II. Epidemiology

  1. Digoxin Toxicity was common with standard dose Digoxin (Incidence 7-20%)
    1. Lower doses used since in the U.S. has resulted in decreased toxicity

III. Risk Factors

IV. Symptoms

  1. Anorexia
  2. Nausea
  3. Vomiting
  4. Somnolence
  5. Muscle Weakness
  6. Diarrhea
  7. Yellow vision (xanthopsia)

VI. Labs

  1. Serum Digoxin Level over 2.5 mg/ml
    1. Does not always correlate with toxicity
    2. Toxicity may occur at low levels and not at high ones
  2. Electrocardiogram
    1. Dysrhythmia
      1. Bradycardia
      2. Premature beats
      3. Bigeminy
      4. Paroxysmal Atrial Tachycardia with 2:1 AV Block
      5. Atrial Fibrillation
      6. Nodal rhythm
      7. Ventricular Tachycardia
    2. T Wave inversion
    3. Sagging or "scooped out" ST Depression
    4. PR interval increased

VII. Management

  1. Stop Digoxin
  2. Correct Hypokalemia
    1. Use caution if Heart Block is present
  3. Treat associated arrhythmias appropriately
  4. Rehydrate to improve Renal Function
    1. Improved Renal Function will lower Digoxin levels
  5. 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
      3. 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)

VIII. Management: Anti-Digoxin antibodies

  1. DigiFab (preferred over Digibind)
    1. Mechanism
      1. Binds free Digoxin and complexes are renally excreted
    2. Indications
      1. Digoxin Toxicity (dysrhythmia, Serum Potassium >5.5, Altered Mental Status)
      2. Acute Digoxin ingestion >10 mg in adults and >4 mg (or 0.1 mg/kg) in children
      3. Chronic Digoxin Toxicity with significant dysrhythmia or Hyperkalemia
    3. Dosing
      1. One vial or 40 mg binds 0.5 mg Digoxin
      2. Acute toxicity: 5 vials (repeat as needed)
      3. Chronic toxicity: 3-6 vials for adults (1-2 for children)
    4. Adverse effects
      1. Postural Hypotension
      2. Hypokalemia
      3. Allergic Reactions (less common than with Digibind)
    5. Efficacy
      1. Only partial benefit in chronic toxicity (lowers level but does not correct Hyperkalemia or Bradycardia)
      2. Chan (2016) Clin Toxicol 54(6):488-94 +PMID: 27118413 [PubMed]
    6. References
      1. Watts and Lovecchio (2016) Crit Dec Emerg Med 30(12): 24
  2. Digibind (40 mg/vial)
    1. Replaced by DigiFab (due to fewer Hypersensitivity Reaction)
    2. Indications
      1. Massive digoxin Overdose
      2. Refractory Digitalis Toxicity
    3. Calculate vials needed based on Digoxin level
    4. Vials = (Digoxin Level in ng/ml) x (WtKg)/100

IX. References

  1. Orman and Hayes in Herbert (2017) EM:Rap 17(4): 6-7

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