1,700 exposures and found that accidental ingestion of American mistletoe was not associated with profound toxicity. One source recommends greater than 20 berries or 5 leaves should be referred for medical evaluation.
The child is evaluated in the ED with the following presenting vital signs: HR 120/min; BP 80/40mmHg; RR=28 breaths/min; T= 98 F; Pulse ox: 98% (RA)
The child has two more episodes of non-bloody emesis in the ED. Diagnostic studies return with the following values: WBC 13K; Hgb 14 gm/dL; Na 145 mEq/L; K 3.3 mEq/L Cl 108 mEq/L; Bicarb 21 mEq/L. The child is given a 20cc/kg intravenous fluid bolus and ondansetron for protracted emesis. After six hours of ED observation, she recovers uneventfully. The parents are counseled regarding poison prevention in the home and instructed that syrup of ipecac is no longer recommended as a gastric decontamination agent in the home or hospital setting.
Timothy Erickson, MD, FACEP, FACMT is a Professor of Emergency Medicine and Medical Toxicology at the University of Illinois at Chicago. He is also Director of the UIC Center for Global Health.
- Hall AH, Spoerke DG, Rumack BH: Assessing mistletoe toxicity. Ann Emerg Med.1986 Nov;15(11):1320-3.
- Krenzelok EP, Jacobsen TD, Aronis, J: American mistletoe exposures. Amer J Emerg Med, 1997, Volume 15, Issue 5, Pages 516-520.
- Spiller HA, Willias DB, Gorman SE, et al: Retrospective Study of Mistletoe Ingestion.1996, Vol. 34, No. 4 , Pages 405-408.
STEP 3: TAKE THE QUIZ
STEP 4: PROCESS PAYMENT