Pong Pong Tree

Hello everyone!

For those of you who don't know me, I am Karen, a the third year resident who will be staying on as one of the ultrasound fellows next year (along with the amazing Dan Ye, who can forget his great recaps of The Pitt), I'm also one of the four chiefs following our previous admin resident and chief Kaitlyn DeStefano (whose POTDs made us laugh and cry). I have big shoes to fill with these two tough acts to follow, but I will work hard to bring fun and educational POTDs!

Continuing on The Pitt bandwagon, I love watching shows, from romances and drama, to murder mysteries and thrillers, to Kdramas and anime; I am a huge consumer of media for better or for worse. Some of my favorites are Outlander, Downton Abbey, Dark, Black Mirror, Squid Game, Attack on Titan, When Life Gives You Tangerines, of course The Pitt and so many more...

Anyways, since yesterday was the finale of HBO's "White Lotus" I wanted to talk about the Pong pong tree. (Spoilers!)

The Pong Pong tree (Cerbera odollam)—also known as the “suicide tree” is native to India and Southeast Asia. This plant contains cerberin, a cardiac glycoside similar to digoxin that disrupts cardiac activity by inhibiting the Na⁺/K⁺- ATPase pump, which can lead to fatal arrhythmias. Cerberin poisoning is difficult to detect and has been used in homicides due to its tasteless nature and delayed onset. There is no specific antidote, though digoxin-specific Fab fragments (DIGIFab) has been used.

There has been only 2 known cases of C. odollam poisoning and 1 fatality reported in the USA:

A 22-year-old pre-operative transgender man-to-woman patient ingested seeds from the Cerbera odollam tree as a suicide attempt. She presented to the emergency department with nausea, vomiting, chest pain, and dizziness approximately 7 hours after ingesting the seeds that she bought online after reading about suicide. 

Initial electrocardiogram (ECG) showed second-degree heart block with 2:1 atrioventricular (AV) conduction and ST-segment depression with biphasic T-waves and initial serum potassium was 5.2mEq/L:

So the team administered atropine, digoxin-Fab fragments, and supportive care with improvement to sinus rhythm with first-degree AV block with persistent ST-segment depression and biphasic T-waves:

However, 2 hours later her condition deteriorated, progressing to high-degree AV block:

And subsequent cardiac arrest 30 minutes later with repeat K of 5.7mEq/L.

Despite additional doses of digoxin-specific antibody fragments (20 vials in total), lipid emulsion 20% (100 ml), right femoral CVC, and 2 hours of aggressive ACLS resuscitative efforts the patient was pronounced dead approximately 12 hours post-ingestion.

This case delineates the severe toxicity associated with C. odollam seed ingestion and highlights the challenges in managing such poisonings, even with advanced supportive measures. We should all be aware of the potential morbidity and mortality linked to this plant toxin and be prepared for aggressive resuscitative interventions.

Although the USA has only had 2 known cases of C. odollam poisoning, will a television show introducing this plant open the gates for more? Hopefully not, but as always, we will be prepared.

Misek R, Allen G, LeComte V, Mazur N. Fatality Following Intentional Ingestion of Cerbera odollam Seeds. Clin Pract Cases Emerg Med. 2018 Jun 12;2(3):223-226. doi: 10.5811/cpcem.2018.5.38345. PMID: 30083638; PMCID: PMC6075506. https://pmc.ncbi.nlm.nih.gov/articles/PMC6075506/

Karen Wong, MD

Emergency Medicine Chief Resident

KaWong@maimo.org

Pneumomediastinal Tamponade

Today's POTD came as a request from the Maimonides Attending Group Chat! This was a request after the Pitt, so taking a play out of Dr. Dan Ye's book to talk about case that is described in the latest episode. 

So without further adue lets look at some pneumomediastium specifically pneumomediastium causing tamponade.

Pneumomediastium: air present in the mediastinum, usually this occurs from air extravastaing from within the airways/lungs or esophagus and migrates into the mediastium. This air then dissects the cervical subcutanous tissues, epidural space, pericardium, and/or peritoneal cavity. 

Pneumomediastium is either typically spontaneous, rare, and typically self limited. Consider risk factors including smoking/tobacco use, recreational drug inhalation. Other causes include intrinsic lung and airway causes including asthma, COPD, bronchiectasis, COPD, ILDz, lung cancer, foreign body, increased intrathoracic pressure (forceful sneezing), increased intravagal tone (such as with childbirth, excessive vomiting, or strenous physical activities). Other iatrogenic cauases include: endoscopy, intubation, central line placement, thoracostomy, or chest/abdominal surgeries, and probably most commonly: traumatic causes: blunt trauma, penetrating trauma, or blast injuries. 

In the Pitt, **SPOILER ALERT**, the patient was shot in the chest and had a penetrating trauma.

Spontaneous pneumomediastum can also present with younger males of tall structure with low body mass. This spontaneous pneumomediastium occurs because of Macklin phenomenon: increased intra-aveolar pressure --> alveolar rupture --> air dissects into peribronchial and perivascular sheaths --> air progresses itno mediastium and surrounding tissues. 

Presentation: 

Most of the time this occurs with retrosternal chest apin that may radiate into the back or neck. 

On physical exam, these patients present with subcutaneous emphysema 

Other signs and symptoms include: rhinolalia (nasal tone of speech), dysphonia, neck swelling, hoarsness, tachycardia or tachypnea 

Diagnosis: 

Diagnosis is made usually on xray, and clinical diagnosis. 

On CXR you may see subcutaneous emphysema, elevated thymus (in peds patients), air around the pulmonary arteries, V shape between the descending aorta and left hemidiaphragm, double bronchial wall, or pleural effusion.

In pneumomediastium causing tamponade, these patients may have explained hypotension. Normally when we think about tamponade, we are able to be clused in with ultrasound findings, pneumomediastium on ultrasound may be seen as the "air gap" sign which would appear as sonographic echos, usually seen with M mode, that obsecure the cardiac structures underneath. If you have ever tried to place an ultrasound probe on a patient's chest with subq emphysema, you see nearly nothing, so this is definitiely more a clinical diagnosis to consider with unexplained hypotension in someone with subq emphysema. 

Tension pneumomediastinum/tamponade leads to compression of great vessels and compromises venous return --> hypotension and hypoxemia 

Management of tension pneumomediastinum that causes tamponade physiology: 

In the show, the patient got bilateral "blowholes": performed by a 2 cm incision infraclavicular through the skin and prepectoral fascia 

Other methods described include b/l chest tubes, placement of penrose drains into the neck 

Otherwise pneumomediastium is treated with supportive care and usually resolves on its own. 

Until next time friends!

Fleming AM, Zambetti BR, Valaulikar GS. Bedside Mediastinotomy for Tension Pneumomediastinum With Tamponade in COVID-19. Ann Thorac Surg. 2021 Oct;112(4):e265-e266. doi: 10.1016/j.athoracsur.2021.01.032. Epub 2021 Jan 30. PMID: 33529601; PMCID: PMC8402946

Iteen AJ, Bianchi W, Sharman T. Pneumomediastinum. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557440/

Sciortino CM, Mundinger GS, Kuwayama DP, Yang SC, Sussman MS. Case report: treatment of severe subcutaneous emphysema with a negative pressure wound therapy dressing. Eplasty. 2009;9:e1. Epub 2009 Jan 7. PMID: 19198645; PMCID: PMC2627309.

https://radiopaedia.org/articles/pneumomediastinum?lang=us

Anticoagulation Reversal

Today I want to talk about anticoagulation reversal. I happened to be on Northside when a patient on dabigatran had an unwitnessed fall with some minor head trauma and got me thinking about my reversal agents, and here's the POTD. 

First it’s worth mentioning when to reverse anticoagulation. The first step to looking at anticoagulation is to determine why the patient is on it and recognizing that reversing the patient is putting them at some sort of risk. Usually within our patient population, patients are on AC for afib,  hx of strokes, though other considerations include any sort of hypercoagulable state. Reversing AC should be considered in life threatening bleeding in the ED. 

Anticoagulation: Warfarin (brand name Coumadin)

• Can be evaluated by INR 

• Intracranial hemorrhage: immediately give PCC 

• Reversal: 

• 10 mg IV Vitamin K over 30 minute + PCC or FFP 

• Of note- PCC/FFP will only work for approximately 8 hours so please give with vitamin K 

• For supratherapeutic INR with no life threatening bleeding, slowly treat: 

• INR 3-5: 

• hold warfarin 

• INR 5-9: 

• hold warfarin 

• Vitamin K (1-2.5 mg PO or IV) if risk for bleeding 

• INR >9: 

• Hold warfarin 

• Vitamin K 2.5-5 mg PO/IV 

Anticoagulant: Dabigatran 

• Can be evaluated by PTT and thrombin time 

• Reversal: 

• Idarucizumab 5 g 

• Dabigatran can be dialyzed out 

Anticoagulation: Factor Xa inhibitors (-xaban most commonly apixaban)

• Can be evaluated through INR (normal INR goes against a significant drug level though does not exclude it entirely)

• Reversal: 

• 4 Factor PCC (KCentra) 

• Adnexanet Alfa may be considered if available though v expensive 

Thrombolytic: tPA 

• Order INR/PTT/fibrinogen though do not wait for results to reverse 

• Reversal: 

• Tranexamic acid: 

• 1 g IV loading dose followed by 1 g infused over the next hour

• Cryoprecipitate: start with 10 units 

• Options: FFPs 2 units and platelet transfusions 

Anticoagulation: 

• Heparin/LMWH: 

• Measure with PTT

• Reverse with protamine 

• Dosing for protamine is quite intricate and depends on bolus, infusions and timing of both. I would recommend coordinating with pharmacy directly. 

Antiplatelet: 

• Could consider TEG or platelet function assays 

• Reversal: 

• Desmopressin (DDAVP) 0.3-0.4 ug/kg infuse over 20-30 minutes 

Hopefully this helps as a quick reference, especially for those of us who will be sadly leaving Maimo and our beautiful anticoagulation orderset that makes reversing all of these things downstairs as painless as possible. 

https://emcrit.org/ibcc/reverse/

Aldhaeefi M, Badreldin HA, Alsuwayyid F, Alqahtani T, Alshaya O, Al Yami MS, Bin Saleh K, Al Harbi SA, Alshaya AI. Practical Guide for Anticoagulant and Antiplatelet Reversal in Clinical Practice. Pharmacy (Basel). 2023 Feb 11;11(1):34. doi: 10.3390/pharmacy11010034. PMID: 36827672; PMCID: PMC9963371.