Digitalis Toxicity Clinical Presentation

Author: Vinod Patel, MD; Chief Editor: Jeffrey N Rottman, MD more...

Updated: Dec 16, 2011

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History
Physical Examination
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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.

Extracardiac symptoms

CNS symptoms include the following:

Drowsiness
Lethargy
Fatigue
Neuralgia
Headache
Dizziness,
Confusion or giddiness
Hallucinations
Seizures (rare)
Paresthesias and neuropathic pain

Visual aberration often is an early indication of digitalis toxicity. Yellow-green distortion is most common, but red, brown, blue, and white also occur. Drug intoxication also may cause snowy vision, photophobia, photopsia, decreased visual acuity, yellow halos around lights (xanthopsia), and transient amblyopia or scotomata.

Gastrointestinal (GI) symptoms in acute or chronic toxicity include the following:

Anorexia
Weight loss
Failure to thrive (in pediatric patients)
Nausea
Vomiting
Abdominal pain
Diarrhea
Mesenteric ischemia - A rare complication of rapid IV infusion

Cardiac symptoms

Cardiac symptoms include the following:

Palpitations
Shortness of breath
Syncope
Swelling of lower extremities
Bradycardia
Hypotension
Dyspnea

The recent addition of a new drug, such as verapamil, diltiazem, erythromycin, tetracycline, or paroxetine, should be noted because these drugs can elevate the digoxin level. Rifampin increases digitalis metabolism by enzymatic stimulation and thereby decreases the digoxin level.

Physical Examination

Patients can have an asymptomatic period of from 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. Nausea, vomiting, and drowsiness are among 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.

General symptoms

The patient's mentation may change according to the severity of digoxin toxicity, as well as associated comorbid conditions. Visual changes occur, but the pupils are spared, and objective findings are few. Drug-induced fever does not occur.

Vital signs

The pulse may be irregular, depending on arrhythmias secondary to atrial fibrillation or arising from the digoxin toxicity itself. Hypotension may be observed if the patient has CHF or dehydration secondary to decreased oral intake.

Neck findings

Symptoms include increased jugular venous pressure.

Cardiovascular symptoms

Digoxin toxicity may cause any dysrhythmia. Classically, dysrhythmias associated with increased automaticity and decreased AV conduction occur (ie, paroxysmal atrial tachycardia with 2:1 block, accelerated junctional rhythm, or bidirectional ventricular tachycardia [torsade de pointes], depicted in the images below).

Bidirectional tachycardia in a patient with digitalis toxicity.

Hemodynamic instability is related directly to the presence of a dysrhythmia or to acute CHF. Associated cardiomegaly may be identified. Cardiovascular findings on physical examination relate to the severity of CHF, dysrhythmias, or hemodynamic instability.

Premature ventricular contractions (PVCs) are the most common dysrhythmia. Bigeminy or trigeminy occurs frequently.

Sinus bradycardia and other bradyarrhythmias are very common. Slow atrial fibrillation with very little variation in the ventricular rate (regularization of the R-R interval) may occur. First-, second-, and third-degree heart block and complete AV dissociation are also very common, while rapid atrial fibrillation and atrial flutter are rare.

Ventricular tachycardia is an especially serious finding. Cardiac arrest from asystole or ventricular fibrillation is usually fatal.

Respiratory symptoms

The respiratory rate is sometimes increased. Basal crepitations are associated with CHF.

GI symptoms

GI symptoms are common, but the abdominal examination is usually nonspecific. An enlarged liver occurs secondary to CHF (ie, hepatic congestion). Hepatojugular reflux is present.

Neurologic symptoms

Neurologic findings are related to changes in sensorium or mental status. Lateralizing findings usually indicate another disease process.

Findings in the extremities

Pedal edema is noted if the patient has renal failure or decompensated CHF.

Proceed to Differential Diagnoses

Contributor Information and Disclosures

Author

Vinod Patel, MD Medical Director, Jefferson Family Medicine Center; Clinical Assistant Professor, Department of Family Medicine, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences

Vinod Patel, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and North American Primary Care Research Group

Disclosure: Nothing to disclose.

Coauthor(s)

Paul Arthur James, MD Professor and Head, Department of Family Medicine, Donald J and Anna M Ottilie Endowed Chair in Family Medicine, University of Iowa, Roy J and Lucille A Carver College of Medicine

Paul Arthur James, MD, is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, North American Primary Care Research Group, Phi Beta Kappa, and Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

Additional Contributors

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