Circulation

In patients with chronic accumulation of digoxin, treat dehydration using intravenous fluids.

Withhold digoxin and all drugs that contribute to cardiovascular instability, including negative chronotropes (eg beta blockers, calcium channel blockers) and drugs that impair renal function or inhibit digoxin elimination (eg NSAIDs, macrolide antibiotics).

Digoxin-specific immune antibody fragments (Digoxin immune Fab) are indicated for potentially lethal chronic digoxin accumulation that is suggested by:

  • cardiac arrest
  • ventricular arrhythmias or runs of ventricular ectopic complexes
  • bradyarrhythmias with associated hypotension.

For bradycardia with associated hypotension, atropine or adrenaline (epinephrine) can be used to improve perfusion. Use:

1 atropine 0.6 mg (child: 0.02 mg/kg up to 0.6 mg) intravenously; repeat once after 15 minutes if required for bradycardia chronic digoxin accumulation atropine

OR

1 adrenaline (epinephrine) 10 to 20 micrograms (child: 0.1 micrograms/kg) intravenously every 2 to 3 minutes, aiming for adequate perfusion (guided by heart rate and blood pressure) chronic digoxin accumulation adrenaline (epinephrine)

FOLLOWED BY

adrenaline (epinephrine) by intravenous infusion (see Adrenaline (epinephrine) intravenous infusion instructions for advice on preparation and administration).

Consider temporary cardiac pacing if the clinical response to atropine or adrenaline is inadequate.

Digoxin immune Fab has no role in the management of patients with bradycardia alone (ie without hypotension) because complete reversal of digoxin has been shown to have limited clinical benefit in this setting.