anwccs simulation center - anwresidency.com toxicity.pdf · overview » cardiac glycoside toxicity...
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Digoxin Toxicity
ANWCCSSimulation Center
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Overview» Cardiac glycoside toxicity
potentially fatal with mortality ranging from 3-50%
» Caused by numerous substances usually by digitalis (one form is Digoxin)
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Conditions leading to Dig Toxicity
» Renal insufficiency/ESRD» ESRD prolongs half-life and reduces volume of
distribution» Advanced age» Cardiac diseases
» Active ischemia, myocarditis, cardiomyopathy, amylodosis, cor pulmonale
» Metabolic factors» Hypokalemia, hypomag, hypoxemia,
hypernatremia, hypercalcemia, acid-base
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Pharmacology» Dig inhibits Na-K-ATPase
» Increasing intracellular Na reducing gradient» Na-Ca driving force reduced increasing
intracellular Ca--increasing cardiac contractility; positive ionotropic effect
» Digoxin also increases the automaticity of Purkinje fibers but slows conduction through the atrioventricular (AV) node. Cardiac dysrhythmias associated with an increase in automaticity and a decrease in AV node conduction may result.
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Kinetics» Digoxin bioavailability is 80%» Half-life 1.6 days» Major storage area in body skeletal
muscle» Not removed by HD» 1/3 body stores/day excreted
» 30% Unchanged in urine» 3% as metabolites in stool
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Signs/Syptoms of Dig Overdose
» History suggesting change in Dig dosage» History of any other new drugs» Fatigue, blurred vision, disturbed color
perception, N/V, anorexia, diarrhea, abdominal pain, HA, dizziness, confusion, delirium, hallucinations
» Bradycardia» Occasional tachycardia» Hypotension in severe cases
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K» Hyperkalemia
» Hyperkalemia in acute settings shows degree of Na-K-ATPase poisoning
» Hypokalemia» Potentiates toxicity--correct immediately
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Normal Dig ECG
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ECG-normal» T wave changes» QT interval
shortening» “Scooped”
appearance of ST segment
» Increase U wave amplitude
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Atrial Tachycardia with AV block
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First Degree AV block
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Mobitz I
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Afib with accelerated Junctional Rhythms
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Bidirectional Ventricular Tachycardia
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Ventricular Bigeminy
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Treatment» Support treatment if needed-intubation, etc» Symptomatic bradycardia-atropine» Do not use transvenous pacing as first line -can
lead to arrhythmias» Avoid Beta agonists (isoproterenol)» Gut decontamination with activated charcoal
(w/in 6-8 hours of acute ingestion)» Manage K as usual except do not use calcium
salts» Replace Mg
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TreatmentDigibind
» Digoxin-specific Fab fragments» Made in sheep» Bind rapidly to intravascular dig» Dig stored in other tissues then goes into
intravascular space and digibind binds that also» Digibind/digoxin complex small and is rapidly
removed by normal kidneys» ESRD on HD responds clinically the same to
digibind except elimination of complex slow» Theoretically can get rebound dig toxicity
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When to Use Digibind» Hemodynamic instability» Life-threatening arrhythmias» Severe Bradycardia-even if atropine
works» Plasma K above 5» Plasma Dig above 10» Presence of dig toxicity rhythm combined
with dig toxic level
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References» http://www.sciencedirect.com.libproxy.lib.unc.edu/science?_o
b=ArticleURL&_udi=B6T8B-42C07N1-8&_user=130907&_coverDate=02%2F28%2F2001&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000004198&_version=1&_urlVersion=0&_userid=130907&md5=461c196c5db7aa1916fb4a1dec1035dd
» Ismail, Nuhad, MD. Digitalis (cardiac glycoside) intoxication. UpToDate. 2007.
» Arnsdorf, Morton, MD. Electrophysiology of arrythmias due to digitalis toxicity. UpToDate. 2007.