First-line treatment for serious toxicity

Consult expert advice.

The indications for a more energetic approach to digoxin toxicity include:

• persistent nausea with vomiting
• heart block
• heart failure
• cardiac arrhythmia

The management includes:

• intravenous potassium:
  • 40 mmol potassium in 5% dextrose over 1 hr
  • ECG monitoring throughout
  • potassium is stopped if sinus rhythm returns or there are signs of hyperkalaemia e.g. peaked T waves
  • a total of 120 mmol may be given
  • if initial potassium levels were normal, then the risk of hyperkalaemia is reduced if the potassium is infused in 250 ml of 20% dextrose with 30 U of soluble insulin
    
    
• intravenous magnesium:
  • magnesium protect the myocardium
  • give 50 ml of 2% magnesium sulphate over 1 hr
  • repeat infusion as required
    
    
• activated charcoal p.o.