digoxin and Emergencies

Significant digitalis toxicity, although uncommon, is a medical emergency. Recognition of the problem and good supportive care (eg, administration of activated charcoal and binding resins, correction of potassium levels, restoration of heart rhythm) are the cornerstones of treatment. If indicated, immunotherapy with digoxin immune Fab (Digibind) is a valuable and effective tool.

Topics: Arrhythmias, Cardiac; Charcoal; Digitalis Glycosides; Digoxin; Emergencies; Humans; Hypokalemia; Immunoglobulin Fab Fragments; Poisoning

Fluid movement from the pulmonary capillaries into the interstitial space occurs continuously and is drained by the lymphatics. With increased leakage or decreased clearance, excessive extravascular lung water accumulates, initially as interstitial edema and subsequently as alveolar edema. The most common cause of pulmonary edema is an increase in microvascular hydrostatic pressure. An increased permeability of the capillaries is the other mechanism of production of pulmonary edema. An acute, critical reduction in colloid osmotic pressure may play a contributory role in pulmonary edema even at normal hydrostatic pressures. Dyspnea, diaphoresis, and anxiety characterize the clinical picture. A history of heart disease and congestive heart failure may be present in CPE, whereas evidence of an inciting event or disease process suggests NCPE. Hypoxia, decreased lung compliance, and increased shunt fraction are seen in both types of pulmonary edema, but the duration of pulmonary edema tends to be more severe and prolonged in NCPE. Evidence of increased permeability in NCPE distinguishes it from CPE. Clinically, this is assumed when pulmonary edema is demonstrated at normal PCWP and when edema fluid protein concentration and COP are close to those of plasma. The management of pulmonary edema consists of the improvement of gas exchange by methods that range from supplemental oxygen administration to mechanical ventilatory support with PEEP, depending on the severity of the disturbance in lung function. Improvement in myocardial function and a decrease in pulmonary congestion are accomplished with diuretics and morphine; in those patients who do not respond to this therapy, manipulation of preload, afterload, and myocardial contractility by vasodilators and inotropic agents may be required. In acute pulmonary edema, intravenously administered agents with a short half-life and rapid onset of action are preferred. The role of colloids in the treatment of pulmonary edema is controversial. The indications for the use of corticosteroids in ARDS are controversial, and an optimum dose has not been determined. Many clinicians tend to choose steroids to treat these patients, but the value of these agents in this setting awaits the results of controlled trials now under way.

Topics: Adrenal Cortex Hormones; Bloodletting; Capillary Permeability; Digoxin; Diuretics; Dobutamine; Dopamine; Emergencies; Heart Diseases; Humans; Hydrostatic Pressure; Lung; Morphine; Nitroglycerin; Nitroprusside; Osmotic Pressure; Plasmapheresis; Posture; Pulmonary Edema; Respiration, Artificial; Tourniquets; Vasodilator Agents

The clinical and laboratory findings in and the treatment of congestive heart failure, supraventricular tachycardia, pericardial disease, and hypoxemic spells are discussed.

Topics: Child; Child, Preschool; Digoxin; Emergencies; Heart Diseases; Heart Failure; Humans; Hypoxia; Infant; Infant, Newborn; Pericarditis; Tachycardia, Paroxysmal

To evaluate the efficacy and safety of a step-by-step fixed dose of specific immunotherapy protocol in case of severe digoxin poisoning in an open uncontrolled prospective study.. Twenty consecutive patients were admitted because of severe digoxin poisoning. The inclusion criteria were: digoxin overdose and either life-threatening arrhythmia; high-degree atrioventricular block, ventricular arrhythmia, or bradycardia less than 50 bpm and hyperkalaemia (>5.5 mmol/l). A two-step protocol of antidigoxin antibodies treatment was carried out. At admission, every patient received two vials of specific Fab-fragments. If after 1 h following infusion ECG signs regressed, no more treatment was given. If ECG signs did not regress, patients were given two more vials. At inclusion and 6 h after immunotherapy, clinical (cardiac rhythm, ECG records) and biological (serum digoxin concentration, potassium) findings were recorded.. Patients had a median (interquartile range) age of 83 (75-90) years. Four patients had acute poisoning and 16 chronic overdoses. Eleven patients showed ventricular arrhythmia, and five had high-degree atrioventricular block. Seventy percent of the patients needed only the first step. Significant decreases were observed in the number of cardiac dysrhythmia (16 vs. three patients), in the median (interquartile range) of serum digoxin concentration [5 microg/l (3.8-6.2) vs. 0.4 microg/l (0.3-2.2)] and in serum potassium [4.6 mmol/l (4.1-5.5) vs. 3.85 mmol/l (3.7-4.55)] before and after immunotherapy. The digoxin-related mortality was 5%.. This protocol of step-by-step digoxin-specific immunotherapy seems to be as effective as the equimolar treatment, and there was significant cost reduction in case of acute poisoning.

Topics: Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Clinical Protocols; Digoxin; Drug Overdose; Electrocardiography; Emergencies; Female; Humans; Immunoglobulin Fab Fragments; Immunologic Factors; Male; Prospective Studies

Mitral valve prolapse is not commonly on the list of differential diagnosis when a patient presents in the emergency department (ED) in severe distress, presenting with non-specific features such as abdominal pain, tachycardia and dyspnea. A healthy 55-year-old man without significant past medical history arrived in the ED with a unique presentation of a primary mitral valve prolapse with an atrial septal defect uncommon in cardiology literature. Early recognition of mitral valve prolapse in high-risk patients for severe mitral regurgitation or patients with underlying cardiovascular abnormalities such as an atrial septal defect is crucial to prevent morbid outcomes such as sudden cardiac death.

Topics: Abdominal Pain; Anticoagulants; Anxiety; Cardiotonic Agents; Continuous Positive Airway Pressure; Digoxin; Dopamine; Dyspnea; Electrocardiography; Emergencies; Heart Septal Defects, Atrial; Heart Valve Prosthesis Implantation; Humans; Male; Metoprolol; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Treatment Outcome; Warfarin

Topics: Causality; Cerebrospinal Fluid Pressure; Digoxin; Diuretics; Emergencies; Female; Humans; Hypertension, Pulmonary; Middle Aged; Papilledema; Pseudotumor Cerebri; Vision Disorders

Topics: Acute Disease; Arrhythmias, Cardiac; Cardiotonic Agents; Causality; Colectomy; Confusion; Digoxin; Diuretics; Electrocardiography; Emergencies; Humans; Hypokalemia; Male; Middle Aged; Muscle Weakness; Nursing Assessment; Paresthesia; Patient Care Planning; Patient Education as Topic; Potassium

Atrioventricular (AV) dissociation is an electrocardiographic syndrome; a descriptive term for a variety of conditions of abnormal cardiac conduction which all feature independent function of the atria and ventricles. AV dissociation can be subclassified as AV dissociation by default (an independent ventricular pacemaker responds to slowing of the dominant atrial pacemaker) versus AV dissociation by usurpation (acceleration of a latent pacemaker takes control of cardiac conduction by exceeding the intrinsic atrial rate). Inclusion of third degree AV block (complete heart block) as a manifestation of AV dissociation is controversial, yet is functionally appealing in that this disorder also features independent activity of the atria and ventricles.

Topics: Aged; Arrhythmias, Cardiac; Bradycardia; Calcium Channel Blockers; Coronary Disease; Diagnosis, Differential; Digoxin; Electrocardiography; Emergencies; Female; Heart Atria; Heart Block; Heart Ventricles; Humans; Male; Middle Aged; Sinoatrial Node; Suicide; Tachycardia, Ventricular

Topics: Aged; Arrhythmias, Cardiac; Cardiac Output, Low; Digoxin; Diuretics; Emergencies; Furosemide; Humans; Male; Potassium

We sought to determine whether there is an association between the rate of prescription of angiotensin-converting enzyme (ACE) inhibitors and the rate of hospitalization for heart failure.. We conducted a cross-sectional study linking prescribing data with hospital admission data from 215 primary health care practices in Greater Glasgow, United Kingdom. We obtained numbers of prescriptions of diuretics. ACE inhibitors, and digoxin and numbers of admissions for heart failure. The mean practice rate of diuretic prescription was 0.7 per patient per year, the mean practice rate of ACE inhibitor prescription was 0.06 per patient per year, the mean practice rate of digoxin prescription was 0.09 per patient per year, and the mean practice rate of admission for heart failure was 3.29 per 1,000 patients per year. There was a strong and significant association between the rate of diuretic prescription and the rate of digoxin prescription. There was only a moderate inverse association between the ratio of ACE inhibitor to diuretic prescriptions and the rate of admissions for heart failure.. ACE inhibitors are underused. Rates of diuretic and digoxin prescriptions correlate strongly and are presumably both markers for similar cardiovascular morbidity. There was no evidence that ACE inhibitors modulated the rate of heart failure admissions.

Topics: Adult; Aged; Angiotensin-Converting Enzyme Inhibitors; Cardiotonic Agents; Cross-Sectional Studies; Digoxin; Diuretics; Drug Utilization; Emergencies; Female; Heart Failure; Humans; Male; Patient Admission; Practice Patterns, Physicians'; Scotland

Topics: Cardiac Glycosides; Cardiac Pacing, Artificial; Child; Digoxin; Emergencies; Humans; Immunoglobulin Fab Fragments; Plant Leaves; Plant Poisoning; Plants, Medicinal; Seeds; Sri Lanka; Vomiting

Two hundred and ninety one patients admitted with atrial fibrillation through the emergency room of a regional hospital in the year 1993 were reviewed to evaluate the presenting features and in-hospital treatment of patients with symptomatic atrial fibrillation. The incidence of atrial fibrillation increased with age (mean age was 73 +/- 12 years) and the ratio of female to male was 1.8:1. The commonest presenting features were palpitation (42.3%), dyspnoea (38.1%) and heart failure (16.4%). The most frequently associated cardiac conditions were hypertension (28.9%), atherosclerotic cardiovascular disease (24.7%) and rheumatic heart disease (17.5%). Pulmonary diseases (18.6%), diabetes mellitus (12.7%) and thyrotoxicosis (6.2%) were the principal associated non-cardiac conditions. Thromboembolic complications were found in 15 patients at presentation (5.2%). Cardiac enzyme assessment was investigated in two thirds of the patients (68.1%), while thyroid function test (59.5%) and echocardiography (29.6%) were less commonly investigated. Digoxin was still the most popular drug used for ventricular rate control, and cardioversion was performed in only 6.9% of patients. Antithrombotic therapy was used in 5.8% of patients only although it was clinically indicated in more than half of the patients (52%). Contraindications of anticoagulation were found in 23 patients (7.9%), including a history of gastrointestinal or cerebrovascular bleeding, active bleeding, chronic renal failure and poor drug compliance. The mean hospital stay was 5 +/- 4 days, compared to a mean stay of 2.7 days for other medical patients. Fourteen patients (4.8%) died during hospitalisation.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Amiodarone; Atrial Fibrillation; Comorbidity; Digoxin; Electric Countershock; Emergencies; Female; Hong Kong; Hospitalization; Humans; Incidence; Length of Stay; Male; Thrombolytic Therapy; Treatment Outcome

Topics: Digoxin; Drug Utilization; Emergencies; Humans

To assess current strategies used to investigate and manage acute atrial fibrillation in hospital.. Prospective survey of all acute admissions over 6 months.. District general hospital serving a population of 230,000 in north east Glasgow.. 2686 patients admitted as emergency cases over 6 months.. Of the 2686 patients, 170 (age range 38-95, mean (SD) 73.5 (10.6) years; 70 men (41%) and 100 women (59%)) were admitted with atrial fibrillation. The principal underlying medical conditions were ischaemic heart disease in 79 (46.5%), rheumatic heart disease in 26 (15.3%), and thyroid disease in six (3.5%). Cardiac failure was present on admission in 61 (36%), cerebrovascular events in 23 (14%), and myocardial infarction in 17 (10%). Of those with a history of atrial fibrillation (102 (60%) including 10 with paroxysmal atrial fibrillation) treatment on admission included digoxin in 71 (70%), warfarin in 20 (20%), and aspirin in 17 (17%); the aspirin was predominantly given for concomitant vascular disease. The mean (SD) inpatient stay was 16 days (19.7) (range 1-154) largely due to the patients with stroke. Thyroid function tests were performed in only 63% and echocardiography in 33%. Overall, the rate of introduction of anticoagulation (seven patients) and attempted cardioversion (21 patient: 19 pharmacological and two electrical) was surprisingly low. Only 49 patients (34% of those not on warfarin) had contraindications to anticoagulation: these included peptic ulcer or gastrointestinal bleeding in 18 (12%), dementia in eight (6%), chronic renal failure or dialysis in eight (6%), and alcohol excess in four (3%).. Standard investigations were inadequately used in patients with atrial fibrillation and there was a reluctance to perform cardioversion or to start anticoagulant treatment.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Atrial Fibrillation; Digoxin; Echocardiography; Electric Countershock; Emergencies; Female; Hospitalization; Humans; Length of Stay; Male; Medical Audit; Middle Aged; Scotland; Thyroid Function Tests; Warfarin

With the aim of studying the characteristics of the use of digoxin in a population which attended a hospital emergency department for heart failure or auricular fibrillation a 3 month observational study was carried out in the emergency department of the Ciudad Sanitaria de la Vall d'Hebron.. One hundred twelve patients treated with digoxin who went to the emergency department for heart failure and/or decompensated auricular fibrillation were studied. Clinical and pharmacological histories, determination of digoxinemia and the usual complementary explorations were performed.. It was found that 50% of the patients were not adequately controlled and treatment was not followed in 21% of the patients. No significant relation was found between the doses of digoxin and the age of the patients. In multivariant analysis (multiple lineal regression) digoxinemia was related with the doses (beta = 0.22, p = 0.01), cardiac frequency (beta = 0.19, p < 0.05), and compliance (beta = 0.18, p = 0.05). Among the patients in whom the cause of decompensation of cardiac failure could not be identified, one third (31%) were found to have infratherapeutic digoxinemia.. Most patients with cardiac decompensation attending an emergency department are those who are not adequately controlled in primary health care and the rate of incomplete following of the prescription is high. Furthermore, one third of the patients who decompensate with no clinically apparent reason has an infratherapeutic plasma concentration of digoxin.

Topics: Adult; Aged; Aged, 80 and over; Analysis of Variance; Atrial Fibrillation; Chi-Square Distribution; Digoxin; Drug Utilization; Emergencies; Female; Heart Failure; Humans; Male; Middle Aged; Regression Analysis; Spain

Topics: Aged; Aged, 80 and over; Cardiomegaly; Digoxin; Electrocardiography; Emergencies; Equipment Failure; Female; Heart Failure; Humans; Pacemaker, Artificial; Radiography

Vagal maneuvers terminate new onset, catheter-induced paroxysmal supraventricular tachycardia (PSVT) in up to 92% of patients. The risk and benefit of vagal maneuvers for treating PSVT in the emergency department (ED) is inadequately defined. The purpose of this study was to determine the efficacy of nonpharmacological vagal interventions in converting spontaneous episodes of PSVT in adult patients and to derive a treatment plan for such patients based on clinical decision analysis. Seventeen adult patients who presented to the ED because of PSVT were treated with carotid sinus massage, Valsalva maneuver, and head-down tilt (alone and in combination). Only three patients converted out of PSVT with vagal intervention. The remainder received verapamil, which converted 12 of the 14 patients (86%) who received the drug (one required digoxin, one required synchronized cardioversion). Vagal maneuvers are safe in young, otherwise healthy patients but problems have been documented in the literature in older patients, who have a higher likelihood of coronary and/or cerebrovascular disease. Clinical decision analysis indicates that young patients should be treated initially with vagal maneuvers but that older patients (above approximately 65 years of age) should be treated initially with verapamil.

Topics: Adult; Aged; Aged, 80 and over; Decision Support Techniques; Digoxin; Electric Countershock; Emergencies; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Prospective Studies; Tachycardia, Supraventricular; Valsalva Maneuver; Verapamil

Topics: Aged; Aged, 80 and over; Digoxin; Electrocardiography; Emergencies; Female; Heart Block; Humans; Male; Tachycardia

Topics: Aged; Aged, 80 and over; Diagnosis, Differential; Digoxin; Dyspnea; Emergencies; Female; Heart Block; Heart Failure; Humans; Immunoglobulin Fab Fragments; Nausea

A 1-month-old infant suffered cardiac arrest shortly after presentation to the emergency department. The child had a history of heart disease treated with digoxin. The infant died despite intensive resuscitative efforts, including the use of digoxin-specific Fab antibodies. A brief discussion of this case and the use of digoxin-specific antibodies is presented.

Topics: Antibodies; Digoxin; Emergencies; Heart Arrest; Heart Failure; Humans; Infant, Newborn; Male; Resuscitation

Topics: Atrial Fibrillation; Atrial Flutter; Digoxin; Edrophonium; Electric Countershock; Emergencies; Humans; Pressure; Propranolol; Tachycardia, Paroxysmal; Verapamil; Wolff-Parkinson-White Syndrome

Topics: Adolescent; Adult; Aspirin; Child; Child, Preschool; Costs and Cost Analysis; Digoxin; Diuretics; Emergencies; Female; Humans; Male; Mitral Valve Stenosis; Myocarditis; Penicillin G Benzathine; Prednisone; Premedication; Pulmonary Edema; Rheumatic Heart Disease; Tropical Climate

Topics: Adult; Aged; Digoxin; Dose-Response Relationship, Drug; Emergencies; Female; Humans; Injections, Intravenous; Male; Middle Aged; Tachycardia, Paroxysmal

Topics: Diazepam; Digoxin; Diuretics; Dyspnea; Emergencies; Epinephrine; Glucocorticoids; Humans; Lidocaine; Myocardial Infarction; Nitrates; Pulmonary Edema; Theophylline

Topics: Abdomen, Acute; Aerosols; Child, Preschool; Chloral Hydrate; Cold Temperature; Coma; Croup; Diazepam; Digoxin; Dyspnea; Emergencies; Epiglottis; Epinephrine; Humans; Infant; Infant, Newborn; Laryngismus; Myocarditis; Plasma Substitutes; Posture; Prednisolone; Prednisone; Shock, Septic

Topics: Aged; Aminophylline; Anti-Bacterial Agents; Asthma; Bronchitis; Digoxin; Diuretics; Emergencies; Expectorants; Humans; Hypoxia; Lung; Prednisolone; Respiration, Artificial; Terbutaline; Vital Capacity

Topics: Digoxin; Emergencies; Humans

A recent "stat" procedure recommended by the manufacturer for use with a commercial digoxin radioassay involves doubling the amount of antibody used in the regular procedure, to compensate for the decrease in binding that results from use of a shorter (10 min) incubation. This has two obvious disadvantages: increased material cost and decreased sensitivity because of the increase in the binding capacity of the assay. In our modified procedure, we kept the binding capacity constant by decreasing the volume of the incubation mixture without increasing the amount of antibody. Total binding and the rate of binding on 10-min incubation are 50.4 and less than 1.3% per minute, respectively. Results by our modified stat procedure compare well with those by the manufacturer's suggested regular procedure in terms of sensitivity, accuracy, and precision, and are more sensitive and economical than those by the manufacturer's suggested stat procedure.

Topics: Digoxin; Emergencies; Humans; Radioimmunoassay; Reagent Kits, Diagnostic

A rapid but precise radioassay for digoxin has been developed by optimizing the conditions for antigen-antibody interaction and for separation of bound and free fractions. This new procedure involves incubation of radioactively labeled antigen, antibody, and standard or sample at 3 degrees C for 10 min. Charcoal is then added, the mixture centrifuged for 5 min, and the radioactivity of the supernate counted. Results are available in less than 1 h after receipt of the specimens, making the procedure suitable for emergency determinations. Results correlate well with those by our routine procedure (Becton Dickinson) (r = 0.9739, y = 0.0356 + 0.9915x, n = 49). Analytical recovery of added pure digoxin exceeds 94%, both within and between assay CV's are less than 8%.

Topics: Antigen-Antibody Reactions; Charcoal; Digoxin; Emergencies; Humans; Kinetics; Radioimmunoassay

Topics: Animals; Arrhythmias, Cardiac; Blood Pressure; Bradycardia; Cardiovascular Diseases; Digoxin; Emergencies; Epinephrine; Female; Fetal Diseases; Fetal Heart; Haplorhini; Heart Failure; Heart Rate; Humans; Hypoxia; Infant; Infant, Newborn; Infant, Newborn, Diseases; Isoproterenol; Lidocaine; Pregnancy; Radiography; Resuscitation; Transposition of Great Vessels

Topics: Aged; Anesthesia; Anesthesia, Conduction; Anesthesia, General; Anesthetics; Cardiovascular Diseases; Cardiovascular Physiological Phenomena; Coronary Disease; Digoxin; Emergencies; Geriatrics; Homeostasis; Humans; Kidney; Liver; Metabolism; Nerve Block; Postoperative Care; Postoperative Complications; Preoperative Care; Respiratory Physiological Phenomena; Respiratory Therapy; Respiratory Tract Diseases; Surgical Procedures, Operative; Thromboembolism

Topics: Digoxin; Electric Countershock; Emergencies; Humans; Lidocaine; Metaproterenol; Prognosis; Shock, Cardiogenic; Tromethamine