Plant poisons: oleander and datura

Seeds/leaves (Thevetia peruviana, Nerium oleander) ingestion; vomiting, sinus bradycardia, AV block, ventricular ectopy/tachycardia, hyperkalaemia. Serum digoxin assay may cross-react (qualitative only).

Continuous ECG; activated charcoal; atropine for bradycardia; temporary transvenous pacing for high-grade block; treat hyperkalaemia with insulin-glucose (avoid calcium); correct Mg2+ and K+.

Digoxin Fab 1200 mg reversed arrhythmias within hours in the Sri Lankan RCT; cost limits use.

'Dry as a bone, red as a beet, hot as a hare, blind as a bat, mad as a hatter': mydriasis, tachycardia, hyperthermia, urinary retention, ileus, delirium; often in food or drink (robbery/spiking) or seeds mistaken for chilli.

Benzodiazepines for agitation, external cooling, catheterise, fluids; avoid antipsychotics with anticholinergic action; physostigmine (rarely available) for severe delirium if no QRS widening.