Pediatric Digitalis Toxicity Treatment & Management

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

Medical Care

General supportive care of digitalis toxicity includes hydration with intravenous (IV) fluids, oxygenation and support of ventilatory function, discontinuation of the drug, and sometimes the correction of electrolyte imbalances.

Fab antibody fragments are extremely effective in the treatment of severe acute digitalis toxicity (see below).

  • GI decontamination may be helpful. Activated charcoal is the preferred method of decontamination. Because of the enterohepatic circulation of digoxin and digitoxin, multiple-dose charcoal (1 g/kg/d) may be beneficial.
    • Induced emesis with ipecac syrup is not recommended because of the increased vagal effect.
    • Gastric lavage may be useful early after ingestion because of the prolonged absorption of digoxin; however, lavage can also increase vagal effects because of the placement of the nasogastric tube.
    • Whole-bowel irrigation may be useful, but clinical data are lacking.
    • Steroid-binding resins, such as cholestyramine and colestipol, can prevent the further absorption of digoxin by interrupting the enterohepatic circulation. These agents are especially effective in patients with significant renal insufficiency.
  • Forced diuresis is not recommended because it has not been shown to increase renal excretion and can worsen electrolyte abnormalities. Dialysis has been shown to produce only small-added clearances.
  • Digoxin immune Fab is now considered first-line treatment for significant dysrhythmias and should be promptly administered if digoxin toxicity is suspected (see indications below, Medications).[14, 3, 15]
    • Atropine may be useful in blocking digoxin-induced effects of enhanced vagal tone on the sinoatrial (SA) and atrioventricular (AV) nodes; it has proven helpful in reversing severe sinus bradycardia.
    • Phenytoin and lidocaine are useful antiarrhythmics for the treatment of digoxin toxicity if Fab fragments are ineffective or unavailable.[16]
    • Quinidine and procainamide should be avoided because they intensify AV block.[16]
    • Cardioversion is generally reserved for the treatment of unstable arrhythmias that are unresponsive to medications such as digoxin-specific Fab. Initial shocks should be at the lowest possible energy levels (10-25 J) because cardioversion can induce intractable ventricular fibrillation.
    • With the availability of digoxin-specific Fab, pacemaker use now has limited value. In one study, the main reason for Fab failure was pacing-induced arrhythmias and delayed or insufficient administration of Fab. This study also had a 36% complication rate with pacing. Generally, pacing should be considered in cases of symptomatic bradycardia or AV block that is unresponsive to medications and in cases in which digoxin-specific Fab is not readily available.
  • Electrolyte imbalances may worsen digitalis toxicity.
    • Potassium supplementation is generally recommended in the setting of hypokalemia (K+< 3meq/L) and first-degree AV block or Wenckebach. Potassium supplementation is also recommended in low-normal potassium levels (K+< 4 meq/L) and ventricular tachycardia, premature ventricular contractions, or supraventricular tachycardia with AV block.[16]
    • Potassium administration is generally contraindicated in the setting of Mobitz II or third-degree AV block.[16]
    • Magnesium administration may be beneficial in cases of hypomagnesemia, although it is unclear how well magnesium levels correlate with digitalis toxicity.[16]
    • Calcium should not be routinely administered, as it can induce ventricular arrhythmias.
Next

Consultations

  • Medical toxicologist
  • Local poison control center personnel
  • Cardiologist
Previous
Proceed to Medication
 
 
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.

References

  1. Gheorghiade M, van Veldhuisen DJ, Colucci WS. Contemporary use of digoxin in the management of cardiovascular disorders. Circulation. 2006;113:2556-2564. [Medline].

  2. Sulafa Ali KM. Collateral effects of antiarrhythmics in pediatric age. Current Pharmaceutical Design. 2008;14:782-787. [Medline].

  3. Woolf AD, Wenger T, Smith TW, Lovejoy FH Jr. The use of digoxin-specific Fab fragments for severe digitalis intoxication in children. N Engl J Med. Jun 25 1992;326(26):1739-44. [Medline].

  4. Thacker D, Sharma J. Digoxin toxicity. Clin Pediatr (Phila). Apr 2007;46(3):276-9. [Medline].

  5. Brophy JM. Rehabilitating digoxin. Eur Heart J. Jan 2006;27(2):127-9. [Medline].

  6. The Internet Drug Reference Top 300 Prescriptions for 2005. RxList. Available at http://www.rxlist.com/script/main/art.asp?articlekey=79509. Accessed March 4, 2010.

  7. Litovitz TL, Klein-Schwartz W, White S, Cobaugh DJ, Youniss J, Drab A, et al. 1999 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2000;18(5):517-74. [Medline].

  8. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila). Dec 2009;47(10):911-1084. [Medline].

  9. Hauptman PJ, Kelly RA. Digitalis. Circulation. Mar 9 1999;99(9):1265-70. [Medline].

  10. Koren G, Parker R. Interpretation of excessive serum concentrations of digoxin in children. Am J Cardiol. Apr 15 1985;55(9):1210-4. [Medline].

  11. Aarnoudse AL, Dieleman JP, Stricker BH. Age- and gender-specific incidence of hospitalisation for digoxin intoxication. Drug Saf. 2007;30(5):431-6. [Medline].

  12. Rathore SS, Wang Y, Krumholz HM. Sex-based differences in the effect of digoxin for the treatment of heart failure. N Engl J Med. Oct 31 2002;347(18):1403-11. [Medline].

  13. Bismuth C, Gaultier M, Conso F, Efthymiou ML. Hyperkalemia in acute digitalis poisoning: prognostic significance and therapeutic implications. Clin Toxicol. 1973;6(2):153-62. [Medline].

  14. Smith TW, Butler VP Jr, Haber E, et al. Treatment of life-threatening digitalis intoxication with digoxin- specific Fab antibody fragments: experience in 26 cases. N Engl J Med. Nov 25 1982;307(22):1357-62. [Medline].

  15. Zucker AR, Lacina SJ, DasGupta DS, et al. Fab fragments of digoxin-specific antibodies used to reverse ventricular fibrillation induced by digoxin ingestion in a child. Pediatrics. Sep 1982;70(3):468-71. [Medline].

  16. Kelly RA, Smith TW. Recognition and management of digitalis toxicity. Am J Cardiol. Jun 4 1992;69(18):108G-118G; disc. 118G-119G. [Medline].

  17. Brubacher JR, Ravikumar PR, Bania T, Heller MB, Hoffman RS. Treatment of toad venom poisoning with digoxin-specific Fab fragments. Chest. Nov 1996;110(5):1282-8. [Medline].

  18. Rajapakse S. Management of yellow oleander poisoning. Clin Toxicol (Phila). Mar 2009;47(3):206-12. [Medline].

  19. Antman EM, Wenger TL, Butler VP Jr, et al. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments. Final report of a multicenter study. Circulation. Jun 1990;81(6):1744-52. [Medline].

  20. Beller GA, Smith TW, Abelmann WH, et al. Digitalis intoxication. A prospective clinical study with serum level correlations. N Engl J Med. May 6 1971;284(18):989-97. [Medline].

  21. Ekins BR, Watanabe AS. Acute digoxin poisonings: review of therapy. Am J Hosp Pharm. Mar 1978;35(3):268-77. [Medline].

  22. Fazio A. Fab fragments in the treatment of digoxin overdose: pediatric considerations. South Med J. Dec 1987;80(12):1553-6. [Medline].

  23. Hastreiter AR, van der Horst RL, Chow-Tung E. Digitalis toxicity in infants and children. Pediatr Cardiol. Apr-Jun 1984;5(2):131-48. [Medline].

  24. Husby P, Farstad M, Brock-Utne JG, et al. Immediate control of life-threatening digoxin intoxication in a child by use of digoxin-specific antibody fragments (Fab). Paediatr Anaesth. Jul 2003;13(6):541-9. [Medline].

  25. Kaufman J, Leikin J, Kendzierski D, Polin K. Use of digoxin Fab immune fragments in a seven-day-old infant. Pediatr Emerg Care. Jun 1990;6(2):118-21. [Medline].

  26. Lewander WJ, Gaudreault P, Einhorn A, et al. Acute pediatric digoxin ingestion. A ten-year experience. Am J Dis Child. Aug 1986;140(8):770-3. [Medline].

  27. Ordog GJ, Benaron S, Bhasin V, et al. Serum digoxin levels and mortality in 5,100 patients. Ann Emerg Med. Jan 1987;16(1):32-9. [Medline].

  28. Rutledge J. Digitalis toxicity in infants and plasma digoxin levels. Pediatr Cardiol. 1985;6(1):51-2. [Medline].

  29. Shumaik GM, Wu AW, Ping AC. Oleander poisoning: treatment with digoxin-specific Fab antibody fragments. Ann Emerg Med. Jul 1988;17(7):732-5. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.