Intern Report 4/26 – Digoxin Toxicity

  • Teaching Points:
    • Clinical Manifestations
      • Neurologic
        • Can present with confusion, lethargy, coma, etc
        • Vision abnormalities can be seen
          • Patients can develop yellow vision
      • Cardiac
        • Most dangerous side effects
        • Classically produces an arrhythmia that could range from atrial tachycardia with AV delay, Bradycardia, junctional rhythm, alternating right and left AV nodal delay, ventricular arrhythmia
        • Alternating right and left BBB is one of the more specific arrhythmias for dig toxicity, although it’s not commonly seen.
      • Gastrointestinal
        • Patients often present with nausea/vomiting and abdominal pain
        • Most common side effects of digoxin toxicity
        • Rare complications include acute mesenteric ischemia
    • Elevation of digoxin level does not correlate with clinical manifestations
    • Digoxin toxicity commonly occurs in decompensated heart failure patients undergoing aggressive diuresis
      • Leads to hypokalemia and low magnesium levels, which potentiates digoxin toxicity.
    • Hyperkalemia is a poor prognostic indicator for acute digoxin toxicity
      • Studies have shown that for patients with K >5.5, mortality was significantly higher
      • Patients with K<5, mortality was much less.
    • Primary treatment of patients with acute digoxin toxicity and hyperkalemia is Digoxin-specific antibody fragment (Fab)
      • It is generally recommended that you do not aggressively treat the hyperkalemia with agents such as calcium gluconate, bicarb, insulin/glucose as Fab will cause potassium to be lowered.
      • Giving these agents could actually cause hypokalemia

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