“Deck the halls with boughs of holly, Fa-la-la-la-la” rings through the station house as everyone is preparing for the department’s holiday party. You and your partner are decorating (and eating Christmas cookies) in between calls. Just as you prepare to hang a glitter-covered endotracheal tube on the tree, dispatch sounds the tones indicating a call. “Ambulance 1, respond to a possible poisoning. Your patient is a 14-month male. Time out, 1717.” The station singing quiets as you and your partner head for the call.
Arrival on Scene
Arriving on the scene, you’re met by a panicked mother and anxious father. While Grandma was watching the baby, he got into the Christmas decorations. Live holly and mistletoe are on the floor waiting to be hung. The family thinks the baby may have eaten some of the berries, and they are concerned because they believe holly and mistletoe berries are lethal when ingested by children. They called 9-1-1 immediately when the possible ingestion was identified.
The little boy is alert and has been crying. He seems content in his mother’s arms and is acting appropriate for his age. He’s alert and tracking you and your partner as you approach. He’s curious about the stethoscope hanging around your neck. On initial inspection, there is no sign of berries in or around his mouth. Berries are on the floor, but it’s impossible to know if any are missing. You and your partner both recall that holly and mistletoe berries are considered poisonous.
The family agrees with your recommendation to transport the child to the emergency department (ED) for evaluation. Your care during transport is mostly supportive watching for symptoms to present. The child is transported and transferred to the ED without change in his condition. The parents thank you as you ready your ambulance for the next call.
You and your partner are correct; holly and mistletoe berries are poisonous. Luckily, however, they are rarely lethal. Holly berries are red and attractive to children. Holly belongs to a family of plants known as Ilex. The chemical in the holly berry thought to cause symptoms is Theobromine, which is a methylxanthine and is similar in structure to caffeine. When ingested, the berry of the holly plant causes nausea, vomiting and diarrhea. In children, this can result in dehydration. When large quantities are ingested, central nervous system depression can be seen. Much of the literature states that ingestion of 20 or more berries by a child can be lethal, but actual cases to substantiate this are difficult to find. In addition to the effects of the berries, the leaves of the holly plant have sharp points and can cause oral trauma if ingested.
Dangers of Mistletoe
Mistletoe is a parasite that grows off trees. There are two primary varieties; Viscum album and Phoradendron leucarpum. Mistletoe has a long history of being used to treat convulsions, delirium, hysteria, heart conditions and cancer. The toxic effects of the plant are in part determined by the host tree where the plant grows, but all contain a substance known as phoratoxin. If ingested, small quantities of mistletoe berries will result in nausea and vomiting. Larger amounts can cause central nervous system depression and seizures. Large amounts of mistletoe berries can also have cardiac effects, resulting in bradycardia and hypotension.
Any patient, adult or child, who has ingested berries from holly or mistletoe should—at minimum—be referred to poison control at 1-800/222-1222. If there is any possibility that large quantities were ingested or, as in this case, a child has ingested it, transport to an ED is recommended. Prehospital treatment is supportive, treating symptoms as they present. Vascular access is appropriate and fluid boluses can be administered to maintain blood pressure. Cardiac effects can be treated following current AHA guidelines and benzodiazepines can be administered to stop seizure activity.
Holidays can be a wonderful time of year, but opportunities for disastrous situations can also present themselves. People adorn their homes with plants that can have toxic effects if ingested by their children or pets. Brittle trees and hot lights combine to ignite, destroying property. As people decorate the exteriors of their homes, they fall from ladders while they attempt to hang the highest star. Overeating and binge drinking become more commonplace; and as families gather, the stressors of the season can increase the incidences of family violence. And sadly, those who are depressed during the holidays often commit suicide.
During all of these events, EMS will be called to intervene and will be expected to make things better. Whether you are spending the holidays at home with your family or at the station with your other family, be safe, take care of each other and have a fantastic holiday season.
1. Mosby’s Handbook of Herbs and Natural Supplements, 3rd edition. Linda Skidmore-Roth, Elsevier-Mosby: 721