digoxin case .ppt
DESCRIPTION
Digoxin caseTRANSCRIPT
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Case Presentation
Dr.Yassin
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History
• 2 years old healthy boy.• Presented with Hx of ingestion of
digoxin tablets . 15 min prior to ER visit.
• Amount is unknown.• Digioxin 62.5 mic .
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History
• No Hx of abnormal movement.• No Hx of vomiting.• No Hx of palpitation.
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History
• Perinatal Hx:• Past medical and surgical Hx:• Allergy:• Vaccination Hx:• Family Hx:• Social Hx:• Developmental Hx:
UNREMARKABLE
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EXAM• Looks well.• HR: 123• RR: 24• B/P: 109\47• Temp: 36.5
• CVS: WNL• RS: WNL• CNS: WNL• ABDOMIN: WNL
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ER course
• Patient taken immediately to ER.• Gastric lavage done revealed tablet
particles.• Charcol given.
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PLAN OF
CARE
investigation treatment education
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digoxin• Antiarrhythmic agent, inotrope.• Cardiac Glycoside.
• T1/2: Premature infants, 61–170 hr.• full-term neonates, 35–45 hr.• infants, 18–25 hr.• children, 35 hr.
• Indication: heart failure, Supraventricular tachycardia .
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Presentation of toxication
• CVS: asystole, atrial or nodal ectopic beats. • A-V block, AV dissociation, S-A block,
ventricular arrhythmias, • first-, second- (Wenckebach), or third-degree
heart block.• CNS: Seizure.lethargy, headache, visual
disturbance. • electrolyte imbalances Hyperkalemia • GIT: diarrhea, nausea, vomiting
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Risk factor
• Impaired renal function.• Hypokalemia.• Hypomagnesemia.• Hypercalcemia. • low thyroxine.
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Monitoring
• Digoxin levels are most useful if measured 4–6 hr after ingestion.
• Therapeutic serum digoxin concentration: <2ng/mL
• Toxic serum digoxin concentration: >4ng/mL
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Monitoring
• 12-lead ECG and continuous cardiac monitoring.
• Monitor electrolytes (calcium, magnesium, potassium) hourly.
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management
• Supportive Care/Decontamination: • CAB• Activated charcoal up to several hours
postingestion.
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Specific treatment• Antidote: Digoxin Specific Antibody
Fragments (Fab)
• Indications: • severe toxicity (ventricular, progressive
bradyarrhythmias, 2nd or 3rd degree heart block).
• serum potassium >5 mEq/L .• serum digoxin concent >4-10 ng/mL ????
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Specific treatment
• Serum digoxin concentration increases after Fab secondary to intravascular diffusion of antibody-bound, inactive digoxin.
• Adverse reactions: Allergic reaction, rebound hypokalemia, CHF (secondary to the sudden decrease in digoxin's inotropic effect).
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Treatment cont• Electrolyte disturbances (hyperkalemia):• typically self-correct after Fab treatment.
• Bradyarrhythmias: Fab is first-line therapy; consider atropine, dopamine, epinephrine, or isoproterenol for second-line therapy.
• Asystole and pulseless electrical activity (PEA) Life-threatening tachyarrhythmias Treat according to Pediatric Advanced Life Support (PALS) protocol.
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Management calculating the dose
• First, determine total body digoxin load (TBL):• TBL (mg) = serum digoxin level (ng/mL) × 5.6 ×
wt (kg) ÷ 1000,• OR TBL (mg) = mg digoxin ingested × 0.8• Then, calculate digoxin immune Fab dose:• Dose in number of digoxin immune Fab vials
(Digibind or DigiFab): vials = TBL ÷ 0.5• Infuse IV over 15–30 min