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  • Volume I:
    First Thirty Minutes
    • Section 1
      Acute Care Algorithm/ Treatment Plans/ Acronyms
      • CALS Approach
        • CALS Universal Approach
        • Patient Transport
      • Airway
        • Rapid Sequence Intubation Algorithm/Rescue Airways
        • Endotracheal Intubation FlowSheet
        • Rapid Sequence Intubation Medications
        • Rapid Sequence Intubation Drug Calculator
        • Rapid Sequence Intubation Dosage Chart
        • Obstructed Airway Algorithm Adult and Pediatric
        • Initial Laboratory Studies
      • Cardiovascular
        • CPR Steps for Adults, Children, and Infants
        • Automated External Defibrillator Algorithm
        • Ventricular Fibrillation-Pulseless Ventricular Tachycardia Algorithm
        • Pulseless Electrical Activity Algorithm-Adult and Peds
        • Asystole Algorithm-Adult and Peds
        • Bradycardia Algorithm
        • Tachycardia Algorithm
        • Atrial Fibrillation/Atrial Flutter Algorithm
        • Electrical Cardioversion Algorithm-Adult and Pediatric
        • Chest Pain Evaluation Algorithm
      • Emergency Preparedness
        • Therapeutic Hypothermia
        • Mobilization Checklist
        • Symptom Recognition-Therapy
        • Blast Injuries
      • Fluids & Electrolytes
        • Causes of Anion and Non-Anion Gap Acidosis
      • Infection
        • Sepsis Guidelines
      • Neonatal
        • Neonatal Resuscitation Algorithm
        • Inverted Triangle-APGAR Score
        • Drugs in Neonatal Resuscitation Algorithm
      • Neurology
        • Altered Level of Consciousness
        • Glasgow Coma Scale-Adult, Peds,Infant
        • Tips From the Vowels Acronym
        • NIH Stroke Scale (Abbreviated)
        • Status Epilepticus Treatment Plan
      • Obstetrics
        • Postpartum Hemorrhage Algorithm
        • Shoulder Dystocia—HELPERR
        • Vacuum Delivery Acronym-ABCDEFGHIJ
      • Ophthalmology
        • Central Retinal Artery Occlusion
        • Chemical Burn Exposure to Eye
      • Pediatrics
        • Pediatric Equipment Sizes
        • Modified Lund Browder Chart
      • Trauma
        • Shock Acronym-Shrimpcan
        • Burn Management Treatment Plan
        • Initial Care of Major Trauma
        • Trauma Flow Sheet
    • Section 2
      Universal Approach
      • CALS Universal Approach To Emergency Advanced Life Support
    • Section 3
      Steps 1-6
      • Steps 1-6
      • Step 1: Activate the Team
      • Step 2: Immediate Control and Immobilization
      • Step 3: Initial Survey
      • Step 3: Simultaneous Team Action By Team Members
      • Step 4: Preliminary Clinical Impression
      • Step 5: Working Diagnosis and Disposition
      • Step 6: Team Process and Review
    • Section 4
      Preliminary Impression/Focused Clinical Pathways
      • Pathway 1: Altered Level of Consciousness (Adult and Pediatric)
      • Pathway 2: Cardiovascular Emergencies (Adult and Pediatric)
      • Pathway 3: Gastrointestinal/Abdominal Emergencies (Adult and Pediatric)
      • Pathway 4: Neonatal Emergencies
      • Pathway 5: Obstetrical Emergencies
      • Pathway 6: Adult Respiratory
      • Pathway 7: Pediatric Respiratory
      • Pathway 8: Adult Trauma (Secondary Survey for Adults)
      • Pathway 9: Pediatric Trauma (Secondary Survey for Trauma in Children)
  • Volume II:
    Resuscitation Procedures
    • Section 5
      Airway Skills
      • Airway Skills 1: Aids to Intubation
      • Airway Skills 2: Bag-Valve-Mask Use
      • Airway Skills 3: Orotracheal Intubation
      • Airway Skills 4: Rapid Sequence Intubation
      • Airway Skills 5: Cricoid Pressure and the BURP Technique
      • Airway Skills 6: Esophageal Tracheal Combitube
      • Airway Skills 7: King Airway
      • Airway Skills 8: Intubating Laryngeal Mask Airway
      • Airway Skills 9: Nasotracheal Intubation
      • Airway Skills 10: Topical Anesthesia
      • Airway Skills 11: Retrograde Intubation
      • Airway Skills 12: Tracheal Foreign Body Removal
      • Airway Skills 13: Cricothyrotomy
      • Airway Skills 14: Tracheotomy
      • Airway Skills 15: Tracheotomy in Infants
      • Airway Skills 16: Transtracheal Needle Ventilation
    • Section 6
      Breathing Skills
      • Section 6 Breathing Skills Portals
      • Breathing Skills 1: Chest Tube Insertion
      • Breathing Skills 2: Chest Suction and Autotransfusion
      • Breathing Skills 3: Endobronchial Tube
      • Breathing Skills 4: Heliox
      • Breathing Skills 5: Needle Thoracostomy
    • Section 7
      Circulation Skills
      • Section 7 Circulation Skills Portals
      • Circulation Skills 1: Arterial and Venous Catheter Insertion
      • Circulation Skills 2: Central Venous Access
      • Circulation Skills 3: Central Venous Pressure Measurement
      • Circulation Skills 4: Emergency Thoracotomy
      • Circulation Skills 5: Intraosseous Needle Placement (Adult)
      • Circulation Skills 6: Pericardiocentesis
      • Circulation Skills 7: Rewarming Techniques
      • Circulation Skills 8: Saphenous Vein Cutdown
      • Circulation Skills 9: Transvenous Cardiac Pacing
    • Section 8
      Disability Skills
      • Section 8 Disability Skills Portals
      • Disability Skills 1: Skull Trephination
      • Disability Skills 2: Raney Scalp Clips
    • Section 9
      Trauma Skills
      • Trauma Skills Portals
      • Trauma Skills 1: Compartment Pressure Measurement
      • Trauma Skills 2: Femur Fracture Splinting
      • Trauma Skills 3: Pelvic Fracture Stabilization
      • Trauma Skills 4: Suprapubic Cystostomy
    • Section 10
      X-Rays Skills
      • X-ray Skills 1: Cervical Spine Rules and Use of Imaging Portal
      • X-ray Skills 2: Cervical Spine X-ray Interpretation
      • Xray Skills 3: Interpretation of a Pelvic X-ray
  • Volume III:
    Definitive Care
    • Section 11
      Airway
      • Rapid Sequence Intubation Portal
      • Airway Obstruction Portal
      • Heliox Treatment Portal
      • Ventilator Management Portal
      • Noninvasive Ventilatory Support Portal
      • Inspiratory Impedance Threshold Device Portal
      • Status Asthmaticus Portal
      • Anaphylaxis Portal
    • Section 12
      Cardiovascular
      • Cardiovascular 1: Classification of Pharmacological (Therapeutic) Interventions Portal
      • Cardiovascular 2: Cardiac Rhythms Portal
      • Cardiovascular 3: Pharmacology of Cardiovascular Agents Portal
      • Cardiovascular 4: Endotracheal Drug Delivery
      • Cardiovascular 5: Ventricular Fibrillation/Pulseless Ventricular Tachycardia Portal
      • Cardiovascular 6: Pulseless Electrical Activity Portal
      • Cardiovascular 7: Asystole Treatment Portal
      • Cardiovascular 8: Tachycardia Treatment Portal
      • Cardiovascular 9: Electrical Cardioversion Portal
      • Cardiovascular 10: Bradycardia Treatment Portal
      • Cardiovascular 11: Acute Coronary Syndromes Portal (Acure Ischemic Chest Pain)
      • Cardiovascular 12: Acute Heart Failure Portal
      • Cardiovascular 13: Hypertensive Crises Portal
      • Cardiovascular 14: Digitalis Toxicity Portal
      • Cardiovascular 15: Long QT Syndrome Portal
      • Cardiovascular Diagnostic Treatment Portals
    • Section 13
      Emergency Preparedness
      • Emergency Preparedness 1: Community-Wide Collaboration Portal
      • Emergency Preparedness 2: Approaches to Planning
      • Emergency Preparedness 3: Hazard Vulnerability Analysis Portal
      • Emergency Preparedness 4: Incident Command System Portal
      • Emergency Preparedness 5: Emergency Management Program Portal
      • Emergency Preparedness 6: Basic All Hazards Response Portal
      • Emergency Preparedness 7: Rapid and Efficient Mobilization Portal
      • Emergency Preparedness 8: Emergency Event Response Classifications Portal
      • Emergency Preparedness 9: Triage Portal
      • Emergency Preparedness 10: Surge Capacity Planning and Scarce Resources Guidelines
      • Emergency Preparedness 11: Glossary of Terms
      • Emergency Preparedness 12: Resources
      • Emergency Preparedness 13: Introduction to Nuclear, Biological, and Chemical Warfare
      • Emergency Preparedness 14: Nuclear Devices Portal
      • Emergency Preparedness 15: Acute Radiation Syndrome Portal
      • Emergency Preparedness 16: Biological Agents Portal
      • Emergency Preparedness 17: Chemical Agents Portal
      • Emergency Preparedness 18: Explosion and Blast Injuries Portal
      • Emergency Preparedness 19: Patient Isolation Precautions
      • Emergency Preparedness 20: Additional References and Resources
    • Section 14
      Endocrine and Metabolic
      • Endocrine and Metabolic 1: Adrenal Crisis Portal
      • Endocrine and Metabolic 2: Diabetic Ketoacidosis Portal
      • Endocrine and Metabolic 3: Myxedma Coma (Severe Hypothyroidism) Portal
      • Endocrine and Metabolic 4: Thyroid Storm Portal (Severe Thyrotoxicosis/Hyperthyroidism)
      • Endocrine and Metabolic 5: Hyperosmolar (Hyperglycemic) Non-Ketotic State Portal
      • Endocrine and Metabolic 6: Acid-Base Portal Concepts and Clinical Considerations
      • Endocrine and Metabolic 7: Disorders of Electrolyte Concentration Portal
    • Section 15
      Environmental
      • Environmental 1: Hypothermia Portal
      • Environmental 2: Hyperthermia/Heat Stroke Portal
      • Environmental 3: Burns Management Portal
      • Environmental 4: Near Drowning Portal
      • Environmental 5: High Altitude Illness Portal
      • Environmental 6: Snake Bite Portal
    • Section 16
      Farming
      • Farming 1: Respiratory Illnesses Portal
      • Farming 2: Farm Wounds/Amputation Portal
      • Farming 3: Chemical Exposures Portal
    • Section 17
      Gastrointestinal/
      Abdominal
      • Gastrointestinal/Abdominal 1: Esophageal Varices Portal
    • Section 18
      Geriatrics
      • Geriatrics 1: General Aging Portal
    • Section 19
      Infection
      • Infection 1: Adult Pneumonia
      • Infection 2: Meningitis Portal
      • Infection 3: Sepsis in Adults Portal
      • Infection 4: Abdominal Sepsis Portal
      • Infection 5: Tetanus Immunization Status Portal
    • Section 20
      Neonatal
      • Neonatal 1: Neonatal Resuscitation Algorithm
      • Neonatal 2: Drugs in Neonatal Resuscitation
      • Neonatal 3: Meconium Suctioning Portal
      • Neonatal 4: Umbilical Artery and Vein Cannulation Portal
      • Neonatal 5: Inverted Triangle/Apgar Score Portal
      • Neonatal 6: Meningitis/Sepsis in Newborn Portal
      • Neonatal 7: Respiratory Distress Syndrome Scoring System Portal
    • Section 21
      Neurology
      • Neurology 1: Status Epilepticus Portal
      • Neurology 2: Stroke Portal
      • Neurology 3: NIH Stroke Scale Portal
      • Neurology 4: Phenytoin and Fosphenytoin Loading Portal
      • Neurology 5: Increased Intracranial Pressure Portal
    • Section 22
      Obstetrics
      • Obstetrics 1: Physiology of Pregnancy Portal
      • Obstetrics 2: Ultrasound Use Portal
      • Obstetrics 3: Bleeding in Early Pregnancy/Miscarriage Portal
      • Obstetrics 4: Dilatation and Curettage Portal
      • Obstetrics 5: Fetal Heart Tone Monitoring Portal
      • Obstetrics 6: Preterm Labor Management Portal
      • Obstetrics 7: Bleeding in the Second Half of Pregnancy Portal
      • Obstetrics 8: Hypertension In Pregnancy Portal
      • Obstetrics 9: Trauma in Pregnancy Portal
      • Obstetrics 10: Emergency Cesarean Section Portal
      • Obstetrics 11: Imminent Delivery Portal
      • Obstetrics 12: Malpresentations and Malpositions: Breech, Occiput Posterior Portal
      • Obstetrics 13: Assisted Delivery Portal
      • Obstetrics 14: Shoulder Dystocia Portal
      • Obstetrics 15: Third-stage and Postpartum Emergencies Portal
      • Obstetrics 16: Thromboembolic Disease and Pregnancy Portal
    • Section 23
      Pediatrics
      • Pediatrics 1: Physiologic and Anatomic Considerations Portal
      • Pediatrics 2: Tracheal Foreign Body Portal
      • Pediatrics 3: Epiglottitis Portal
      • Pediatrics 4: Laryngotracheal Bronchitis (Croup) Portal
      • Pediatrics 5: Bacterial Tracheitis Portal
      • Pediatrics 6: Bronchiolitis Portal
      • Pediatrics 7: Pneumonia Portal
      • Pediatrics 8: Sepsis Portal
      • Pediatrics 9: Meningitis Portal
      • Pediatrics 10: Diphtheria Portal
      • Pediatrics 11: Glasgow Coma Scale Portal
      • Pediatrics 12: Intraosseous Vascular Access
    • Section 24
      Sedation/
      Pain Control/
      Anesthesia
      • Sedation/Pain Control/Anesthesia 1: Procedural Sedation
      • Sedation/Pain Control/Anesthesia 2: Management of Combative, Agitated, Delirious Patients
      • Sedation/Pain Control/Anesthesia 3: Malignant Hyperthermia Portal
    • Section 25
      Toxicology
      • Toxicology 1: Systematic Approach
      • Toxicology 2: Essential Antidotes Portal
      • Toxicology 3: Acetaminophen Overdose Portal
      • Toxicology 4: Aspirin Overdose Portal
      • Toxicology 5: Tricyclic Antidepressants Overdose Portal
      • Toxicology 6: Beta Blocker Toxicity Portal
      • Toxicology 7: Calcium Channel Blocker Toxicity Portal
      • Toxicology 8: Bendodiazepine Overdose Portal
      • Toxicology 9: Alcohol Withdrawal Portal
      • Toxicology 10: Toxic Alcohols: Methanol and Ethylene Glycol
      • Toxicology 11: Cocaine Ingestion Portal
      • Toxicology 12: Narcotic Overdose Portal
      • Toxicology 13: Amphetamine Analog Intoxication Portal
      • Toxicology 14: Iron Ingestion Portal
      • Toxicology 15: Carbon Monoxide Poisoning Portal
      • Toxicology 16: Hyperbaric Oxygen and Normobaric Oxygen
      • Toxicology 17: Cyanide Poisoning Portal
      • Toxicology 18: Organophosphates Toxicity Portal
    • Section 26
      Trauma Care
      • Trauma Care 1: Shock Portal
      • Trauma Care 2: Shock Evaluation Overview Portal
      • Trauma Care 3: Use of Hemostatic Agents to Control Major Bleeding Portal
      • Trauma Care 4: Severe Traumatic Brain Injury—Adult 
      • Trauma Care 5: Severe Traumatic Brain Injury—Pediatric
      • Trauma Care 6: Compartment Syndrome
    • Section 27
      Tropical Medicine
      • Tropical Medicine 2: Introduction
      • Tropical Medicine 3: Fever and Systemic Manifestations
      • Tropical Medicine 4: Gastrointestinal and Abdominal Manifestations
      • Tropical Medicine 5: Dermatological Manifestations
      • Tropical Medicine 6: Muscular Manifestations (Including Myocardium)
      • Tropical Medicine 7: Neurological Manifestations
      • Tropical Medicine 8: Ocular Manifestations
      • Tropical Medicine 9: Pulmonary Manifestations
      • Tropical Medicine 10: Urogenital Manifestations
      • Tropical Medicine 11: Disorders of Nutrition and Hydration
      • Tropical Medicine 12: Medicine in Austere Environs
      • Tropical Medicine 13: Antiparasitic Primer
      • Tropical Medicine 14: Concise Parasitic Identification
      • Tropical Medicine 15: Bibliography
    • Section 28
      Ultrasound
      • Ultrasound 1: Emergency Ultrasound Applications Portal
      • Ultrasound 2: Emergency Ultrasound Techniques Portal

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Cardiovascular 14: Digitalis Toxicity Portal

Introduction: Digitalis toxicity is a common adverse drug reaction. Digoxin, the form of cardiac glycoside primarily prescribed in clinical medicine, is most often used to treat supraventricular tachyarrhythmias and CHF.

Signs and Symptoms of Digitalis Toxicity1

  1. GI symptoms—including anorexia, nausea, or vomiting—are mediated by the effects of excess digitalis on the chemoreceptors of the medulla in the brain.
  2. Neurologic symptoms—including headache, fatigue, confusion, delirium, seizures, or visual color disturbance—are mediated by the effects of excess digitalis on the chemoreceptors of the medulla of the brain.
  3. Cardiac arrhythmias associated with digitalis toxicity are variable and may be hard to differentiate from rhythm disturbances caused by underlying heart disease, but most commonly the rhythm disturbances include ventricular ectopic rhythms, bradycardia with varying degrees of AV block, and atrial arrhythmias. Rhythms that especially suggest digitalis toxicity include paroxysmal atrial tachycardia with block, non-paroxysmal accelerated junctional tachycardia, bi-directional VT, new onset ventricular bigeminy, and regularized AF. Digitalis-induced cardiac arrhythmias are a result of disturbances of impulse formation and conduction within different cardiac tissues resulting from digitalis altering the refractory period, impulse transmission, and automaticity of the conduction tissue along with rhythm changes mediated by sympathetic activity and increased vagal tone.

Treatment of Digitalis Intoxication

The treatment of digitalis overdose in cases of chronic digitalis use is primarily dictated by the degree of cardiac toxicity and the hemodynamic stability demonstrated by the patient. If the patient is hemodynamically stable and displaying the common arrhythmias—such as PVCs, first-degree AV block, or AF with a slow ventricular rate—appropriate treatment consists of temporary withdrawal of the drug, ECG monitoring, and later dose adjustment to prevent recurrent problems. If the rhythm disturbance is unstable or causing hemodynamic compromise, then active intervention is indicated to the degree necessary to stabilize the patient's rhythm, until which time the excess digitalis dissipates.

In serious digitalis toxicity, specific treatment considerations include:

  1. With acute digitalis overdose (within 1 hour), consider active treatment to remove the excess digitalis with activated charcoal (AC) 1 g/kg PO. Avoid the use of naso- or- orogastric tubes as vagal stimulation may induce arrhythmias.
  2. Hypokalemia is commonly observed in patients with digitalis-induced ectopic tachyarrhythmias. These arrhythmias are frequently improved by giving potassium plus volume replacement, but hyperkalemia must be avoided.1 Give potassium therapy with caution when heart block is present, since elevating the serum potassium concentration may further impair atrial ventricular conduction.2
  3. Hypomagnesemia is frequently associated with hypokalemia and digitalis toxicity. Either rule out hypomagnesemia or give magnesium sulfate IV along with potassium IV for digitalis toxicity and cardiac arrhythmias.
  4. Digoxin-specific antibody therapy (Digibind or Digoxin Immune FAB [antigen binding fragments])3,4,5 is available and effective for acute or severe symptomatic digitalis toxicity. FAB fragments bind to free digoxin, creating an inactive compound that is excreted by the kidneys. The effect of FAB fragments begins within minutes of IV dose and results in complete removal of the effects of digitalis within 30 minutes. Although expensive, FAB fragments may be lifesaving in certain circumstances. Indications for the use of FAB fragments in digitalis toxicity include:
    1. Refractory VT
    2. Refractory VF
    3. High-grade AV block
    4. Shock or fulminant CHF
    5. Cardiac arrest
    6. Hyperkalemia (serum potassium > 5)3
    7. Steady state serum levels of digitalis > 10 ng/mL in adults3
    8. PEDS: Steady state serum levels > 5 ng/mL in children and infants5
    9. Acute ingestion of > 10 mg of digoxin in adults or (PEDS) > 0.3 mg/kg in infants, or > 4 mg in previously healthy children3,5
  5. Dosage of FAB fragments: Each 38 mg vial of FAB fragments will bind 0.5 mg of digoxin or digitoxin.3 Dosing tables are available from a regional poison control center or are present on the drug insert sheets that come with the Digibind (FAB fragments).

Dosage calculations of FAB fragments may be determined as follows:

  1. In acute ingestion of known amounts of digoxin, the number of vials of FAB fragments to give equals number of mg of digitalis ingested X 0.8 divided by 0.5 mg digitalis bound/vial.3 (ie, number of vials = mg digitalis X 0.8 divided by 0.5).
  2. If the serum digoxin level is known in the case of chronic digitalis ingestion, the number of vials of FAB fragments to give equals the serum digoxin level times the patient's weight in kg divided by 100.3
  3. If there is an unknown quantity of digoxin ingested acutely, give 10 vials of FAB fragments3 or 5 vials for a child.6

Another alternative is to give half the calculated dose and observe for response at the end of the infusion. Resolution of signs, symptoms, and arrhythmias warrants further observation; continued signs of toxicity require further FAB administration. 7, 8

Give FAB fragments IV over a 30-minute time interval through a 0.22 μm filter, except in cases where the patient is in impending cardiac arrest or is in cardiac arrest, and then give as an IV bolus.3

Side effects of FAB fragments include3:

    1. Exacerbations of CHF with the loss of digitalis effect
    2. Rapid ventricular rate in AF
    3. Hypokalemia that may appear many hours after the ingestion of the FAB fragments
  1. Treatment of digitalis-induced bradycardia/heart block

Digitalis-induced bradycardia is often mediated through the vagus nerve, so atropine (0.5 mg IV) is the initial treatment. (Repeat as needed.) The use of transvenous pacemakers for treating bradycardia or heart block associated with digitalis toxicity must be used with great caution; digitalis-toxic patients are susceptible to pacemaker-induced ventricular rhythm disturbances.

  1. Treatment of digitalis-induced ventricular premature beats and non-sustained VT
    • The initial management of ventricular ectopy consists of appropriate IV replacement of potassium, magnesium, and volume, if needed.
    • Give lidocaine first 1 to 1.5 mg/kg IV; repeat 0.5 mg/kg every 2 to 3 minutes up to 3 mg/kg. Follow with 2 to 4 mg/kg drip.9
    • Phenytoin is a not listed by the manufacturer for the treatment of digitalis toxicity but has been found to be useful in some cases when lidocaine is not effective. Give phenytoin 100 mg IV every 5 minutes by slow infusion; repeat until the arrhythmia is controlled up to maximum of 20 mg/kg.9
  2. Treatment of digitalis-induced sustained VT without shock or cardiac arrest
    • VT that is not associated with shock or cardiac arrest needs to be treated with combination therapy using anti-arrhythmic medication plus FAB fragments.
    • Initial drug therapy consists of lidocaine 1 to 1.5 mg/kg IV; repeat 0.5 mg/kg every 2 to 3 minutes up to 3 mg/kg. Follow with IV drip 2 to 4 mg/min.9
    • The FAB fragments should become effective within 30 to 60 minutes, and then the lidocaine may be stopped.3
  3. Treatment of digitalis-induced unstable VT
    • Treat VT associated with hemodynamic compromise or shock with immediate cardioversion plus 10 to 20 vials of FAB fragments IV given rapidly plus anti-arrhythmic therapy.
    • For the cardioversion, start with 25 to 50 J. Use this lower energy because digitalis-toxic patients tend to have adverse reactions to direct current (DC) counter-shock. If the patient does not respond to the initial counter-shock of 25 to 50 J, then immediately re-shock with 200 J. For a third attempt, go up to 300 J.10
    • Use lidocaine IV (as delineated for VT).
  4. Treatment of digitalis-induced VF or pulseless VT

VF and pulseless ventricular tachycardia due to digitalis toxicity initially requires following ACLS guidelines of electrical defibrillization, intubation, oxygenation, and administration of epinephrine.

Further therapy consists of:

    1. Giving lidocaine (bolus 1.5 mg/kg IV push followed by 0.5 mg/kg every 8 to 10 minutes up to 3 mg/kg).
    2. Give FAB fragments 20 vials IV push.
    3. Re-attempt defibrillation every minute until achieving cardioversion.

  1. Use of beta-adrenergic blocking drugs with digitalis toxicity

Beta blocking drugs have been used for digitalis-induced arrhythmias because beta blockers tend to decrease the heart automaticity. Nevertheless, beta blockers decrease conduction and myocardial contractility, so use with great caution, if at all.1,9

  1. Use of IA anti-arrhythmic drugs (quinidine, procainamide) with digitalis toxicity is not suggested as good clinical practice.9
  1. DC counter-shock of digitalis-toxic patients

Use DC counter-shock in digitalis-toxic patients with great caution. DC counter-shock may cause severe irreversible arrhythmias. Use lower energy settings to decrease risk.10

  1. Magnesium sulfate used to be recommended for the treatment of digitalis-induced ventricular arrhythmias.9 ECC/AHA recommendations now suggest that magnesium only be given when the patient has a magnesium deficiency or displays torsades de pointes.11

References

  1. Braunwald E. WB Saunders Company. Heart Disease, a Textbook of Cardiovascular Medicine. 1984:2:523-26.
  2. Fisch C, et al. Potassium and the monophasic action potential, electrocardiogram, conduction and arrhythmias. Progr Cardiovasc Dis. 1966:8:387.
  3. Physicians’ Desk Reference. 2002:56:1514-5.
  4. Smith TW, et al. Treatment of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: Experience in 26 cases. N Engl J Med. 1982:307:1357-62.
  5. American Heart Association. Advanced Cardiac Life Support. 1997:11-12 to 14.
  6. Levine M, O’Connor A. Dosing regimen for digoxin-specific antibody (Fab) fragments in patients with digoxin toxicity. http://www.uptodate.com/contents/dosing-regimen-for-digoxin-specific-antibody-fab-fragments-in-patients-with-digoxin-toxicity/contributors. Updated October 14, 2010. Accessed July 7, 2011.
  7. Ford M, et al. Clinical Toxicology, 1st Edition. New York: WB Saunders; 2001.
  8. Bateman D. Digoxin-specific antibody fragments: how much and when? Toxicol Rev. 2004;23:135-43.
  9. Wyugaarden JB, et al. Cecil Textbook of Medicine. 1992:19:204-205.
  10. Lown B, et al. Cardioversion and digitalis drugs: Changed threshold to electric shock in digitalized animals. Circ Res. 1965:17:519.
  11. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation Supplement. 2000; 102: (8):I-123-I124.
Edition 13-October 2011

Copyright©CALS. Comprehensive Advanced Life Support | © 2012 CALS Program