Digoxin ToxicityICU / resuscitation

Emergency / Toxicology · Ward Pathways · Free — no sign-in

N/V, yellow-green vision, arrhythmia; ↑K in acute

ABCDE

Monitor; correct K⁺/Mg; atropine for bradycardia; digoxin-Fab for life-threatening toxicity.

Calculators:
  1. Check: K, Mg, Ca + digoxin level
  2. Severe (arrhythmia / K >5 / hemodynamic) → Digoxin immune Fab
  3. Bradycardia → atropine; correct Mg

Order set

  • Digoxin level
  • K⁺, Mg, Ca, U&E
  • ECG/monitoring
  • Digoxin-specific Fab if severe

Criteria

AdmitSymptomatic toxicity / arrhythmia
ICULife-threatening arrhythmia, hyperkalaemia
DialysisNot effective for digoxin (protein-bound) — use Fab
DischargeRhythm stable, level/electrolytes normalised, dosing reviewed
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • Life-threatening arrhythmia
  • K⁺ >5 (acute)
  • Hemodynamic instability
Differentials
  • Other bradyarrhythmia causes
  • Electrolyte disturbance
Common mistakes
  • Ignoring Mg
  • Over-fearing calcium — the "stone heart" concern is a historical caution not supported by modern case-series data; if hyperkalaemia needs membrane stabilisation, calcium is acceptable — but Fab remains definitive
Disposition & follow-up

Fab for severe toxicity; correct electrolytes; monitor.

Discharge package
MedicationsReview digoxin dose/indication; correct electrolytes
Follow-upRecheck level/renal
Warning symptomsNausea, visual changes, palpitations
💊 Treatment detail — doses & preparation
Digoxin-specific Fabdigoxin antidote
DoseAcute OD: 10–20 vials if arrest/life-threatening; chronic toxicity: 3–6 vials; empirical if level >10 ng/mL or K⁺ >5
Preparation40 mg vial reconstitute + dilute in 100 mL NS over 30 min
MonitorK⁺ (drops fast; watch post-Fab hyperkalaemia rebound in CKD), arrhythmia resolution; total digoxin level uninterpretable after Fab
Potassium chlorideelectrolyte
DosePO 40–100 mmol/day divided. IV: 10 mmol/h peripheral, 20 mmol/h central with cardiac monitor
PreparationIV: NEVER undiluted push — 10 mmol in 100 mL or 40 mmol/L bag via pump
MonitorK⁺ q4–6 h during replacement, ECG, urine output >0.5 mL/kg/h
Avoid pacing/calciumsafety
DoseTranscutaneous pacing poorly effective and risky; IV calcium "stone heart" fear is historical nuance — acceptable if hyperkalaemia needs membrane stabilisation; Fab definitive. Non-arrest Fab dosing: vials = serum level (ng/mL) × weight (kg) / 100, or tablets ingested × 0.8 / 0.5
Preparation—
MonitorK⁺, digoxin level (pre-Fab), ECG
📖 poisons-centre / EXTRIPReviewed July 2026

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