1. Case Presentation
Dr.Yassin
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2. History
• 2 years old healthy boy.
• Presented with Hx of ingestion of
digoxin tablets . 15 min prior to ER
visit.
• Amount is unknown.
• Digioxin 62.5 mic .
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3. History
• No Hx of abnormal movement.
• No Hx of vomiting.
• No Hx of palpitation.
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4. History
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Perinatal Hx:
Past medical and surgical E
Hx:
L
B
Allergy:
A
K
Vaccination Hx: AR
M
E
Family Hx:
R
Social Hx: UN
Developmental Hx:
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5. EXAM
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Looks well.
HR: 123
RR: 24
B/P: 10947
Temp: 36.5
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CVS: WNL
RS: WNL
CNS: WNL
ABDOMIN: WNL
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6. ER course
• Patient taken immediately to ER.
• Gastric lavage done revealed tablet
particles.
• Charcol given.
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7. impression
Digoxin ingestion
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8. PLAN
OF
CARE
investigation
treatment
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education
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9. investigation
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10. investigation
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11. Powerpoint Templates
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12. investigation
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13. investigation
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14. Digoxin
Toxication
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15. digoxin
• Antiarrhythmic agent, inotrope.
• Cardiac Glycoside.
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T1/2: Premature infants, 61–170 hr.
full-term neonates, 35–45 hr.
infants, 18–25 hr.
children, 35 hr.
• Indication: heart failure, Supraventricular
tachycardia .
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16. Presentation of toxication
• CVS: asystole, atrial or nodal ectopic beats.
• A-V block, AV dissociation, S-A block,
ventricular arrhythmias,
• first-, second- (Wenckebach), or third-degree
heart block.
• CNS: Seizure.lethargy, headache, visual
disturbance.
• electrolyte imbalances Hyperkalemia
• GIT: diarrhea, nausea, vomiting
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17. Risk factor
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Impaired renal function.
Hypokalemia.
Hypomagnesemia.
Hypercalcemia.
low thyroxine.
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18. Monitoring
• Digoxin levels are most useful if measured
4–6 hr after ingestion.
• Therapeutic serum digoxin concentration:
<2ng/mL
• Toxic serum digoxin concentration:
>4ng/mL
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19. Monitoring
• 12-lead ECG and continuous cardiac
monitoring.
• Monitor electrolytes (calcium, magnesium,
potassium) hourly.
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20. management
• Supportive Care/Decontamination:
• CAB
• Activated charcoal up to several hours
postingestion.
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21. Specific treatment
• Antidote: Digoxin Specific Antibody
Fragments (Fab)
• Indications:
• severe toxicity (ventricular, progressive
bradyarrhythmias, 2nd or 3rd degree heart
block).
• serum potassium >5 mEq/L .
• serum digoxin concent >4-10 ng/mL ????
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22. Specific treatment
• Serum digoxin concentration increases
after Fab secondary to intravascular
diffusion of antibody-bound, inactive
digoxin.
• Adverse reactions: Allergic reaction,
rebound hypokalemia, CHF (secondary to
the sudden decrease in digoxin's inotropic
effect).
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23. Treatment cont
• Electrolyte disturbances (hyperkalemia):
• typically self-correct after Fab treatment.
• Bradyarrhythmias: Fab is first-line therapy;
consider atropine, dopamine, epinephrine, or
isoproterenol for second-line therapy.
• Asystole and pulseless electrical activity
(PEA) Life-threatening tachyarrhythmias
Treat according to Pediatric Advanced Life
Support (PALS) protocol.
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24. THANK
YOU
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25. Management calculating the dose
• First, determine total body digoxin load (TBL):
• TBL (mg) = serum digoxin level (ng/mL) × 5.6 ×
wt (kg) ÷ 1000,
• OR TBL (mg) = mg digoxin ingested × 0.8
• Then, calculate digoxin immune Fab dose:
• Dose in number of digoxin immune Fab vials
(Digibind or DigiFab): vials = TBL ÷ 0.5
• Infuse IV over 15–30 min
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