Michelle Troendle Case conference August 6, 2014

 Casino Royale Casino Royale

 1) Digitalis purpurea (foxglove)  2) Nereum oleander (oleander)  3) Thevetia peruviana (yellow oleander)  4) Convallaria majalis (lily of the valley)  5) Urginea maritima (red squill)  6) Bufo alvarius (Colorodo River toad)

 Purple, pink, white, yellow  Grows to about 3 feet  Whole plant toxic Foxglove Toxin: Digitoxin

Common oleander Toxin: oleandrin

Lily of the valley Toxin: convallotoxin, convallarin

 Common method of suicide in Sri Lanka  Also called Lucky Nut Yellow oleander Toxin: thevetin

Red squill Toxin: scillaren

 GI distress – nausea, vomiting, abdominal pain  Lethargy  Confusion  Atrial and ventricular ectopy (may progress to VT or VF)  Sinus bradycardia  Sinus arrest  High-degree AV block

 What is the most common dysrhythmia associated with digoxin toxicity?  PVCs

ACUTECHRONIC  Heart Block  K+ > 5  15 ng/mL anytime after ingestion  > 10 ng/mL 6 hrs after ingestion  Ingestion of:  10 mg adult  4 mg child  Dysrhythmia  GI symptoms  Altered mental status  Heart block  Hypotension

 It blows to calculate  3 general ways to dose:  1) Estimate quantity of digoxin acutely ingested and assume 80% bioavailability  2) Obtain a serum digoxin concentration (SDC) and using a pharmacokinetic formula incorporate the apparent Vd of digoxin using the patient’s body weight (kg)  3) use an empiric dose based on the average requirement for an acute or chronic overdose in an adult or child

 # of vials = Amount ingested (mg) x 80%.5 (mg/vial)  Limitation – history made be inaccurate, which can cause error in calculating dose

 # vials = SCD (ng/dL) x Weight (kg) 100

ACUTECHRONIC  Adults: vials  Children: 10 vials *This is a lot easier, but will frequently overestimate or underestimate Fab requirements  Adults: 3-6 vials  Children: 1-2 vials * Each vial of DSFab contains 38 mg (digibind) or 40 mg (digifab) of purified DSFab that will bind approximately.5 mg digoxin or digitoxin

LIKESDISLIKE  Digoxin toxicity can cause ventricular tachycardia  Did they give him digi- fab?  Ipicac – no no no no!!!!!!  Patients with ventricular tachycardia have a heart rate well over 130s  Patients with ventricular tachycardia with a pulse get cardioverted, not defibrillated  Patients generally don’t defibrillate themselves  You do not shock asystole