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Oxygen, cardiac monitoring, IV access, and transport are usually the only requirements.Atropine is indicated for hemodynamically unstable bradyarrhythmias; lidocaine is indicated for ventricular tachycardia.給予氧氣、心電圖監視，點滴，轉院。在緩脈造成血液循環不穩定時可以給予ATROPINE，如果VT可以給予LIDOCAINEEmergency Department CareGuide treatment of patients with digoxin toxicity by their signs and symptoms and the specific toxic effects. Treatment should not necessarily be driven by digoxin levels alone. Therapeutic options range from simply discontinuing digoxin therapy for patients who are stable with chronic toxicity to fab fragments, pacemaker, antiarrhythmic drugs, magnesium, and hemodialysis for acute severe ingestions.根據病患的症狀和徵象來治療中毒病患，不要完全依賴血中毛地黃濃度。治療方式：停用藥物，給予fab fragment，裝新律調節器，給予抗心律不整藥物，給予Mg，急性嚴重中毒需洗腎。Initiate supportive therapy with oxygen, cardiac monitoring, and IV access. Activated charcoal is indicated for acute overdose or accidental ingestion. Cholestyramine binds enterohepatically-recycled digoxin and digitoxin, although no outcome studies have been performed.Gastric lavage increases vagal tone and may precipitate or worsen arrhythmias. Consider pretreatment with atropine if gastric lavage is performed.首先給予氧氣、心電圖監視器、點滴，急性中毒可以給予活性碳，可以給予Cholestyramine 來吸收腸肝循環的毛地黃。洗胃可能會增加迷走神經興奮性，可能會加重心律不整的狀況。給予GASTRIC LAVAGE前可以先給予ATROPINE。The availability of a digitalis-fab antibodies (Digibind) antidote usually renders gastric lavage unnecessary. Management of dysrhythmias varies, depending on the presence or absence of hemodynamic instability, the nature of the arrhythmia, the presence or absence of electrolyte disturbances, and the preferences of toxicology and/or cardiology consultants.
DIGIBIND的使用讓洗胃變的無用武之地，治療心律不整需配合循環穩定與否、心律不整的型態、是否有電解質失調以及心臟科醫師會診。
Bradyarrhythmias that are hemodynamically stable may be treated with observation and discontinuation of the drug.
心跳太慢但循環穩定的狀況，可以先觀察以及停用藥物。
Ensure proper hydration to optimize renal clearance of excess drug.
適當的補充水分讓腎臟可以將藥物排出。
GI binding agents (eg, charcoal, cholestyramine) may be utilized to bind enterohepatically-recycled digitalis.
腸胃吸附劑可以將腸肝循環的毛地黃吸附。
Hemodynamically stable supraventricular arrhythmias may be treated conservatively with observation and discontinuation of digoxin.
血液循環穩定的心室上心律不整可以先觀察以及停用藥物。
In the setting of rate-related ischemia or hemodynamic instability, Digibind is the treatment of choice.
DIGIBIND可以使用在因為心跳過慢引起的缺血症狀或血液循環不穩定的狀況。
Hemodynamically unstable bradyarrhythmias respond best to Digibind. Atropine may be used for temporary adjuncts. Cardiac pacing has been used successfully, but it can lower the fibrillatory threshold and induce arrhythmias. PVCs, bigeminy, or trigeminy may be observed unless the patient is hemodynamically unstable, in which case lidocaine may be effective. Ventricular tachycardia responds best to Digibind. Lidocaine and Dilantin may be useful. Lidocaine may be given in boluses of 100 mg, according to advanced cardiac life support (ACLS) guidelines. If lidocaine is successful, begin a maintenance infusion at 1-4 mg/min. Phenytoin has been administered in boluses of 100 mg every 5-10 min up to a loading dose of 15 mg/kg. Avoid procainamide and bretylium. Asystole and ventricular fibrillation are very serious findings. Digibind is indicated; however, its effect is limited by poor cardiac blood flow. Nevertheless, the use of digoxin-fab fragments is associated with a 50% survival rate. Cardioversion is relatively contraindicated because asystole or ventricular fibrillation may be precipitated. Calcium channel blockers are contraindicated because they may increase digoxin levels. Short-acting beta-blockers (eg, esmolol) may be helpful, but advanced or complete AV block may be precipitated.Consider magnesium therapy as a temporizing antiarrhythmic agent until fab fragments are available. It may be lifesaving when ventricular tachycardia or ventricular fibrillation is present.After an initial bolus of 2 g intravenously, a maintenance infusion at 1-2 g/h is initiated. Monitor magnesium levels approximately every 2 hours. The therapeutic goal is a level between 4 and 5 mEq/L. Correct electrolyte abnormalities, especially hypokalemia and hypomagnesemia. Dysrhythmias may be reversed with correction of electrolyte imbalances. Treat hyperkalemia when K+ level is greater than 5.5 mEq/L. Calcium is not recommended to treat hyperkalemia in this setting because ventricular tachycardia or ventricular fibrillation may be precipitated. This is based on the fact that intracellular calcium levels are already high in the setting of digoxin toxicity. However, anecdotal case reports and animal studies have been published that refute the dangers of calcium administration. Unless the patient is in extremis, other measures should be preferentially used to treat hyperkalemia. Sodium bicarbonate and/or glucose and insulin are indicated. Treatment with digoxin-fab fragments is indicated for hyperkalemia with K+ level greater than 5 mEq/L. Kayexalate (0.5 g/kg PO) also is helpful in binding potassium and enterohepatically-recycled digitalis. However, digoxin-induced hyperkalemia reflects an extracellular shift, not an increase in total body potassium. Caution is indicated when using Kayexalate concurrently with insulin/glucose/bicarbonate and/or Digibind because hypokalemia may be precipitated, which may worsen clinical toxicity.Digoxin-fab fragments (Digibind) are generally indicated for the following: Dysrhythmias associated with hemodynamic instability. Altered mental status attributed to digoxin toxicity. Hyperkalemia with K+ greater than 5 mEq/L. Serum digoxin level greater than 10 ng/mL in adults at steady state (ie, 6-8 h post acute ingestion or at baseline in the clinical setting of chronic toxicity). Ingestion greater than 10 mg in adults (40 X 0.25 mg tablets) or greater than 0.3 mg/kg in children.
Oxygen, cardiac monitoring, IV access, and transport are usually the only requirements.Atropine is indicated for hemodynamically unstable bradyarrhythmias; lidocaine is indicated for ventricular tachycardia.給予氧氣、心電圖監視，點滴，轉院。在緩脈造成血液循環不穩定時可以給予ATROPINE，如果VT可以給予LIDOCAINEEmergency Department CareGuide treatment of patients with digoxin toxicity by their signs and symptoms and the specific toxic effects. Treatment should not necessarily be driven by digoxin levels alone. Therapeutic options range from simply discontinuing digoxin therapy for patients who are stable with chronic toxicity to fab fragments, pacemaker, antiarrhythmic drugs, magnesium, and hemodialysis for acute severe ingestions.根據病患的症狀和徵象來治療中毒病患，不要完全依賴血中毛地黃濃度。治療方式：停用藥物，給予fab fragment，裝新律調節器，給予抗心律不整藥物，給予Mg，急性嚴重中毒需洗腎。Initiate supportive therapy with oxygen, cardiac monitoring, and IV access. Activated charcoal is indicated for acute overdose or accidental ingestion. Cholestyramine binds enterohepatically-recycled digoxin and digitoxin, although no outcome studies have been performed.Gastric lavage increases vagal tone and may precipitate or worsen arrhythmias. Consider pretreatment with atropine if gastric lavage is performed.首先給予氧氣、心電圖監視器、點滴，急性中毒可以給予活性碳，可以給予Cholestyramine 來吸收腸肝循環的毛地黃。洗胃可能會增加迷走神經興奮性，可能會加重心律不整的狀況。給予GASTRIC LAVAGE前可以先給予ATROPINE。The availability of a digitalis-fab antibodies (Digibind) antidote usually renders gastric lavage unnecessary. Management of dysrhythmias varies, depending on the presence or absence of hemodynamic instability, the nature of the arrhythmia, the presence or absence of electrolyte disturbances, and the preferences of toxicology and/or cardiology consultants.
DIGIBIND的使用讓洗胃變的無用武之地，治療心律不整需配合循環穩定與否、心律不整的型態、是否有電解質失調以及心臟科醫師會診。
Bradyarrhythmias that are hemodynamically stable may be treated with observation and discontinuation of the drug.
心跳太慢但循環穩定的狀況，可以先觀察以及停用藥物。
Ensure proper hydration to optimize renal clearance of excess drug.
適當的補充水分讓腎臟可以將藥物排出。
GI binding agents (eg, charcoal, cholestyramine) may be utilized to bind enterohepatically-recycled digitalis.
腸胃吸附劑可以將腸肝循環的毛地黃吸附。
Hemodynamically stable supraventricular arrhythmias may be treated conservatively with observation and discontinuation of digoxin.
血液循環穩定的心室上心律不整可以先觀察以及停用藥物。
In the setting of rate-related ischemia or hemodynamic instability, Digibind is the treatment of choice.
DIGIBIND可以使用在因為心跳過慢引起的缺血症狀或血液循環不穩定的狀況。
Hemodynamically unstable bradyarrhythmias respond best to Digibind. Atropine may be used for temporary adjuncts. Cardiac pacing has been used successfully, but it can lower the fibrillatory threshold and induce arrhythmias. PVCs, bigeminy, or trigeminy may be observed unless the patient is hemodynamically unstable, in which case lidocaine may be effective. Ventricular tachycardia responds best to Digibind. Lidocaine and Dilantin may be useful. Lidocaine may be given in boluses of 100 mg, according to advanced cardiac life support (ACLS) guidelines. If lidocaine is successful, begin a maintenance infusion at 1-4 mg/min. Phenytoin has been administered in boluses of 100 mg every 5-10 min up to a loading dose of 15 mg/kg. Avoid procainamide and bretylium. Asystole and ventricular fibrillation are very serious findings. Digibind is indicated; however, its effect is limited by poor cardiac blood flow. Nevertheless, the use of digoxin-fab fragments is associated with a 50% survival rate. Cardioversion is relatively contraindicated because asystole or ventricular fibrillation may be precipitated. Calcium channel blockers are contraindicated because they may increase digoxin levels. Short-acting beta-blockers (eg, esmolol) may be helpful, but advanced or complete AV block may be precipitated.Consider magnesium therapy as a temporizing antiarrhythmic agent until fab fragments are available. It may be lifesaving when ventricular tachycardia or ventricular fibrillation is present.After an initial bolus of 2 g intravenously, a maintenance infusion at 1-2 g/h is initiated. Monitor magnesium levels approximately every 2 hours. The therapeutic goal is a level between 4 and 5 mEq/L. Correct electrolyte abnormalities, especially hypokalemia and hypomagnesemia. Dysrhythmias may be reversed with correction of electrolyte imbalances. Treat hyperkalemia when K+ level is greater than 5.5 mEq/L. Calcium is not recommended to treat hyperkalemia in this setting because ventricular tachycardia or ventricular fibrillation may be precipitated. This is based on the fact that intracellular calcium levels are already high in the setting of digoxin toxicity. However, anecdotal case reports and animal studies have been published that refute the dangers of calcium administration. Unless the patient is in extremis, other measures should be preferentially used to treat hyperkalemia. Sodium bicarbonate and/or glucose and insulin are indicated. Treatment with digoxin-fab fragments is indicated for hyperkalemia with K+ level greater than 5 mEq/L. Kayexalate (0.5 g/kg PO) also is helpful in binding potassium and enterohepatically-recycled digitalis. However, digoxin-induced hyperkalemia reflects an extracellular shift, not an increase in total body potassium. Caution is indicated when using Kayexalate concurrently with insulin/glucose/bicarbonate and/or Digibind because hypokalemia may be precipitated, which may worsen clinical toxicity.Digoxin-fab fragments (Digibind) are generally indicated for the following: Dysrhythmias associated with hemodynamic instability. Altered mental status attributed to digoxin toxicity. Hyperkalemia with K+ greater than 5 mEq/L. Serum digoxin level greater than 10 ng/mL in adults at steady state (ie, 6-8 h post acute ingestion or at baseline in the clinical setting of chronic toxicity). Ingestion greater than 10 mg in adults (40 X 0.25 mg tablets) or greater than 0.3 mg/kg in children.
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