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Check local/national poisons advice. Establish where to get stocks of Digoxin immune FAB as they are expensive and so local stocks may be poor. Hyperkalaemia is a useful sign of severe Digoxin toxicity
Management Strategy | Description |
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Immediate Discontinuation of Digoxin | Stop digoxin administration immediately upon suspicion of toxicity to prevent further accumulation of the drug. Consider gastric lavage if seen within 1 hour and/or give activated charcoal if within 1 hour of ingestion in a cooperative patient. Repeated dosing may be helpful. |
Monitor and Stabilize the Patient |
Check Creatinine/K/Mg: Correct hypokalaemia and hypomagnesemia as they exacerbate digoxin toxicity.
Cardiac Monitoring: Manage arrhythmias and hypotension due to digoxin toxicity. |
BNF Digoxin-Specific Antibody Fragments (Digoxin Immune Fab) | Consider Digoxin Immune Fab (Digibind) if adult dose > 10 mg ingested, serious life threatening arrhythmias, Digoxin level > 15 nmol/ml (12 ng/ml), K > 5 mmol/l. This binds and removes free digoxin, facilitating its excretion. Digoxin immune FAB known as Digibind and DigiFab. In a cardiac arrest continue giving multiple vials of this for up to 30 minutes as resuscitation continues. Each Digibind vial will bind approximately 0.5 mg of Digoxin (or digitoxin) so multiple vials will need to be given in a significant overdose e.g. 10 mg Digoxin taken. You will have to summon as much as possible e.g. 20 vials. |
Treat Hyperkalaemia | Hyperkalaemia is a common and serious manifestation of digoxin toxicity. If K > 6.0 mmol/l Insulin with glucose, sodium bicarbonate. Use calcium gluconate under senior advisement. IV Calcium may worsen arrhythmias ("stone heart"). Take senior advice. |
Manage Arrhythmias | Bradyarrhythmia: IV Atropine or temporary pacing if severe. Tachyarrhythmias: For VT/VF Lidocaine 50-100 mg or phenytoin may be used. IV Magnesium may be given. Avoid amiodarone and other antiarrhythmics that can exacerbate toxicity. Anecdotally VT may respond to phenytoin or magnesium sulphate. If defibrillation is necessary then 25 J may be all that is required. Higher defibrillation energies may induce ventricular fibrillation. |
Supportive Care | Oxygen, IV fluids. Treat nausea, vomiting, or other gastrointestinal symptoms with appropriate medications. |
Monitor Digoxin Levels | Measure serum digoxin levels. Clinical status and ECG findings are more critical for decision-making. Digoxin levels do not correlate well with toxicity, especially in chronic toxicity cases. |
Address Underlying Causes | Manage any precipitating factors, such as AKI/CKD, drug interactions (e.g., with verapamil, amiodarone, or macrolide antibiotics), or electrolyte disturbances. |