ACMT Toxicology Visual Pearls: Suicide plant

Answer: 2 – Cardiac glycoside poisoning

The “Suicide Tree” (Cerbera odollam), also known as “pong pong,” is related to the Oleander and contains cardiac glycosides. It is native to India and Southern Asia, and the seeds have long been used for both suicide and homicide in the Eastern world.^1,2 Due to its availability via internet sales, deaths are now being reported in the Western world as well.³

Clinical presentation is similar to that of cardiac glycoside poisoning, with cardiac dysrhythmias, bradycardia, and hyperkalemia. In addition to supportive care, digoxin immune Fab fragments should be administered.

Bedside Pearls for Cardiac Glycoside Poisoning

Indications for Digoxin Immune Fab

• Known consumption of over 10 mg digoxin in an adult or 4mg or >0.1 mg/kg in children
• Life-threatening toxicity of digoxin overdose
  1. Ventricular arrhythmias
  2. Symptomatic bradycardia
  3. High degree heart block not responsive to atropine
  4. Hyperkalemia >5.5 mEq/L in adults or >6.0 mEq in children along with rapidly progressive signs of digoxin toxicity
• Steady-state serum concentration >10 ng/mL, or chronic ingestion causing steady state serum concentration >6 ng/mL in adults or >4 ng/mL in children
• Improvement should be noted in about 30 minutes after antidote administration.

Potential for simplified dosing⁴

• In imminent cardiac arrest, it may be justified to give a full neutralizing dose of digoxin-Fab (ie, empiric 5-10 vials).
• In acute poisoning, a bolus of 80 mg (2 vials), repeat if necessary, titrated against clinical effect, is likely to achieve equivalent benefits with much lower total doses.
• With chronic poisoning, it may be simplest to give 40 mg (1 vial) at a time and repeat after 60 min if there is no response.

Monitoring levels

• After acute ingestion, digoxin levels drawn prior to 6 hours will be falsely high.
• After antidote administration, digoxin levels will be very high (bound and unbound digoxin will be measured). If a true level is needed, you must order a free (unbound) digoxin level.

Chronic Digoxin Poisoning⁵

• Elevated digoxin concentrations alone may not be solely responsible for bradycardia and hyperkalemia in the chronic setting.
• Digoxin immune Fab is not a magic bullet in chronic digoxin poisoning.

Product Information [PDF]: DigiFab(R) intravenous injection lyophilized powder for solution, digoxin immune fab ovine intravenous injection lyophilized powder for solution. BTG International Inc. (per manufacturer), West Conshohocken, PA, 2014.