Background

Yews are widely present in Europe as ornamental trees and containing highly cardiotoxic alkaloids, toxicity being attributed to sodium and calcium channel blocking characteristics. This case report aims to increase awareness of the possible yew tree intoxication in the setting of therapy refractory cardiogenic shock as information regarding the yew tree as a potential suicidal agent is readily available. Furthermore, we would like to underline the importance of early extra corporal life support (ECLS) as a successful resuscitation measure in patients suffering from severe cardiogenic shock due to yew poisoning.

Case

Emergency services were alerted after a 22-years old ingested a decoction from the yew tree with suicidal intention. Upon arrival of the emergency team, the patient was somnolent (GCS 8) and cyanotic. Initial rhythm was pulseless electric activity (PEA) and resuscitation was started immediately, several times a ROSC was reached, although rapidly deteriorating into PEA, pulseless ventricular tachycardia or ventricular fibrillation. ACLS algorithm was followed without proper hemodynamic stabilization of the patient. After consulting the northern Germany poison information center the patient was transported to a tertiary care center with VA-ECMO team in standby. While transporting, hemodynamic stability further deteriorated, and the patient arrived endotracheally intubated and externally paced 73 minutes after the emergency services were alerted. After repeated consultation of the northern Germany poison information center the patient received an esophagogastroscopy, directly in the catheter laboratory after pacemaker placement. Subsequently the 22-year-old was transferred to ICU. In time rhythm stability deteriorated further, requiring several times overdrive pacing to terminate ventricular tachycardia. Ultimately decision was taken to implant a VA-ECMO to stabilize cardiac function. In the following the patient required further defibrillations. 11 hours and 33 minutes after hospital admission the patient converted into stable sinus rhythm. After a total of three days the VA-ECMO was explanted and the patient was discharged, without any acute brain modifications in CT and without any obvious neurologic sequelae, leaving the ICU on foot, being directly referred to a specialist clinic for psychiatry. 

Discussion

We report the successful treatment of a young male individual who intoxicated himself by ingesting a decoction of the yew tree in suicidal intention. Numerous treatment modalities have been considered, but almost all have supportive action rather than a direct antagonizing effect, and bridge time until elimination of the toxins or aim for a lower availability of the alkaloids. Conservative measures that have been implied are activated charcoal, hypertonic saline, Digi-FAB, anti-arrhythmic agents such as lidocaine and amiodarone, catecholamines and atropine. Aside from applied medications, endoscopic gastric lavage, external and transvenous pacing take a role in the treatment. Hemofiltration have been proven in-efficient. Newer treatment considerations include hyperinsulinemia-euglycemic therapy as well as intravenous lipid infusion. No known antidote exists and ultimately the implantation of VA-ECMO appears to be the last resort once a patient intoxicated with yew tree alkaloids becomes hemodynamically unstable and therapy-refractory to the mentioned treatments.