Treatment of Cardiac Glycoside Toxicity in Ventricular Fibrillation and Cardiac Arrest
This protocol addresses life-threatening digoxin toxicity presenting in patients who are in cardiac arrest, where immediate intervention is required.
Clinical Scenario
Signs of life-threatening digoxin toxicity in a patient in cardiac arrest. Qualifying presentations include:
- Ventricular tachycardia or fibrillation
- Asystole or symptomatic high-degree atrioventricular block
- Severe hyperkalaemia (serum potassium >6.5 mmol/L)
- Hypotension (systolic blood pressure <100 mmHg) associated with end-organ dysfunction
Treatment Approach
The indicated treatment involves immediate administration of digoxin immune Fab — the complete protocol with full dosing criteria is available below.
Monitoring goals: Following treatment, close monitoring is required until normalisation of serum potassium, body temperature, blood pressure, ECG, and renal function — with particular attention to potassium levels in the first 6 hours.
References
DOI: 10.1097/MEJ.0000000000001065
- Ventricular tachycardia or fibrillation
- Asystole or symptomatic, high-degree atrioventricular block
- Severe hyperkalaemia (serum potassium >6.5 mmol/L)
- Hypotension (systolic blood pressure <100 mmHg) associated with end-organ dysfunction
- The consensus expert opinion was that for patients with digoxin toxicity in cardiac arrest (loss of cardiac output due to asystole, pulseless electrical activity or tachyarrhythmias), five vials of digoxin immune Fab (40 milligrams per vial) are administered immediately.
- For patients with potentially life-threatening digoxin toxicity who are in cardiac arrest, five vials (or as many vials as available up to a maximum of five) of digoxin immune Fab (40 milligrams per vial) should be administered immediately; if an adequate clinical response is not seen after 30 min, a further five vials can be given.
- Patients should be monitored closely after administration of digoxin immune Fab, including assessment of serum potassium concentrations, body temperature, blood pressure, ECG and renal function (serum urea and creatinine and estimated glomerular filtration rate); monitoring should continue until potassium concentration, ECG and renal function are 'normalised'.
- Potassium levels should be assessed regularly, particularly during the first 6 h following treatment.
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