DIGOXIN TOXICITY: SIGNS & MANAGEMENT

Common Signs and Symptoms:

ECG Signs:

Bigeminy:

Regularised AF:

Bidirectional VT:

Atrial flutter with AV block:

MANAGEMENT:

1. Stop Digoxin
2. Correct Hypokalemia
   1. Use caution if Heart Block is present
3. Treat arrhythmias :
1. Bradyarrhythmias
   • digibind
   • atropine
   • adrenaline (but may aggravate cardiac irritability)
   • pacing (rarely effective)
2. Tachyarrhythmias
   • digibind
   • MgSO4 as an adjunctive measure
   • Lignocaine (unproven)
   • often refractory to cardioversion


4. Avoid potentially harmful interventions
   1. Calcium infusion (e.g. Calcium Chloride or Calcium Gluconate)
      1. "Stone heart" theoretical concern that intracellular calcium is already high in Digoxin Toxicity
      2. However original theory was from the 1950s and recent studies fail to find significant effect (Levine (2011) J Emerg Med 40(1):41-6 +PMID:19201134 [PubMed])
   2. Catecholamines
   3. Electrical Cardioversion
      1. Safe if Digoxin Level is under 2 ng/ml
      2. Use lowest possible energy if needed (start at 10-20 J and increase in 10-20 J increments)
5. Digibind (40 mg/vial)
1. Indications
   1. Massive digoxin Overdose
   2. Refractory Digitalis Toxicity
2. Calculate vials needed based on Digoxin level
3. Vials = (Digoxin Level in ng/ml) x (WtKg)/100

Links: ifeinthefastlane.com

          fpnotebook.com

          medscape.org