Serial monitoring of serum magnesium levels, telemetry, respiratory rate, deep tendon reflexes, and blood pressure is appropriate.Magnesium is contraindicated in the setting of bradycardia or AV block and should be used cautiously in patients with renal failure. Cepeda Piorno J, Pobes Martinez de Salinas A, Gonzalez Garcia ME, Fernandez Rodriguez E. [Use of MDRD equation to detect occult renal failure and reduce the risk of digitalis overdose]. The clinical manifestations digoxin toxicity are the same in infants, children, and adults, and the treatment is the same across all these age groups.For prehospital care, administration of oxygen, cardiac monitoring, establishment of intravenous (IV) access, and transport are usually the only requirements. Some clinicians have suggested using 10-25 joules initially in ventricular tachycardia or fibrillation, but most clinicians suggest starting at 50-100 joules for a wide, complex ventricular tachycardia, rather than at the 200 joules recommended in ACLS protocols.With the availability of digoxin-specific Fab, pacemaker use now has limited value. Bidirectional tachycardia in a patient with digitalis toxicity. Monitor magnesium levels approximately every 2 hours. Effective management also relies on early recognition that a dysrhythmia and/or noncardiac manifestation may be related to digitalis intoxication.General principles of management include the following:Assessment of the severity of the toxicity and its etiology (eg, accidental ingestion, unintentional or deliberate overdose, altered digoxin metabolism due to diminished renal clearance or interaction with other drugs)Consideration of factors that influence treatment, including age, medical history, chronicity of digoxin intoxication, existing heart disease and/or renal insufficiency, and ECG changesContinuous hemodynamic assessment, including 12-lead electrocardiogram (ECG) and cardiac monitoringPrompt measurement of electrolyte levels, including potassium and calcium, and of serum creatinine and digoxin levelsActivated charcoal is indicated for acute overdose or accidental ingestion. Sex-based differences in the effect of digoxin for the treatment of heart failure.

Observe patients for at least 6 hours on a cardiac monitor. Contemporary use of digoxin in the management of cardiovascular disorders.

Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. It has proved helpful in reversing severe sinus bradycardia.Magnesium sulfate, 2 g IV over 5 minutes, has been shown to terminate dysrhythmias in digoxin-toxic patients with and without overt cardiac disease. This will tell you WHY the drug was ordered…what condition is this medication treating in your patient? Atropine is indicated for hemodynamically unstable bradyarrhythmic patients; lidocaine is indicated for ventricular tachycardia.Supportive care of digitalis toxicity includes hydration with IV fluids, oxygenation and support of ventilatory function, discontinuation of the drug, and, sometimes, the correction of electrolyte imbalances. 1999 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.
Patients who have taken an intentional overdose should be cleared by a psychiatry consult before discharge.Gheorghiade M, van Veldhuisen DJ, Colucci WS. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Digoxin can reduce the uptake of doxorubicin into cardiac tissue and thus temper the cardiomyopathy caused by doxorubicin.

For patients with rate-related ischemia or hemodynamic instability, digoxin Fab fragments is the treatment of choice.Short-acting beta blockers (eg, esmolol) may be helpful for supraventricular tachyarrhythmias with rapid ventricular rates, but these agents may precipitate advanced or complete atrioventricular (AV) block in patients with sinoatrial or AV node depression. 2002 Careful patient monitoring, including drug levels, is required in these clinical settings.Advanced age decreases the volume of distribution and renal clearance.
Collateral effects of antiarrhythmics in pediatric age. Ahmed A, Waagstein F, Pitt B, et al.

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