Digoxin ToxicityICU / resuscitation

Elderly on digoxin for AF with CKD; 3 days of nausea, vomiting, yellow-tinged vision, confusion; HR 38 with regularised AF; K⁺ 5.9; digoxin 4.1 ng/mL (or deliberate yellow oleander seed ingestion)

• Ventricular arrhythmia
• High-grade AV block
• K⁺ >5.5 (acute)
• Hypotension

• Hyperkalaemia from other causes
• β-blocker/calcium-channel blocker toxicity
• Sick sinus syndrome
• Other cardiac glycosides (oleander, toad venom)

• Admit: Symptomatic toxicity, arrhythmia, raised K⁺, high level
• ICU: Life-threatening arrhythmia, hyperkalaemia, haemodynamic compromise
• Dialysis: Not effective for digoxin removal (large volume of distribution) — only for AKI indications

• Yellow oleander (Thevetia) seeds cause the same cardiac glycoside poisoning — common in South India and Sri Lanka; Fab works.
• Bidirectional VT or "regularised" AF in a patient on digoxin = toxicity until proven otherwise.
• Chronic toxicity occurs with modest levels in the elderly with CKD and hypokalaemia.

• Continue digoxin while toxicity is suspected
• Rely on the digoxin level after Fab
• Leave hypokalaemia or hypomagnesaemia uncorrected
• Use high-energy cardioversion as first choice

• Ignoring Mg²⁺
• Level interpretation after Fab
• Missing the interacting drug
• Restarting at the old dose

Monitored bed/CCU until rhythm and K⁺ stable.