Digoxin

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Case Presentation

Dr.Yassin

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History

• 2 years old healthy boy.

• Presented with Hx of ingestion of digoxin tablets . 15 min prior to ER visit.

• Amount is unknown.

• Digioxin 62.5 mic .


History

• No Hx of abnormal movement.

• No Hx of vomiting.

• No Hx of palpitation.


History

• Perinatal Hx:

• Past medical and surgical Hx:

• Allergy:

• Vaccination Hx:

• Family Hx:

• Social Hx:

• Developmental Hx:UNREM

ARKABLE


EXAM• Looks well.

• HR: 123

• RR: 24

• B/P: 109\47

• Temp: 36.5

• CVS: WNL

• RS: WNL

• CNS: WNL

• ABDOMIN: WNL


ER course

• Patient taken immediately to ER.

• Gastric lavage done revealed tablet particles.

• Charcol given.


impression

Digoxin ingestion


PLAN OF

CARE

investigation treatment education


investigation


investigation



investigation


investigation


Digoxin Toxication


digoxin• Antiarrhythmic agent, inotrope.• Cardiac Glycoside.

• T1/2: Premature infants, 61–170 hr.• full-term neonates, 35–45 hr.• infants, 18–25 hr.• children, 35 hr.

• Indication: heart failure, Supraventricular tachycardia .


Presentation of toxication

• CVS: asystole, atrial or nodal ectopic beats. • A-V block, AV dissociation, S-A block,

ventricular arrhythmias, • first-, second- (Wenckebach), or third-degree

heart block.• CNS: Seizure.lethargy, headache, visual

disturbance. • electrolyte imbalances Hyperkalemia • GIT: diarrhea, nausea, vomiting


Risk factor

• Impaired renal function.

• Hypokalemia.

• Hypomagnesemia.

• Hypercalcemia.

• low thyroxine.


Monitoring

• Digoxin levels are most useful if measured 4–6 hr after ingestion.

• Therapeutic serum digoxin concentration: <2ng/mL

• Toxic serum digoxin concentration: >4ng/mL


Monitoring

• 12-lead ECG and continuous cardiac monitoring.

• Monitor electrolytes (calcium, magnesium, potassium) hourly.


management

• Supportive Care/Decontamination:

• CAB

• Activated charcoal up to several hours postingestion.


Specific treatment• Antidote: Digoxin Specific Antibody

Fragments (Fab)

• Indications:

• severe toxicity (ventricular, progressive bradyarrhythmias, 2nd or 3rd degree heart block).

• serum potassium >5 mEq/L .

• serum digoxin concent >4-10 ng/mL ????


Specific treatment

• Serum digoxin concentration increases after Fab secondary to intravascular diffusion of antibody-bound, inactive digoxin.

• Adverse reactions: Allergic reaction, rebound hypokalemia, CHF (secondary to the sudden decrease in digoxin's inotropic effect).


Treatment cont• Electrolyte disturbances (hyperkalemia):• typically self-correct after Fab treatment.

• Bradyarrhythmias: Fab is first-line therapy; consider atropine, dopamine, epinephrine, or isoproterenol for second-line therapy.

• Asystole and pulseless electrical activity (PEA) Life-threatening tachyarrhythmias Treat according to Pediatric Advanced Life Support (PALS) protocol.


THANK YOU


Management calculating the dose

• First, determine total body digoxin load (TBL):• TBL (mg) = serum digoxin level (ng/mL) × 5.6 ×

wt (kg) ÷ 1000,• OR TBL (mg) = mg digoxin ingested × 0.8• Then, calculate digoxin immune Fab dose:• Dose in number of digoxin immune Fab vials

(Digibind or DigiFab): vials = TBL ÷ 0.5• Infuse IV over 15–30 min

Health & Medicine

Digoxin