Similar in structure and effect to digitalis, all parts of the plant contain the cardiac glycosides oleandrin, oleandroside, nerioside, and digitoxigenin. Cardiac glycosides act by inhibiting the Na, K-ATPase pump and lead to hyperkalemia and a variety of dysrhythmias. Of all plants containing cardiac glycosides (lily of the valley, foxglove, and oleander), oleander is the most toxic.
These glycosides cross-react sufficiently such that a positive serum digoxin level will qualitatively confirm an ingestion. Quantitative levels are not accurate, however, and should not be used to quantify the amount of ingestion or potential toxicity. Effects include nausea, vomiting, diarrhea, abdominal pain, confusion, and cardiac dysrhythmias.
Potassium levels should be closely monitored. Hyperkalemia may be severe and refractory to the usual treatments (insulin, dextrose, bicarbonate), and may require hemodialysis.6 Calcium is generally not recommended, as it may exacerbate the digitalis toxicity. In addition to GI decontamination and routine antidysrhythmic therapy, digoxin-specific Fab antibody fragments are recommended for patients with significant symptoms.7
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