MOFFITT CARDIOLOGY REPORT PEARLS 5/23/17: Digoxin Toxicity and DigiFab!

Hey Everyone! Thanks to Jesse and YY for discussing the case of an elderly man with bradycardia due to possible digoxin toxicity! We also discussed a second case of possible Heyde syndrome and looked at an echo with aortic valve endocarditis. Pearls below focusing on digoxin toxicity:

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Top Pearls:

  1. In a patient with a-fib, regularization of a-fib is a sign of digoxin toxicity!
  2. An elevated digoxin level is helpful, but a normal level does not rule out digoxin toxicity!
  3. Digoxin-specific Fab fragments (DigiFab) indicated for unstable arrhythmias, among other indications (see below). Digibind was discontinued in the U.S.

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For those who want more info:

Check out Myung’s previous pearls on bradycardia and digoxin toxicity:

https://ucsfmed.wordpress.com/2016/10/18/bradycardia-and-digoxin-toxicity/

A few additional pearls from today’s discussion:

  • In a patient with a-fib, regularization of a-fib is a sign of digoxin toxicity!
  • An elevated digoxin level is helpful, but a normal level does not rule out digoxin toxicity!

Management of digoxin toxicity:

  • CABs, tele, IV access, ECG, finger stick glucose if AMS
  • Digoxin-specific antibody (Fab) fragments (Digibind was discontinued in the U.S. The newer model is called DigiFab! LOVE that name.)
    • See below for recommended indications
  • Atropine can temporize bradyarrhythmias
  • IV fluid can temporize hypotension (caution heart failure)
  • ACLS for life-threatening ventricular arrhythmias

Indications for DigiFab:

  • Life-threatening or hemodynamically unstable arrhythmia
    • VT, VF, asystole, complete heart block, Mobitz II heart block, symptomatic bradycardia
  • Hypotension
  • Hyperkalemia (K>5)
  • End-organ dysfunction (renal failure, AMS)
  • Some advocate treating based on dig level or amount ingested, controversial

More info on DigiFab:

  • Each vial (40 mg) of Fab binds approximately 0.5 mg of digoxin. Dosing is complicated- look it up or discuss with pharmacy! 10 vials initially for ingestion of unknown amount.
  • Side effects = hypotension, phlebitis, hypokalemia, hypersensitivity reaction, serum sickness, and digoxin withdrawal effect can lead to VT or decompensated heart failure.

 

Evernote: https://www.evernote.com/shard/s272/sh/6d089b2b-b315-41bf-b3dd-da76094bbff4/dc0e80c410e3b6c43af300f05516eb18

 

Have a great day everyone!

SamMy

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