Pediatric Digitalis Toxicity Medication

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

Medication Summary

Since the approval of purified digoxin-specific Fab antibody fragments by the FDA in 1986, the outcome in severe acute digitalis poisoning has been drastically improved. Other supportive medications may include phenytoin or lidocaine for arrhythmias, atropine, and possibly electrolyte supplementation (see above, Treatment).

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Digoxin immune Fab

Class Summary

This agent is used in the management of poisoning, overdoses, prevention of toxic effects, and metabolic disorders in which toxic substances accrue. In cases of digitalis toxicity, specific antidigoxin antibodies are used to treat hemodynamically unstable or life-threatening arrhythmias and hyperkalemia. Digoxin immune Fab has also been used to treat cardiac glycoside toxicity from oleander and toad venom.[17, 18]

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Digoxin immune Fab (Digibind)

 

50,000-Da molecule derived from IgG fragment of sheep antidigoxin antibodies. This relatively pure Fab product is safe and extremely effective. Indications for use include life-threatening arrhythmias (eg, severe bradyarrhythmia, second- or third-degree heart block, ventricular tachycardia or fibrillation), initial potassium level >5 mmol/L, digoxin serum levels >10 ng/mL at 6-8 h after ingestion, digoxin serum levels >15 ng/mL in acute ingestion, and ingestion >10 mg in healthy adults or >4 mg in children.

Binds free digoxin in vascular and interstitial space and decreases free plasma digoxin levels by binding intracellular digoxin from its binding sites in heart and interstitial and intravascular spaces. Raises intravascular levels of inactive antibody-bound digoxin to very high levels, which decrease over several days as it is excreted renally. Response typically observed within 20-30 min; elimination half-life of drug-antibody complex is about 16 h.

Affinity for digitoxin is 10 times less than for digoxin. In recent case series including pediatric patients, 90-93% response rate within minutes or hours, with complete resolution within 180 min in as many as 79% of patients. Mean time to initial response was 19 min; complete resolution of symptoms in 88 min. Each vial contains 40 mg Fab and binds 0.6 mg of digoxin.

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Antiarrhythmic agents

Class Summary

These agents alter the electrophysiologic mechanisms responsible for arrhythmia. These are used as an alternative to digoxin immune Fab.

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Atropine IV/IM

 

Anticholinergic agent used to increase heart rate by means of vagolytic effects, increasing cardiac output.

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Phenytoin (Dilantin)

 

Depresses spontaneous depolarization in ventricular tissues.

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Lidocaine hydrochloride (Xylocaine)

 

Class IB antiarrhythmic that increases electrical stimulation threshold of ventricle, suppressing automaticity of conduction through the tissue.

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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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