digoxin and Water-Electrolyte-Imbalance

Poisoning due to deliberate self-harm with the seeds of yellow oleander (Thevetia peruviana) results in significant morbidity and mortality each year in South Asia. Yellow oleander seeds contain highly toxic cardiac glycosides including thevetins A and B and neriifolin. A wide variety of bradyarrhythmias and tachyarrhythmias occur following ingestion. Important epidemiological and clinical differences exist between poisoning due to yellow oleander and digoxin; yellow oleander poisoning is commonly seen in younger patients without preexisting illness or comorbidity. Assessment and initial management. Initial assessment and management is similar to other poisonings. No definite criteria are available for risk stratification. Continuous ECG monitoring for at least 24 h is necessary to detect arrhythmias; longer monitoring is appropriate in patients with severe poisoning. Supportive care. Correction of dehydration with normal saline is necessary, and antiemetics are used to control severe vomiting. Electrolytes. Hypokalemia worsens toxicity due to digitalis glycosides, and hyperkalemia is life-threatening. Both must be corrected. Hyperkalemia is due to extracellular shift of potassium rather than an increase in total body potassium and is best treated with insulin-dextrose infusion. Intravenous calcium increases the risk of cardiac arrhythmias and is not recommended in treating hyperkalemia. Oral or rectal administration of sodium polystyrene sulfonate resin may result in hypokalemia when used together with digoxin-specific antibody fragments. Unlike digoxin toxicity, serum magnesium concentrations are less likely to be affected in yellow oleander poisoning. The effect of magnesium concentrations on toxicity and outcome is not known. Hypomagnesaemia should be corrected as it can worsen cardiac glycoside toxicity. Gastric decontamination. The place of emesis induction and gastric lavage has not been investigated, although they are used in practice. Gastric decontamination by the use of single dose and multiple doses of activated charcoal has been evaluated in two randomized controlled trials, with contradictory results. Methodological differences (severity of poisoning in recruited patients, duration of treatment, compliance) between the two trials, together with differences in mortality rates in control groups, have led to much controversy. No firm recommendation for or against the use of multiple doses of activated charcoal can be made at present, and furthe. Digoxin-specific antibody fragments remain the only proven therapy for yellow oleander poisoning. Further studies are needed to determine the place of activated charcoal, the benefits or risks of atropine and isoprenaline, the place and choice of antiarrhythmics, and the effect of intravenous magnesium in yellow oleander poisoning.

Topics: Antibodies, Blocking; Antidotes; Antiemetics; Arrhythmias, Cardiac; Blood Pressure; Charcoal; Digoxin; Electrocardiography; Emetics; Fluid Therapy; Humans; Nerium; Ondansetron; Plant Poisoning; Potassium; Resuscitation; Therapeutic Irrigation; Water-Electrolyte Imbalance

In Uganda, few children with congenital heart diseases (CHD) benefit from early corrective cardiac surgery. These children are at high risk of developing heart failure and electrolyte imbalances; factors which increase their risk of developing arrhythmias. This study aimed to determine the prevalence and factors associated with arrhythmias among children with congenital heart diseases receiving care at Mulago Hospital.. This was a cross-sectional study carried out from August 2013 to March 2014 at Mulago Hospital. Children were consecutively enrolled into the study. Standard 12-lead electrocardiograms (ECGs) were performed on 194 children with CHD (age range 10 days-15 years). Data was analysed using SPSS 16.0.. Out of 194 children studied, 53/194 (27.3 %, 95 % CI 21.0 - 33.6) children had arrhythmias. Of the CHD children, 44/194 (22.7 %, 95 % CI 16.8 - 28.6) had first degree AV block while 9/194 (4.6 %, 95 % CI 1.7 - 7.6) children had either ectopic atrial rhythm, premature atrial contractions, junctional rhythm, complete atrioventricular (AV) dissociation or premature ventricular contractions. Children using digoxin were more likely to have first degree AV block (OR 3.75, 95 % CI 1.60-8.86) while those aged 5 years and below were less likely to have first degree AV block (OR 0.16, 95 % CI 0.07-0.37).. Arrhythmias are common among children with CHD receiving care from Mulago Hospital. These are associated with digoxin use, child's age and electrolyte imbalances; factors which can easily be assessed, managed and where possible modified in these children during their care.

Topics: Adolescent; Age Factors; Arrhythmias, Cardiac; Cardiotonic Agents; Child; Child, Preschool; Cross-Sectional Studies; Digoxin; Electrocardiography; Female; Heart Defects, Congenital; Hospitals; Humans; Infant; Infant, Newborn; Male; Prevalence; Referral and Consultation; Risk Factors; Time Factors; Uganda; Water-Electrolyte Imbalance

Digitalis glycosides are among the oldest drugs used in cardiology. Nowadays, due to the limited indications for their use (advanced heart failure, usually concomitant with atrial fibrillation), cases of poisoning induced by this class of drugs are rarely observed. Digoxin produces a positive inotropic and bathmotropic effect on the heart, but has a negative chronotropic and dromotropic effect. Cardiac glycosides have a narrow therapeutic window, so digitalis treatment can easily lead to symptoms of overdose. In patients taking digoxin, the drug therapeutic level should be maintained at 1-2 ng/ml; the toxic effects occur at concentrations > 2.8 ng/ml and are mainly related to disturbances of cardiac function and of the circulatory system, as well as gastrointestinal symptoms and CNS disturbances. We present, a 45-years-old patient who was hospitalized following the ingestion with suicidal intent of 100 0.25 mg tablets of digoxin. In spite of rapidly applied gastric irrigation and administration of activated charcoal, the drug level in the patient's blood was estimated at 12.0 ng/ml. During her stay on the ward, typical symptoms of severe poisoning were observed: from gastric symptoms (severe nausea, vomiting) to numerous severe arrhythmias and conduction disturbances. Type I, II and III AV blocks were detected, as well as numerous ventricular and supraventricular extrasystoles. These conduction disorders required the use of temporary endocardial pacing. Due to the unavailability of specific antidotes (antidigitalis antibodies) and lack of efficient methods of extracorporeal elimination of the drug, symptomatic treatment comprising the correction of electrolyte disturbances and heart rate control remains the most effective.

Topics: Arrhythmias, Cardiac; Atrial Fibrillation; Digoxin; Electrocardiography; Female; Fluid Therapy; Humans; Middle Aged; Nausea; Suicide, Attempted; Vomiting; Water-Electrolyte Imbalance

Topics: Acid-Base Imbalance; Action Potentials; Arrhythmias, Cardiac; Digitalis Glycosides; Digoxin; Electrocardiography; Heart; Humans; Water-Electrolyte Imbalance

Topics: Aged; Autopsy; Digoxin; Diuretics; Female; Forensic Medicine; Heart Diseases; Humans; Hypertension; Iatrogenic Disease; Middle Aged; Water-Electrolyte Imbalance

The leucocyte data on four malnourished children who died suddenly when high-energy feeding was started were retrospectively analysed. The pretreatment rate constant for sodium efflux in leucocytes was higher and the intracellular sodium concentration lower in this group than in 13 malnourished children who recovered uneventfully with feeding. Two other children with unusual leucocyte electrolyte values and sodium pump activity were identified and closely monitored when high-energy treatment was begun. They rapidly developed the syndrome of extracellular fluid overload but were successfully treated with diuretics and digoxin. Though the precise relation between the findings in the leucocytes and the development of this overload syndrome is not clear, the pretreatment leucocyte values are nevertheless valuable in predicting which malnourished children are at risk of sudden death when refeeding is started.

Topics: Child, Preschool; Death, Sudden; Digoxin; Female; Furosemide; Humans; Infant; Leukocytes; Male; Nutrition Disorders; Potassium; Sodium; Sudden Infant Death; Water-Electrolyte Imbalance