Pediatric Digitalis Toxicity Clinical Presentation

  • Author: Kenneth T Kwon, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Jul 9, 2010
 

History

Most cases of pediatric digitalis poisoning are unintentional ingestions; thus, a good social history with emphasis on available medications and the extent of home childproofing is necessary.

  • CNS
    • Lethargy or drowsiness
    • Confusion or giddiness
    • Headaches
    • Hallucinations
    • Visual changes, including aberrations in color vision (chromatopsia) and yellow halos around lights (xanthopsia), transient amblyopia or scotomata, and decreased visual acuity
    • Seizures (rare)
    • Syncope
  • GI system
    • Nausea and vomiting
    • Diarrhea
    • Anorexia, weight loss, or failure to thrive
    • Abdominal pain
  • Cardiovascular system (see Procedures)
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Physical

Patients can have an asymptomatic period of several minutes to several hours after the oral administration of a single toxic dose. Clinical signs may be subtle or obvious, depending on the severity of toxicity. Acute toxicity is rarely subtle, and chronic toxicity may be difficult to diagnose. CNS changes, most notably nausea, vomiting, and drowsiness are the most common extracardiac manifestations. Visual changes usually affect patients with chronic toxicity.

Emphasis should be placed on the vital signs and the neurologic and cardiovascular findings.

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Causes

  • Therapeutic administration can cause toxicity.
    • Usual therapeutic doses
    • Doses with errors in prescription, dispensing, or administration
  • Acute nontherapeutic overdose can cause toxicity.
    • Unintentional
    • Suicidal
    • Homicidal
  • The main causes of digitalis toxicity in the pediatric population include the following:
    • Erroneous dosing in infants, which is usually parenteral and frequently fatal
    • Unintentional ingestion in younger children, which is rarely fatal
    • Intentional ingestion in older children and young adults, which results in variable mortality rates. In addition, many suicide attempts with digitalis ingestion have been reported in the pediatric population.
  • Electrolytic abnormalities can worsen digitalis toxicity.
    • Hypokalemia can worsen toxicity. Hypokalemia is usually observed with chronic toxicity or in patients taking diuretics. Hypokalemia reduces the rate of sodium-activated and potassium-activated adenosine triphosphatase (Na+ K+ ATPase) pump turnover and exacerbates pump inhibition due to digitalis.
    • Hyperkalemia can also worsen toxicity. In pediatric patients, hyperkalemia is usually a complication of acute toxicity rather than a cause; however, preexisting hyperkalemia increases the risk of morbidity and mortality.
    • Hypomagnesemia, hypercalcemia, and hypernatremia can aggravate toxicity.[4]
  • Concomitant use of the following drugs can exacerbate digitalis toxicity:
    • Quinidine, procainamide, amiodarone, calcium channel blockers, beta-blockers
    • Diuretics, including spironolactone
    • Erythromycin and tetracycline: These agents can increase serum digoxin levels by inactivating an enteric bacterium (Eubacterium species) that is present in 10% of the population. This bacterium inactivates digoxin in the GI tract.
  • Other risk factors include the following:
    • Renal dysfunction
    • Hypo- or hyperthyroidism
    • Hypoxemia
    • Alkalosis
    • Myocardial disease
    • Extremes of age
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Contributor Information and Disclosures
Author

Kenneth T Kwon, MD  Director of Pediatric Emergency Medicine, Associate Clinical Professor, Department of Emergency Medicine, University of California at Irvine Medical Center, Co-Director, Pediatric Emergency Services, Mission Regional Medical Center/Children's Hospital of Orange County at Mission

Kenneth T Kwon, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Megan Boysen, MD  Resident Physician, Department of Emergency Medicine, University of California Irvine Medical Center

Megan Boysen, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

William T Zempsky, MD  Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Paul D Petry, DO, FACOP, FAAP  Consulting Staff, Freeman Pediatric Care, Freeman Health System

Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

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