eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Digitalis: Follow-up

Author: Donald Schreiber, MD, CM, Associate Professor of Surgery (Emergency Medicine), Stanford University School of Medicine
Contributor Information and Disclosures

Updated: Dec 1, 2008

Follow-up

Further Inpatient Care

  • Admission criteria
    • New cardiac dysrhythmias
    • Severe bradyarrhythmias
    • Advanced AV block
    • Acute prolongation of the QRS interval
    • Severe electrolyte abnormalities, especially hypokalemia or hyperkalemia
    • Dehydration
    • Inability to care for self
    • Suicidal ideation
  • Admit patients with cardiac abnormalities to a monitored bed.
  • ICU admission criteria include hemodynamic instability, refractory dysrhythmias, hyperkalemia, and renal failure. Admit patients receiving Digibind to ICU or critical care unit (CCU).

Further Outpatient Care

  • Observe patients with acute ingestion on a cardiac monitor for 6 hours. In the absence of cardiac dysrhythmias, toxic digoxin levels, or hyperkalemia, patients may be discharged with appropriate follow-up care.
  • Patients with chronic toxicity and noncardiac symptoms may be discharged if factors that led to the toxicity have been corrected (eg, electrolyte disorders, dehydration, drug-drug interactions) and proper care can be ensured. Discontinue use of the drug. Arrange follow-up care in the next 24 hours with a primary care provider.
  • Intentional overdose requires psychiatric follow-up.

Transfer

  • Transfer may be indicated if patient is unstable and the hospital has no ICU or CCU capabilities, no appropriate consultants (eg, toxicologist, cardiologist, intensivist), or when Digibind (if indicated) is not available. Treatment is best discussed with the regional poison control center and the patient's primary practitioner.

Deterrence/Prevention

  • Digoxin toxicity may develop in patients with dehydration, worsening renal function, or new electrolyte disturbances. Drug interactions are an important causative factor. Careful patient monitoring, including drug levels, is required in these clinical settings.
  • Advanced age decreases the volume of distribution and renal clearance. Elderly patients and those with chronic renal failure require lower maintenance doses.

Complications

  • Refer to complications of Digibind therapy, as outlined in the Medication section.

Prognosis

  • Morbidity and mortality rates increase if the patient has a new dysrhythmia, advanced AV block, or other significant ECG abnormality.

Patient Education

  • Educate the patient to be aware of possible drug interactions when starting any new medication.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis in patients with dysrhythmias, electrolyte abnormalities, or renal insufficiency
  • Cardioverting the digoxin-toxic patient with an unstable supraventricular arrhythmia
  • Administration of intravenous calcium to treat hyperkalemia if digoxin toxicity is suspected or confirmed unless the patient is in extremis
  • Failure to arrange psychiatric follow-up in cases of intentional overdose
  • Erroneous parenteral dosing in neonates and infants

Special Concerns

  • Infants and children taking digoxin tolerate higher doses and plasma levels.
    • The pediatric volume of distribution is greater and the half-life of digoxin is less.
    • Pediatric myocardial cells may be less sensitive to the toxic effects of digoxin.
    • Decreased sensitivity to dysrhythmias by infants and children may contribute to increased tolerance to digoxin.
    • Infants and children manifest the same signs of toxicity as adults.
    • The treatment of toxicity in pediatric patients is the same as in adults.
 


More on Toxicity, Digitalis

Overview: Toxicity, Digitalis
Differential Diagnoses & Workup: Toxicity, Digitalis
Treatment & Medication: Toxicity, Digitalis
Follow-up: Toxicity, Digitalis
Multimedia: Toxicity, Digitalis
References
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References

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Further Reading

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Keywords

digitalis toxicity, digoxin toxicity, cardiac glycoside toxicity, foxglove plant, digoxin poisoning, acute digoxin overdose, digoxin overdose, acute ingestion of digoxin, cardiac glycoside overdose

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Contributor Information and Disclosures

Author

Donald Schreiber, MD, CM, Associate Professor of Surgery (Emergency Medicine), Stanford University School of Medicine
Donald Schreiber, MD, CM is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Sanofi-Aventis None Speaking and teaching; Scios Grant/research funds None; Abbott Point of Care Inc Grant/research funds None; Schering Plough Inc None Speaking and teaching; AstraZeneca Grant/research funds None

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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