Download Digoxin

Michelle Troendle
Case conference
August 6, 2014
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Casino Royale
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Digitalis purpurea (foxglove)
Nereum oleander (oleander)
Thevetia peruviana (yellow oleander)
Convallaria majalis (lily of the valley)
Urginea maritima (red squill)
Bufo alvarius (Colorodo River toad)
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Purple, pink, white, yellow
Grows to about 3 feet
Whole plant toxic
Foxglove
Toxin: Digitoxin
Common oleander
Toxin: oleandrin
Lily of the valley
Toxin: convallotoxin, convallarin
Yellow oleander
Toxin: thevetin
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Common method of suicide in Sri Lanka
Also called Lucky Nut
Red squill
Toxin: scillaren
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GI distress – nausea, vomiting, abdominal pain
Lethargy
Confusion
Atrial and ventricular ectopy (may progress to VT
or VF)
Sinus bradycardia
Sinus arrest
High-degree AV block
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What is the most common dysrhythmia
associated with digoxin toxicity?
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PVCs
ACUTE
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Heart Block
K+ > 5
15 ng/mL anytime after
ingestion
> 10 ng/mL 6 hrs after
ingestion
Ingestion of:
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10 mg adult
4 mg child
CHRONIC
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Dysrhythmia
GI symptoms
Altered mental status
Heart block
Hypotension
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It blows to calculate
3 general ways to dose:
1) Estimate quantity of digoxin acutely ingested and
assume 80% bioavailability
 2) Obtain a serum digoxin concentration (SDC) and using
a pharmacokinetic formula incorporate the apparent Vd of
digoxin using the patient’s body weight (kg)
 3) use an empiric dose based on the average requirement
for an acute or chronic overdose in an adult or child
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# of vials = Amount ingested (mg)
.5 (mg/vial)
x 80%
Limitation – history made be inaccurate, which
can cause error in calculating dose
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# vials = SCD (ng/dL) x Weight (kg)
100
ACUTE
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Adults: 10-20 vials
Children: 10 vials
*This is a lot easier, but will
frequently overestimate
or underestimate Fab
requirements
CHRONIC
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Adults: 3-6 vials
Children: 1-2 vials
* Each vial of DSFab contains
38 mg (digibind) or 40 mg
(digifab) of purified DSFab
that will bind
approximately .5 mg
digoxin or digitoxin
LIKES
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Digoxin toxicity can
cause ventricular
tachycardia
Did they give him digifab?
DISLIKE
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Ipicac – no no no no!!!!!!
Patients with ventricular
tachycardia have a heart
rate well over 130s
Patients with ventricular
tachycardia with a pulse
get cardioverted, not
defibrillated
Patients generally don’t
defibrillate themselves
You do not shock asystole