II. Epidemiology
III. Risk Factors
- Hypokalemia
- Hypomagnesemia
- Hypercalcemia
- Medication use interfering with Digoxin excretion
IV. Symptoms
- Anorexia
- Nausea
- Vomiting
- Somnolence
- Muscle Weakness
- Diarrhea
- Yellow vision (xanthopsia)
V. Signs
VI. Labs
- Serum Digoxin Level over 2.5 mg/ml
- Does not always correlate with toxicity
- Toxicity may occur at low levels and not at high ones
-
Electrocardiogram
- Dysrhythmia
- Bradycardia
- Premature beats
- Bigeminy
- Paroxysmal Atrial Tachycardia with 2:1 AV Block
- Atrial Fibrillation
- Nodal rhythm
- Ventricular Tachycardia
- T Wave inversion
- Sagging or "scooped out" ST Depression
- PR interval increased
- Dysrhythmia
VII. Management
- Stop Digoxin
- Correct Hypokalemia (and other electrolyte abnormalities)
- Use caution if Heart Block is present
- Treat associated arrhythmias appropriately
- Rehydrate to improve Renal Function
- Improved Renal Function will lower Digoxin levels
- Avoid potentially harmful interventions
- Calcium infusion (e.g. Calcium Chloride or Calcium Gluconate)
- "Stone heart" theoretical concern that intracellular calcium is already high in Digoxin Toxicity
- 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]
- Catecholamines
- Electrical Cardioversion or transcutaneous pacing
- Digoxin Toxicity results in a hyperexcitable Myocardium at risk for malignant arrhythmia (VF, VT)
- Safe if Digoxin Level is under 2 ng/ml
- Use lowest possible energy if needed (start at 10-20 J and increase in 10-20 J increments)
- Calcium infusion (e.g. Calcium Chloride or Calcium Gluconate)
- Facilitate Digitalis neutralization and elimination
- Measures for refractory cardiovascular collapse
VIII. Management: Anti-Digoxin antibodies
- DigiFab (or DigitalisAntibody Fragment Therarapy, preferred over Digibind)
- Mechanism
- Binds free Digoxin and complexes are renally excreted
- Indications
- Digoxin Toxicity (dysrhythmia, Serum Potassium >5.5, Altered Mental Status)
- Acute Digoxin ingestion >10 mg in adults and >4 mg (or 0.1 mg/kg) in children
- Chronic Digoxin Toxicity with significant dysrhythmia or Hyperkalemia
- Dosing
- One vial or 40 mg binds 0.5 mg Digoxin
- Acute toxicity: 5 vials (repeat as needed)
- Chronic toxicity: 3-6 vials for adults (1-2 for children)
- Adverse effects
- Postural Hypotension
- Hypokalemia
- Allergic Reactions (less common than with Digibind)
- Efficacy
- Only partial benefit in chronic toxicity (lowers level but does not correct Hyperkalemia or Bradycardia)
- Chan (2016) Clin Toxicol 54(6):488-94 +PMID: 27118413 [PubMed]
- References
- Watts and Lovecchio (2016) Crit Dec Emerg Med 30(12): 24
- Mechanism
- Digibind (40 mg/vial)
- Replaced by DigiFab (due to fewer Hypersensitivity Reaction)
- Indications
- Massive digoxin Overdose
- Refractory Digitalis Toxicity
- Calculate vials needed based on Digoxin level
- Vials = (Digoxin Level in ng/ml) x (WtKg)/100
IX. References
- Orman and Hayes in Herbert (2017) EM:Rap 17(4): 6-7
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Concepts | Injury or Poisoning (T037) |
English | digitalis toxicity, Digitalis toxicity, Digitalis Toxicity |
Spanish | Toxicidad digitálica |
Portuguese | Toxicidade digitálica |
Italian | Tossicità da digitale |
German | Toxizitaet von Digitalis |
French | Toxicité digitalique |
Dutch | digitalisvergiftiging |
Czech | Toxicita digitalisu |
Japanese | ジギタリス毒性, ジギタリスドクセイ |
Hungarian | Digitálisz toxicitás |
Ontology: Poisoning by digoxin (C0274727)
Concepts | Injury or Poisoning (T037) |
SnomedCT | 10385009 |
English | digoxin toxicity (diagnosis), digoxin toxicity, toxicity from digoxin, digoxin poisoning, toxicity digoxin, digoxin intoxication, digoxin toxicities, Poisoning by digoxin, Digoxin poisoning, Digoxin toxicity, Poisoning by digoxin (disorder) |
Spanish | Intoxicación por digoxina, intoxicación por digoxina (trastorno), intoxicación por digoxina, toxicidad por digoxina |
Portuguese | Toxicidade de digoxina |
Italian | Tossicità da digossina |
German | Toxizitaet von Digoxin |
French | Intoxication digitalique |
Dutch | digoxinevergiftiging |
Czech | Toxicita digoxinu |
Japanese | ジゴキシン毒性, ジゴキシンドクセイ |
Hungarian | Digoxin toxicitás |
Ontology: Digibind (C0687706)
Concepts | Amino Acid, Peptide, or Protein (T116) , Immunologic Factor (T129) |
MSH | C050199 |
English | Digibind, DigiBind, digibind |