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Digitalis and You

Digitalis and You. Michelle Troendle Case conference August 6, 2014. Movie #3: Casino Royale!. Casino Royale. Where do you find this in nature?. 1) Digitalis purpurea (foxglove) 2) Nereum oleander (oleander) 3) Thevetia peruviana (yellow oleander)

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Digitalis and You

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  1. Digitalis and You Michelle Troendle Case conference August 6, 2014

  2. Movie #3: Casino Royale! • Casino Royale

  3. Where do you find this in nature? • 1) Digitalis purpurea (foxglove) • 2) Nereum oleander (oleander) • 3) Thevetiaperuviana (yellow oleander) • 4) Convallariamajalis (lily of the valley) • 5) Urgineamaritima (red squill) • 6) Bufoalvarius (Colorodo River toad)

  4. Digitalis • Purple, pink, white, yellow • Grows to about 3 feet • Whole plant toxic Foxglove Toxin: Digitoxin

  5. Nerium oleander Common oleander Toxin: oleandrin

  6. Convallariamajalis Lily of the valley Toxin: convallotoxin, convallarin

  7. Thevetiaperuviana • Common method of suicide in Sri Lanka • Also called Lucky Nut Yellow oleander Toxin: thevetin

  8. Urgineamaritima Red squill Toxin: scillaren

  9. Bufotoxin

  10. Digoxin

  11. Signs of an acute overdose • GI distress – nausea, vomiting, abdominal pain • Lethargy • Confusion • Atrial and ventricular ectopy (may progress to VT or VF) • Sinus bradycardia • Sinus arrest • High-degree AV block

  12. Quiz • What is the most common dysrhythmia associated with digoxin toxicity? • PVCs

  13. EKG changes – name a pathagnomicdysrhythmia

  14. EKG – another pathagnomicdysrhythmia

  15. When to treat digoxin toxicity Acute Chronic • Heart Block • K+ > 5 • 15 ng/mL anytime after ingestion • > 10 ng/mL 6 hrs after ingestion • Ingestion of: • 10 mg adult • 4 mg child • Dysrhythmia • GI symptoms • Altered mental status • Heart block • Hypotension

  16. Dosing of Dig-fab • It blows to calculate • 3 general ways to dose: • 1) Estimate quantity of digoxin acutely ingested and assume 80% bioavailability • 2) Obtain a serum digoxin concentration (SDC) and using a pharmacokinetic formula incorporate the apparent Vd of digoxin using the patient’s body weight (kg) • 3) use an empiric dose based on the average requirement for an acute or chronic overdose in an adult or child

  17. Ok let’s go through this – option 1 • # of vials = Amount ingested (mg) x 80% .5 (mg/vial) • Limitation – history made be inaccurate, which can cause error in calculating dose

  18. Calculation based on dig level • # vials = SCD (ng/dL) x Weight (kg) 100

  19. Empiric Acute Chronic • Adults: 10-20 vials • Children: 10 vials *This is a lot easier, but will frequently overestimate or underestimate Fab requirements • Adults: 3-6 vials • Children: 1-2 vials * Each vial of DSFab contains 38 mg (digibind) or 40 mg (digifab) of purified DSFab that will bind approximately .5 mg digoxin or digitoxin

  20. Let’s review this scene Likes Dislike • Digoxin toxicity can cause ventricular tachycardia • Did they give him digi-fab? • Ipicac – no nonono!!!!!! • Patients with ventricular tachycardia have a heart rate well over 130s • Patients with ventricular tachycardia with a pulse get cardioverted, not defibrillated • Patients generally don’t defibrillate themselves • You do not shock asystole

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