Wasu Tachawattanakul MD Objective Source of cardioactive steroid Pharmacokinetics of cardioactive steroid Clinical manifestation Management and antidote William Withering 1741 1799 Systemic effect of foxglove ID: 1015951
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1. Medical Toxicology – Cardioactive steroidWasu Tachawattanakul, M.D.
2. ObjectiveSource of cardioactive steroidPharmacokinetics of cardioactive steroidClinical manifestationManagement and antidote
3. William Withering 1741 –1799 Systemic effect of foxglove
4. Cardioactive steroid - CASSteroid nucleusDigitoxoses
5. Cardioactive steroid – CAS
6. Source of Cardioactive steroid
7. Source of Cardioactive steroidยี่โถ – OleanderNerium Oleander
8. รำเพย – Yellow oleanderNerium Oleander
9. รำเพย – Yellow oleanderNerium Oleander
10. ชวนชม – Desert Rose; Impala LilyAdenium obesum
11. Foxglove – Digitalis purpureaLily of valley – Convallaria majalisDogbane – Apocynum cannabinum
12. คางคก Toad
13. Pharmacokinetics of cardioactive steroid
14. Pharmacologyof Digoxin
15. Pharmacology and ToxicologyNormal depolarizationNormal repolarization
16. Pharmacology and ToxicologyPharmacologic CASToxicologic CAS
17. Electrophysiologic effects of CAS on myocardium
18. Clinical manifestation& management
19. Case Report – Acute digitalis intoxicationA 30 year old female Ingestion of 70 tablets of 0.25 mg digoxin (total dose 17.5 mg) 1hr. PTAShe had developed nausea and recurrent vomiting 20 minutes after ingestion
20. Case Report – Acute digitalis intoxicationPR 102/ minute, BP of 106/70 mmHg, RR 20/ minute, and was maintaining oxygen saturation of 99% on room air. Systemic examination was unremarkable Initial electrocardiograph : NSRRoutine lab & Serum digoxin lv.Rx. Gastric lavage & Activated charcoal
21. Case Report – Acute digitalis intoxicationInitial investigations Serum digoxin levels of 12.63 ng/mlSerum calcium 8.3 mg/dl, potassium 4.6 mmol/L, sodium 137 mmol/L, magnesium 3.13 mg/dl Normal hemogram, liver & renal function tests
22. At ICU – 2 hrs. after admissionPersistent vomiting Diplopia, blurring and yellowing of vision Intermittent episodes of bradycardia along with hypotension (SBP up to 70 mmHg)
23. Electrocardiographs initially showed variable and prolonged PR with atrial ectopics, which subsequently converted into complete heart block
24. Case Report – Acute digitalis intoxicationNonavailability of Fab fragments.Immediate cardiology opinion was taken and temporary pacemaker was inserted.Hemoperfusion was done
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26. Serum digoxin levels during resin hemoperfusionClearing of vision and resolution of nausea and vomiting within 4 hours of resin hemoperfusion. Her heart rate also improved and her atrioventricular block also be corrected over the next 24 hours.
27. Case Report – Acute digitalis intoxicationSerum digoxin levels dropped to 3.06 ng/ml after 24 hours and to 2.56 ng/ml after 36 hours of resin hemoperfusionDischarged after 4 days of hospitalization.
28. Acute digitalis intoxicationGI symptoms : nausea, vomiting, anorexia, and vague abdominal pain.Cardiac manifestations : bradydysrhythmias or AV block.Neurologic manifestations : weakness or confusion can occur independently of the blood pressure
29. Xanthopsiaviewing yellow-green halos around objects.
30. Chromatopsiaaltered color perception
31. ManagementGI DecontaminationGastric lavage : < 1 hr.Activated charcoal : < 1-2 hr.Whole bowel irrigation : No
32. ManagementEnhance eliminationMultidose AC : YesUrine alkalinization : NoHemodialysis : Yes
33. Antidote : Digoxin specific antibodyDSFab bind intravascular free digoxin and excrete through kidneyIndication for DSFabLife-threatening dysrhythmiasHyperkalemia > 5.5 mEq/LSerum digoxin lv. > 10 ng/ml (in acute poisoning)Serum digoxin lv. > 6 ng/ml (in chronic poisoning)
34. DSFab Dosing : ไม่ทราบปริมาณ Empirical doseAcute : 10-20 vialChronic : Adult 3-6 vial, Child 1-2 vial
35. DSFab Dosing : ทราบปริมาณยาที่กินEx. Digoxin(0.25) 70 tabsDSFab(vial) = [(0.25x70) / 0.5 ] x 0.8= 28 vial“DSFab 1 vial : Digoxin 0.5 mg”Digoxin bioavailability = 0.8
36. DSFab Dosing :ทราบ Serum digoxin Lv. Ex. Serum digoxin Lv. = 10 ng/ml ( Wt.= 60 kg )DSFab(vial) = (10 x 60) / 100= 6 vialDSFab vial = [ Serum digoxin Lv(ng/ml) x Wt(kg.) ] / 100
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38. Case Report – Chronic digitalis intoxicationCase Female 60 Yr. U/D HT DM type2 DLP IHD AFCurrent MedGlipizide(5) 1x1 PO acHumalin 12-0-8 SC acAtorvastatin(10) 1 tab PO hsEnalapril(5) 1x2 PO pcISDN(10) 1x3 PO acASA(81) 1x1 PO pcFurosemide(40) 1x1 PO pcDigoxin(0.25) 1x1 PO pc
39. Case Report – Chronic digitalis intoxicationPresent with drowsiness, fatigue, nausea, anorexia 1 week prior to arrivalBP 100/60 mmHg, PR 52/min , RR 14/min, Temp 36.1˚C DrowsinessOther physical examinations were normal
40. Case Report – Chronic digitalis intoxication
41. Case Report – Chronic digitalis intoxicationLaboratory investigationNa = 136, K = 2.8, Cl = 102, CO2 = 21Serum digoxin Lv. = 5.4 ng/ml (Last Digoxin ingestion = 10 hr. Prior to arrival)
42. Chronic digitalis intoxicationTypically occurs in the context of intercurrent illness, especially with impaired renal functionOnset over days to weeks
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44. Management of chronic digoxin intoxicationResuscitationSupportive care and monitoringDecontamination : not indicatedEnhanced elimination : HDAntidote : DSFabSeek and treat underlying cause/inter-current illness
45. Thank you of your attention