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Digitalis poisoning: the basis for treatment with antidigoxin antibodies

Nogu√© S, Cino J, Civeira E, Puiguriguer J, Burillo-Putze G, Due√Īas A, Soy D, Aguilar R, Corominas N

Secci√≥n de Toxicolog√≠a Cl√≠nica, √Ārea de Urgencias, Hospital Cl√≠nic, Barcelona, Grupo de Investigaci√≥n ¬ďUrgencias: procesos y patolog√≠as¬Ē, IDIBAPS, Barcelona, Spain. Servicio de Cardiolog√≠a, Hospital General de Catalunya, Sant Cugat del Vall√©s, Barcelona, Spain. Servicio de Medicina Intensiva, Hospital Cl√≠nico Universitario, Zaragoza, Spain. Servicio de Urgencias y Unidad de Toxicolog√≠a Cl√≠nica, Hospital Son Espases, Palma de Mallorca, Spain. Servicio de Urgencias, Hospital Universitario, Tenerife, Spain. Unidad de Toxicolog√≠a Cl√≠nica, Hospital R√≠o Hortega, Valladolid, Spain. Servicio de Farmacia, Hospital Cl√≠nic, Barcelona, Espa√Īa. Servicio de Farmacia, Hospital Josep Trueta, Girona, Spain.

Digitalis poisoning, particularly in persons under long-term digoxin therapy, is a reason
for repeated visits to Spanish emergency departments. Acute poisoning is rare but may
occur as a result of attempted suicide or the intake of plants that contain cardiac
glycosides. Kidney failure modifies digoxin pharmacokinetics and is an important trigger
for severe adverse reactions to the drug. Clinical manifestations are nonspecific but
usually include gastrointestinal events (nausea, vomiting, diarrhea, and abdominal pain)
along with circulatory effects (hemodynamic instability, dizziness or lightheadedness,
and syncope). Bradycardia (slow atrial fibrillation, conduction blocks) is common and
may cause asystole. Tachyarrhythmias may lead to ventricular fibrillation. In acute
digitalis poisoning, hyperkalemia is a risk factor for cardiac arrest. The digoxin plasma
concentration can indicate the severity of the poisoning, provided the tissue-to-plasma
ratio is at steady state. To treat acute poisoning, administer activated charcoal within the
first few hours after digitalis intake. In such cases, or in poisoning during long-term
digoxin therapy, continuous electrocardiographic monitoring is essential and potassium
and magnesium concentrations should be brought within the normal range. The firstline
treatment for bradycardia is atropine. Ventricular arrhythmias are treated with
phenytoin or lidocaine. In life-threatening situations, antidigoxin antibodies must be
used. They should be available in all referral or high-level tertiary care facilities and are
administered according to the total digoxin body load.

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