Morning report

Orhue Odaro, PGY3

Sept 12, 2017
ECG
Teaching objectives

• Recognize Digoxin toxicity and pitfalls in mgmt

• Review indications for the use of reversal agents

• Understand limitations of lab testing after reversal

DIGOXIN TOXICITY: THE HORSE THAT
BECAME A ZEBRA
• Non-specific presentation
• Acute: asx for hours. Cardiac, GI manifestations
• Chronic: subtle; neurologic manifestations, vision changes
• Elevated serum levels ≠ Toxicity
• Digoxin molecules are large: No HD
Enter Digifab…ulous

• Give for:
• life-threatening arrhythmias
• Evidence of end-organ dysfunction
• Hyperkalemia

• varied dosing in acute vs chronic*

• Total dig levels after Fab = USELESS

• Free dig levels after = USEFUL but UNAVAILABLE

Evaluating the Evidence

• The cohort
• 50% chronic
• 39% intentional ingestion
• 10% accidental ingestion

• The Outcome
• 80% recovered fully
• 10% improved
• 10% No response

• Overall, 90% of patients showed

improvement

Antman et. Al. PMID 2188752

beware…

• Cardiac arrhythmias
• Hyperkalemia in acute toxicity increases mortality*
• Hypokalemia in chronic toxicity potentiates toxic effects
Take Home Points

• Suspect Dig toxicity in an altered patient on chronic digoxin.

• Give DigiFab for: cardiac arrhythmias, neurotoxicity, hyperkalemia.

Monitor clinically for improvement.

• Manage HYPOkalemia NOT HYPERkalemia.

References
• Antman EM et al. Treatment of 150 cases of life-threatening
digitalis intoxication with digoxin-specific Fab antibody fragments.
Final report of a multicenter study. Circulation, 81 (6) (1990), pp.
1744-1752
• Kanji S, MacLean RD. Cardiac glycoside toxicity: more than 200
years and counting. Crit Care Clin. 2012 Oct;28(4):527-35.
• Ewy GA. Digoxin: The Art and Science. Am J Med. 2015
Dec;128(12):1272-4.
• Yang et al. Digitalis toxicity: a fading but crucial complication to
recognize. Am J Med. 2012 Apr;125(4):337-43.