suicide plantThe seeds of the Suicide Plant, when ingested, may result in significant toxicity, including the ECG findings shown. Which kind of toxicity does it cause?

  1. Anticholinergic poisoning
  2. Cardiac glycoside poisoning
  3. Cardiac sodium channel blockade
  4. Cholinergic poisoning
  5. Nicotinic poisoning

ECG Findings


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.


Eddleston M, Haggalla S. Fatal injury in eastern Sri Lanka, with special reference to cardenolide self-poisoning with Cerbera manghas fruits. Clin Toxicol (Phila). 2008;46(8):745-748. [PubMed]
Gaillard Y, Krishnamoorthy A, Bevalot F. Cerbera odollam: a “suicide tree” and cause of death in the state of Kerala, India. J Ethnopharmacol. 2004;95(2-3):123-126. [PubMed]
NACCT Abstracts 2016. Clin Toxicol (Phila). 2016;54(8):659-811. [PubMed]
Chan B, Buckley N. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014;52(8):824-836. [PubMed]
Chan B, Isbister G, O’Leary M, Chiew A, Buckley N. Efficacy and effectiveness of anti-digoxin antibodies in chronic digoxin poisonings from the DORA study (ATOM-1). Clin Toxicol (Phila). 2016;54(6):488-494. [PubMed]
Louise Kao, MD, FACMT

Louise Kao, MD, FACMT

Associate Professor of Clinical Emergency Medicine
Indiana University School of Medicine
Louise Kao, MD, FACMT

Latest posts by Louise Kao, MD, FACMT (see all)