This document discusses the management of digitalis toxicity. It begins with an example case of a 3-year-old girl brought to the emergency department after ingesting her grandmother's heart pills. The document then covers the predisposing factors, clinical manifestations, diagnosis, and treatment of digitalis toxicity. It discusses evaluating patients on digoxin for signs of toxicity and monitoring potassium and renal function. Treatment involves stopping digoxin, decontamination, electrolyte management, and the antidote Digibind for life-threatening cases. The take-home message is that digoxin toxicity risk factors include electrolyte abnormalities and renal impairment, and treatment involves supportive care and Digibind in severe cases.

1. Management of
digitalis toxicity
Dr. Suzan Morsy
Ass. Prof. Clinical Pharmacology, FCMS,
Jeddah KSA

2. By the end of this session
student should be able to:
• Perform appropriate History taking for a case of
digitalis toxicity
• Perform Clinical examination for a case of
digitalis toxicity
• Determine Investigations used to diagnose
digitalis toxicity
• DescribeTreatment of digitalis toxicity

3. • The bottle was labelled “digoxin
0.25 mg tablets,” and there were 10
left.
• The Grandmother estimated that
there were probably 40 pills in the
bottle this morning when she took
her usual dose.
• Since the child had been playing
alone for some time, the ingestion
could have occurred anytime within
the past 90 minutes.
A 3-year-old girl is rushed into the Emergency Department carried by her
mother.The mother states that the child just consumed “a bottle of heart pills.”
The mother and the patient were apparently visiting the patient’s grandmother
this afternoon, when the mother discovered her daughter playing in the
bedroom with an open bottle of pills.

4. Physical
Examination:
• T: 99.4°F
• HR: 40 bpm
• RR: 30 breaths per
minute
• BP: 98/52 mm Hg
• Weight 33 pounds
(15 kg)
• Bedside glucose: 84
• General: Age
appropriate, lethargic
female, whimpering
and whining in the
bed. Responds irritably
to any stimuli.There
are no signs of trauma.
• Pulmonary: Clear to
auscultation.
• CV: Bradycardic,
regular rhythm.
• Initial ECG shows sinus
bradycardia with first
degree AV block.

5. Digoxin

6. What are
Predisposing factors
for digitalis toxicity ?

7. Predisposing factors to digitalis toxicity
Age (elderly and
paediatrics)
Hypokalaemia
Hypercalcemia
Renal impairment
High dose for long
duration
Drugs:
• Drugs causing
hypokalemia (e.g.
furosemide)
• Calcium

8. What are the cardiac
manifestations of digitalis
toxicity ?

9. Clinical picture of digitalis toxicity
Cardiac
Bradycardia
Multiple ventricular ectopic beats
Ventricular bigeminy
Atrial tachycardia (with variable block)
Vetricular tachycardia and ventricular fibrillation

10. ECG for this patient showed
the corresponding figure.
What is your assessment ?

11. Ventricular ectopic beats.
• There are broad bizarre QRS complexes (arrows)
• with no preceding P wave in between normal sinus beats.
• Their configuration varies,
• so these are multifocal ectopics

13. What are the Non-cardiac
manifestations of digitalis
toxicity ?

14. Others
GIT (Nausea, vomiting, abdominal pain,
anorexia, diarrhea)
Ocular
a. Xanthopsia: colored vision, yellow and green patches,
b. Diplopia (Double vision)
c. Scotomata (a partial loss of vision or blind spot in an
otherwise normal visual field)
Neurological: Confusion, lethargy
Skin rash

15. How to diagnose digitalis
toxicity ?

16. Diagnosis:
1. History
2. Symptoms and signs
3. Investigations:
a. ECG
b. Plasma digoxin level:
• Therapeutic range
usually 1–2 μg/L
• Concentrations > 4
μg/L usually associated
with toxicity, especially
with chronic poisoning

17. History
taking for a
patient
treated by
DigoxinTo
identify
early toxicity
A. WIIP
B. Ask about risk factors which increase risk of
digitalis toxicity
1. For how long are you taking digoxin
2. What is the dose of digoxin you are taking?
3. Are you compliant to the dose and the follow up
regimen?
4. Are you taking any other drug (Furosemide,
diuretics)?
5. Are you taking calcium supplements?
6. When was the last time you had renal function test?
Do you have any renal disease?
7. When was the last time your Potassium level in
blood was measured?

18. C. Ask about
manifestations
of digitalis
overdose
1. Have you felt of any heart-related
symptoms (Palpitation, drowsiness,
dizziness, syncope)
2. Have you felt of any GIT symptoms
((Nausea, vomiting, abdominal pain,
anorexia, diarrhea)
3. Have you experienced eye-related
manifistations
a. Xanthopsia: colored vision, yellow and
green patches
b. Diplopia (Double vision)
c. Scotomata (a partial loss of vision or blind
spot in an otherwise normal visual field)
4. Have you any skin rash or itching?

20. What are the treatment of
this patient?

21. Treatment of DigitalisToxicity
1. Airway, Breathing and Circulation management
2. Stop digoxin (and diuretics if patient was receiving diuretics)
3. GIT decontamination: Gastric lavage with repeated doses of activated
charcoal And Cholestyramine
4. Mild toxicity: Potassium sulfate
5. Supraventricular tachyarrhythmias: Propranolol

22. 6. Ventricular tachycardia: Lignocaine, lidocaine or
Phenytoin
7. Severe bradycardia: Atropine
8. Hyperkalaemia: EDTA or Insulin plus Glucose
9. Severe toxicity: DIGIBIND

23. Is Digibind indicated for
this patient?
What is the dose needed?

24. Indications of DIGIBIND
1. Life-threatening arrhythmia
2. Hemodynamic instability
3. Severe bradycardia
Dose of Digibind:
• 1 vial of digibind = 40 mg Neutralizes 0.6
mg of digoxine
• No. of digibind vials needed
• = Digoxin level in blood (ng/ml)X wt
(Kg)/100

25. What are the adverse drug
reactions and contraindications
of Digibind?

26. Adverse effects of DIGIBIND
1. Allergic reaction
2. Exacerbation of HF
3. Hypokalemia
4. Increase ventricular response to atrial fibrillation and flutter
https://digifab.health/en-us/why-digifab/mechanism-of-action
CONTRAINDICATIONS:
1. Allergy to sheep proteins, papain, papaya extract

27. Take home message
1. Digoxin can induce acute or chronic toxicity
2. Risk factors for digitalis toxicity include hypokalemia or hypercalcemia, renal
impairment, drugs
3. Therapeutic drug monitoring is essential
4. Manifestations of digitalis toxicity include cardiac, GIT, neurological and skin
manifistations
5. Treatment include supportive therapy, stop further absorption and treatment
of cardiac manifistations
6. DIGIBIND is the antidote for digoxine

28. Essential readings
1. Casarett & Doull's Essentials ofToxicology. 4th Edition 2021 Mcgraw-Hill.
(https://www.dropbox.com/sh/epbrllqx07wy83t/AACN5rhji5cZ9xmruwuU5zr
sa?dl=0)
2. Biswas Gautam Review of Forensic Medicine andToxicology 4th edition 2018.
Jaypee