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FRCEM Final SAQ > Toxicology emergencies > Flashcards

Toxicology emergencies Flashcards

1
Q

What is the toxicity for salicylate poisoning with
regards to :

A. Ingested dose for toxicity
B. Serum levels for toxicity

A

A-The ingested dose:

  • 125mg/kg - mild toxicity
  • 250mg/kg moderate toxicity
  • 500 mg/kg severe - fatal toxicity

B- Serum levels for toxicity

  • mild toxicity = < 450mg/L
  • moderate toxicity = 450-700mg/L
  • Severe toxicity = > 700mg/L
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2
Q

GIve 6 treatment options in the ED to manage Salicylate poisoning ?

A
  1. Consider oral activated charcoal (50 g for an adult, 1 g/kg for a child) if ingested more than 125 mg/kg body weight salicylate less than one hour previously.
  2. Gastric lavage if the patient has ingested more than 500 mg/kg body weight salicylate within one hour.
  3. Aggressive rehydration.
  4. Urinary alkalinisation:

If the salicylate concentration in an adult is above 500 mg/L (3.6 mmol/L): 225 mL of 8.4% over 60 minutes

  1. treat Hypokalaemia:
  2. consider Haemodialysis as the treatment of choice for severe poisoning
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3
Q

In Severe Salicylate poisoning -

give 9 indications for considering haemodialysis as the treatment of choice

A
  1. Plasma concentrations greater than 700 mg/L
  2. Acute kidney injury
  3. Congestive cardiac failure
  4. Non-cardiogenic pulmonary oedema
  5. Coma
  6. Convulsions
  7. CNS effects not resolved by correction of acidosis
  8. Persistently high salicylate concentrations unresponsive to urinary alkalinisation
  9. Severe metabolic acidosis (pH below 7.2)
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4
Q

A. What level is carbon monoxide toxicity consistent with in non-smokers and smokers?

B. Describe 4 Physical signs of carbon monoxide poisoning?

A

A. non-smokers- 3-4%
smokers - 10%

  1. cherry red macula ( eyes )
  2. cherry red skin ( skin )
  3. ataxia ( brian )
  4. cognitive deficit ( brain )
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5
Q

What are the indications for hyperbaric oxygen therapy in a patient with Carbon monoxide poisoning?

A
  1. COHB level > 20% ( severe )
  2. Pregnancy
  3. neuro - loss of conciousness
  4. neuro - neurological abnormality
  5. neuro - psychiatric abnormality
  6. cardiac - ECG abnormalities & arrythmias
  7. cardiac - cardiac ischaemia
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6
Q

How do you calculate serum osmolality?

What is a normal osmolar gap?

What is an abnormally raised osmolar gap suggestive of?

A

Calculated osmolality = Glucose + Urea + 2x Na

A normal osmolar gap is < 10.
A small gap exists because the calculation does not take into account some normal osmotic charged elements like potassium, chloride, sulphate etc.

Elevation suggests the presence of exogenous osmotically active particles and includes 4 main groups:

  1. Alcohols – Ethylene Glycol, methanol, ethanol,
    acetone, isopropyl alcohol
  2. Sugars – Mannitol,
  3. Sorbitol Lipids – e.g. hypertryglyceridaemia
  4. Proteins – Hypergammaglobulinaemia

Ethylene glycol has a metabolite called glycolate, which is similar in structure to lactate. This can be wrongly interpreted by blood gas machines as an abnormally elevated lactate

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7
Q

What are the specific management points in treating ethylene glycol poisoning?

A
  1. if presenting within 1 hour of ingestion consider Gastric decontamination - gastric aspiration.
    ( not activated charcoal as it is innefective in absorbing ethylene glycol )
  2. Specific antidotes:
    * ethanol - oral 2.5ml/kg of 40% vodka or
    IV 10ml/kg of 10% ethanol
  • fomepizole 15mg/kg ( competitive inhibitor of alcohol
    dehydrogenase )
  1. other standard supportive treatment:
    * persistent acidosis: 50ml of 8.4% NAHCO3
    * hypotension
    * seizures
    * reduced GCS
  2. Renal dialysis - 5 indications ( see next flash card)
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8
Q

What are the 5 indications for Renal dialysis in the management of ethylene glycol poisoning?

A
  1. an ethylene glycol level of >500mg/l
  2. renal - renal failure refractory to all therapy
  3. metabolic - severe metabolic acidosis ( PH < 7.25 )unresponsive to other treatment
  4. electrolyte - severe electrolyte imbalance refractory
  5. clinical - clinical deterioration despite supportive management
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9
Q

What are the key findings on blood gas analysis of ethylene glycol poisoning?

A 
a metabolic acidosis with raised anion gap ( > 10 )
 AND
 raised osmolar gap ( > 10mmol/L ) 
AND
 a falsely elevated lactate level
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10
Q

Give a differential diagnosis for oligo-arthiritis?

A
  1. septic ( Lyme’s disease, bacterial, viral , fungal )
  2. inflammatory ( RA, Psoriatic arthritis, IBD )
  3. crystal ( gout, pseudogout )
  4. systemic - ankylosing spyndylitis, reiters syndrome, reactive arthritis, SLE ,sarcoidosis,
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11
Q

In Tricyclic antidepressant overdose - which medication ( in order of recommended use as per GEMNET guidelines ) would you prescribe for managing hypotension?

Resource:
GEMNET- guideline for the management of tricyclic antidepressant overdose

A

1st - IV fluid with 0.9% NACL
2nd - 50ml of 8.4% NaHC03 ( if no response to IV fluid)
3rd option- vasopressors ( if not responded to 1 & 2 )
4th option - 10mg IV glucagon ( to treat life-threatening hypotension or arrythmias not respinding to other measures)

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12
Q

What ED principles of managment would you apply to the initial treatment of a patient with TAD overdose?

Resource:
GEMNET- guideline for the management of tricyclic antidepressant overdose

A
  1. Decontaminate: if presenting within 1 hour of ingestion
    • activated charcoal AND gastric lavage
  2. serial ECG’s
  3. Blood gas analysis
  4. treat haemodynamic instability
  5. manage seizures with benzodiazepines ( avoid
    phenytoin.
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13
Q

4 indications for immediate RSI in patients with TCA overdose?

Resource:
GEMNET- guideline for the management of tricyclic antidepressant overdose

A
  1. Airway compromise
  2. Inadequate respiration
    (bradypnoea, hypoxia,significant hypercapnia
  3. GCS ≤8/15
  4. Unmanageable agitation
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14
Q

In TCA-induced arrythmias - what is the 1st & 2nd line therapeutic options in you management?

Resource:
GEMNET- guideline for the management of tricyclic antidepressant overdose

A

1st line: 50 mL of 50% Na HC03 - give when QRS > 100ms

2nd line: 2g magnesium sulphate or

*10mg IV glucagon
(if life threatening hypotension or arrythmia)

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15
Q

In TCA overdose & toxicity - what 2 specific ECG features have a high risk for TCA induced arrythmias

A

prolonged QRS interval > 0.10 sec and Right axis deviation

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16
Q

in TCA overdose what are the:

  1. 3 main complications
  2. 3 ECG features of toxicity
A
  1. 3 MAIN COMPLICATIONS OF TCA TOXICITY
    * hypotension
    * arrythmias
    * seizures
  2. 3 MAIN ECG FEATURES:
    QRS > 100ms ( > 0.10sec )
    QTc >430ms
    R/S ratio > 0.7 in aVR
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17
Q

Name 3 drug therapies used in treating calcium channel blocker overdose i.e. verapamil?

A
  1. HIET - high dose insulin euglycaemic therapy
  2. 10 % calcium gluconate or calcium chloride
  3. intralipid ( calcium channel blockers are lipid soluble)
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18
Q

a patient develps pain on his finger when exposed to dilute hydroflouric acid.

  1. What is the immediate treatment?
  2. what is the local and remote implications of diffusion into the tissue?
  3. the pain persists after 20 minutes depsite irrigation and local treatment. what other steps can be considered?
A
  1. 2.5% calcium gluconate gel
  2. Local- deep tissue necrosis
    Remote - hypocalcaemia
  3. 10% calcium gluconate in a biers block infusion

NOTE:

  1. Apply a topical 2.5% calcium gluconate slurry to the affected area (made by mixing 3.5 g of calcium gluconate with 5 oz of a water based lubricant e.g. K-Y jelly)
  2. If this has not controlled the pain within 30 minutes and the area of tissue damage continues to increase, a local infiltration of 5-10% calcium gluconate should be used.
  3. If the pain is still not controlled after this then an intra-arterial infusion of 10 ml of 10% calcium gluconate or calcium chloride in 50 mls of 5% dextrose should be set up over 4 hours. This allows a large amount of calcium to be delivered directly to the damaged tissue.
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19
Q

Which substances are not absorbed by activated charcoal?

A

Pneumonic PHAILS

P- pesticides
H- heavy metals
A - alcohols,acids,alkali's
I - iron
L - lithium
S - solvents

(heavy metals - iron, lithium, lead, mercury , arsenic

also alcohols: methanol and ethylene glycol )

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20
Q

What is the antidote for iron toxicity?

and what is its mechanism of action?

A

desferrioxamine 15mg/kg/hour.

it chelates iron in the circulation and is excreted in the urine

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21
Q

What are the Indications to give IV desferrioxamine?

A
  1. Fe level > 500 mcg/dl
  2. Presence of metabolic acidosis
  3. Lethargy/coma
  4. Shock
  5. Toxic appearance
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22
Q

What are the clinical features of TAD overdose?

A

A. Anticholinergic-

Tachycardia, hyperthermia, Mydriasis, anhydrosis, red skin, decreased bowel sounds, Ileus, urinary retention, distended bladder

B. Alpha1 blockade- tachycardia, miosis - midrange pupil

neurological effects

Excitation- Agitation, delirium,myoclonic jerks,Hyper-reflexia,clonus, seizures, hyperthermia

Inhibition-sedation , coma

C. Serotonin syndrome-

Hyperpyrexia, agitation, coma

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23
Q

What are the features of severe salicylate toxicity?

A

Clinical features of severe poisoning:

  1. Hyperpyrexia ( think brain on fire )
  2. cerebral oedema ( brain swells up )
  3. convulsions ( starts fitting )
  4. arrythmias ( heart starts fibbrillating )
  5. Pulmonary oedema ( lungs drown in water )
  6. Renal failure ( kidneys fail and )
  7. Worsening metabolic acidosis

( these are also the complications of severe poisoning )

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24
Q

What features of aspirin/ salicylate toxicity would you look for in a patient?

A 
Tinnitus,
deafness, 
Hyperventilation,
Hypersalivate,
nausea/ vomiting,
seizures, 
disorientation, 
coma.
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25
Q

If a pregnant lady is exposed to Carbon Monoxide poisoning, what is the effect on Foetal Haemoglobin?.

A

Foetal Hb has much higher affinity to Carbon monoxide than maternal Hb and causes Anoxic brain injury and death.

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26
Q

List any 2 delayed neurological sequale of Carbon monoxide poisoning?

A

Neurological deterioration after a lucid period of about 2 weeks is called delayed neurological sequale

· Ataxia

· Tremor

· Memory loss

· Dementia

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27
Q

List 2 antidotes for cyanide poisoning?

A

Dicobalt edetate and hydroxycobalamin

Sodium Thiosulfate.

28
Q

What is the commonest Electrolyte abnormality with Digoxin toxicity and why?

A

Hyperkalaemia -

due to blockade of sodium,potassium atp-ase pump

29
Q

What are the causes of a high anion gap ?

A

C Carbon monoxide, cyanide, CHF

·A aminoglycosides

·T Theophylline

·M Methanol

·U Uraemia

·D DKA, Alcoholic keto acidosis, starvation ketoacidosis

·P paracetamol, paraldehyde

·I Iron , Isoniazid, inborn errors of metabolism

·L Lactic acidosis

·E Ethanol, Ethylene glycol

·S Salicylates

30
Q

What are the late complications of iron overdose/toxicity?

A

Late sequelae 2-5 weeks -

Gastric outlet obstruction -secondary to corrosive effects on the pyloric mucosa.

31
Q

What are the clinical features of iron toxicity?

A

Iron has two distinct toxic effects-
caustic injury to GI mucosa and systemic toxicity by impairing cellular metabolism.

  1. Early features

***6-12 hrs-
vomiting and Bloody diarrhoea, due to corrosive effects of iron.

**12-48hours after ingestion

GI tract symptoms - Abdominal pain, vomiting, haematemesis and diarrhoea.

Severe lethargy, seizures, coma, metabolic acidosis, leukocytosis, coagulopathy, renal failure and cardiovascular collapse.

  • Metabolic derangement eg hypoglycaemia, leukocytosis and severe lactic acidosis.
  • Hepatic failure, jaundice, seizures.
32
Q

What specific treatment would you prescribe in iron toxicity?

A

Desferrioxamine. Dose is -15mg/kg/Hr

Indicated if serum iron levels are > 90 umol/L

33
Q

What are the complications of iron toxicity?

A
  1. Iron induced coagulopathy
  2. Cardiomyopathy
  3. Renal failure
  4. Hepatic failure
  5. Gastric outlet obstruction -secondary to corrosive effects on the pyloric mucosa.
  6. Metabolic derangement - hypoglycaemia, leukocytosis and severe lactic acidosis.
  7. Coma and shock are the most common causes of early death from iron toxicity.
34
Q

in iron overdose:

Despite administration of the chelating agent, correction of hypoxia and adequate fluid resuscitation the metabolic acidosis persists. Name 2 further measures you could take to Manage patient.

A

Sodium bicarbonate - consider if Metabolic acidosis persists.

Whole bowel irrigation- Macrogols like Moviprep given orally or NG- solution continued till rectal fluid is clear. monitor fluid balance and electrolytes and renal functions.

Gastric lavage with airway protection.

Dialysis - Haemodialysis in very high serum levels, supportive in Acute renal failure and facilitates removal of Iron- Desferrioxamine complex.

Exchange transfusion

35
Q

A 34 year old lady has taken on overdose of 80 tablets of 200mg ferrous sulphate. She took these 8 hours back. She is now feeling unwell. Her serum Iron levels are 10mg/l.

Name the chelating agent and what are the biochemical indications for its use in Iron overdose? (2)

A

Desferrioxamine. Dose is -15mg/kg/Hr

Indicated if serum iron levels are > 90 umol/L
Metabolic acidosis

36
Q

What parametres would you consider a patient for a liver transplant after a paracetamol overdose?

Resource:
MDCalc APP

A
  • Arterial pH less than 7.3 ( on admission )

OR

  • hepatic encephalopathy grade III or IV AND
    coagulopathy ( PT > 100s or INR > 6.5 ) AND
    AKI serum creatinine > 300 micromol/litre

OR

  • hyperlactataemia ( 3.5mmol/l after 4 hours OR >
    3mmol/l after 12 hours
37
Q

A young female has ingested poppers ( amyl nitrite ) and her blood has turned chocolate colour.

  1. what has happened?
  2. can you name 2 congenital causes of this?
A
  1. Methaemaglobinaemia
  2. *Haemoglobin M disease
    • Cytochrome b5 reductive deficiency.
38
Q

A 15 year old girl has been brought in unconscious, blue and lying in a pool of vomit. She has drank poppers (Amyl nitrite). Observations. HR 84/ min, BP- 70/42 mmHG. The Arterial blood gas sample obtained appears chocolate brown.

  1. List any 2 other acquired causes of Methaemoglobinaemia.
  2. can you name 2 alternate antidotes to methylene blue?
A
  1. Acquired causes of methaemaglobinaemia
  • aniline dyes
  • metaclopramide
  • prilocaine
  • sulphonamides
  1. *hyperbaric oxygen
    • ascorbic acid
    • exchange transfusion
39
Q

What is a contra-indication to methylene Blue antidote in methaemaglobinaemia?

A

G6PD deficiency

40
Q

A 34 year old lady is brought into the Emergency department by her partner following an overdose. She has had a tonic clonic convulsion and is confused . Husband reports that his wife is on medications for depression. You suspect Tricyclic antidepressant overdose.

  1. What would be your immediate drug of choice and the dose
A
  1. 50mmol of 8.4% sodium bicarbonate

Sodium bicarbonate reduces the duration of QRS and decreases the risk of arrhythmia caused by the sodium channel blockade of tricyclic antidepressants.

41
Q

You suspect Tricyclic antidepressant overdose.

Describe two ways to monitor treatment response in this patient?

A
  1. resolving metabolic acidosis
  2. resolving ECG features
  3. haemodynamic stability :after fluid resuscitation -
    hypotension resolves
42
Q

You suspect Tricyclic antidepressant overdose.

  1. In case of persistent metabolic acidosis even after correction of hypoxia and fluid resuscitation - what treatment would you prescribe?
  2. in patients with cardiogenic shock or hypotension unresponsive to fluid resuscitation - what treatment would you prescribe?
  3. If cardiotoxicity is unresponsive to your above measures what other drug would you consider giving?
A
  1. 50mmol of 8.4% sodium bicarbonate
  2. IV glucagon 5-10mg bolus
  3. 20% intralipid 1.5ml/kg
43
Q

Which drugs can precipitate neuroleptic malignant syndrome?

A

Drugs as risk factors for Neuroleptic malignant syndrome

· Haloperidol

· Fluphenazine

· Clozapine

· Risperidone

· Lithium

· Prochlorperazine

· Promethiazine

· Metoclopramide

· Anticholinergic drugs

44
Q

What are the clinical features of neuroleptic malignant syndrome?

A

Diagnostic features Major-

Hyperthermia T > 38

Muscle rigidity

Neuroleptics started within 1-4 weeks

5 of the following.

Altered mental state

Tachycardia

Hypotension

Tremor

Incontinence

Diaphoresis

Increased CK or myoglobin

Metabolic acidosis

Leukocytosis

45
Q

What is the differential diagnosis of neuroleptic malignant syndrome

A

Serotonin syndrome

Malignant hyperpyrexia

Recreational drug toxicity - ecstasy

OP poisoning

Encephalitis

Rhabdomyolysis

46
Q

WHat is the equation to calculate anion gap?

WHat is a normal anion gap?

A
  1. Anion gap equation:

cations - anions

( Na + K ) - Chloride- HC03

  1. Normal anion gap is less than 12mEq/L

( MDCALC resource )

47
Q

What are the ECG changes of Digitalis effect vs Digoxin toxicity?

A

DIgitalis effect:

  • downsloping ST depression with characteristic sagging appearance
  • falttened inverted T waves
  • short QT interval

Digoxin TOxicity:

  • severe bradycardia
  • PR prolongation
  • QRS prolongation
  • AV block
48
Q

What clinical features fit the classic triad of serotonin syndrome?

A

triad of:

 autonomic hyperactivity ( tahcycardia, hypertension) 
 neuromuscular abnormality
 mental state changes
49
Q

Which drugs can precipitate serotonin syndrome in a patient already taking tricyclic antidepressants?

A

Other anti-depressants/ anti-psychotic medication:

  • SSRI’s
  • SNRI’s
  • MAOIs

Illicit drugs:

Cocaine
Amphetamines
MDMA ( ecstasy )

50
Q

What are the features of Korsakoff syndrome?

A

korsakoff’s syndrome:

amnesia
short term memory loss
confabulation
lack of insight

51
Q

What is the indication to give activated charcoal in patient with paracetamol overdose?

A

Ingested < 1 hour ago AND > 150mg/kg dose

52
Q

6 indications to starting NAC therapy in a patient with paracetamol overdose?

A
  1. 4-15 hours after single ingestion
    paracetamol level on or above treatment line
  2. > 4 hours after last ingestion of staggered overdose
    paracetamol level on or above treatment line
  3. > 4 hours after an uncertain timing of overdose and
    paracetamol level on or above treatment line
  4. > 15hours after single ingestion and
    paracetamol level is STILL detectable
  5. INR > 1.3
  6. ALT > 53 iu/L

NOTE:
if patient has taken a significant ingestion that is > 150mg/kg/24 hours AND you will NOT get the blood results back within 8 hours of the ingestion - then this is an indication to prescribe NAC within 1 hour of arrival in the ED
( taken from frcemsuccess website )

53
Q

What are the adverse features of NAC?

A
  1. nausea
  2. vomiting
  3. flushing
  4. tachycardia
  5. shock
    6 bronchospasm
54
Q
  1. what is the causative organism of botulism?

2. what are the symptoms?

A
  1. clostridium botulinum
2.1.  general symptoms: DDDDD ( 5 D's )
Diplopia &amp; blurred vision
Droopy eyelids
Dysphonia 
Dyshphagia
Diahroea and vomiting
Descending paralysis

2.2. severe features:
*respiratory failure - diaphragmatic paralysis
*autonomic dysfunction i.e.
( postural hypotension, bladder & bowel dysfunction )

55
Q
  1. what is the differential diagnosis of the clinical features of botulinum toxicity?
  2. what is the treatment for botulinum toxicity?
A

Differential diagnosis:

myaesthenia gravis
guilian barre syndorme
motor neuron disease
lambert-eaton syndrome

  1. treatment:
    botulinum anti-toxin
    supportive treatment with mechanical ventilation if indicated
56
Q

Which 4 substances may require haemodialysis if taken as an intentional overdose?

A

2 alcohols:

  • methanol
  • ethylene glycol poisoning

2 metals

  • iron
  • lithium
57
Q

Give the antidote for:

  1. paracetamol
  2. organophosphate
  3. calcium channel blocker
  4. Local infiltration of hydrofluoric acid
  5. cyanide poisoning:
    * severe cases
    vs
    * smoke inhalation victims
A
  1. paracetamol —> acetylcysteine
  2. organophosphate —> Pralidoxime chloride
  3. Ca Channel blocker —> 10% calcium chloride OR
    - –> 10 mg IV glucagon
  4. Local Infilt HFL acid —> 10% calcium gluconate
    • severe cyaniDE —> DE( dicobalt edetate)
    • Smoke inhalation —> Cyanokit ( hydroxycobalamine)
58
Q

What are the indications to give cyanokit ( hydroxycobalamin in smoke inhalation victims?

resource:
GEMNET toxicology guidelines

A

smoke inhalation victims that have

  • a severe lactic acidosis
  • are comatose
  • in cardiac arrest
  • or have significant cardiovascular compromise
59
Q

Give the antidote for:

  1. B-blocker overdose
  2. Benzodiazepines
  3. Severe Local anaesthetic toxicity
  4. methaemaglobinaemia
  5. opiods
A
  1. B-blocker overdose —> 10 mg IV Glucagon
  2. Benzodiazepines —> FLumazenil
    ( c/i in mixed TCA/benzo overdose and patient with history of epilepsy)
  3. Sever LA toxicity —> 1.5mL IV 20% Intralipid
  4. Methaemaglobinaemia—> 1mg/kg of 1% methylene blue
  5. opiods —> naloxone
60
Q

Give the antidote for:

  1. dystonic reactions
  2. serotonin syndrome
  3. NMS/ drug induced hyperpyrexia
  4. Iron
  5. Digoxin
A
  1. dystonic reactions —> Procyclidine
  2. serotonin syndrome —> cyproheptadine
  3. NMS —> Dantrolene
  4. Iron —> desferrioxime
  5. Digoxin —> digoxin specific antibody
    fragments
61
Q

give the antidote for:

  1. ehtylene glycol/methanol
  2. Dabigatran
  3. sulphonylureas
  4. digital ischaemia related to injection of epinephrine
  5. heparin
  6. isoniazid
A
  1. ehtylene glycol/methanol —>1. Fomepizole is the
    antidote of choice
    2. Ethanol IV/PO
  2. Dabigatran —> Idarucizumab
  3. sulphonylureas —>octreotide
  4. digital ischaemia related
    to injection of epinephrine—> Phentolamine
  5. heparin —> Protamine Sulphate
  6. isoniazid —> Pyridoxine
62
Q
  1. What are the clinical features of methaemaglobinaemia?
  2. How would you grade the severity?
  3. What 3 treatment options would you consider?
A
  1. Clinical features
    * cyanosis
    * low SP02
    * PA02 on ABG is normal despite low sp02
    * chocolate discolouration of blood
  2. Severity grade:
    *Serum level > 10 % :
    in Asymptomatic patient - stop the agent and observe

*serum level 20-40%:
&a symptomatic - give 1mg IV of 1% methylene blue

*serum level >40%
cardiac arrest - Exchange transfusion

  1. treatment options:
    * 1% methylene blue
    * hyperbaric oxygen
    * exchange transfusion
63
Q

What predisposes to digoxin toxicity?

A

Renal impairment

Hypokalaemia

64
Q

What are the clinical features of digoxin toxicity?

A

The clinical features of digoxin toxicity include:
• General: weakness, fatigue, general malaise
• Cardiac: almost any arrhythmia or heart block
• Neurological: headache, facial pain, dizziness,
confusion, delirium, psychoses and hallucinations
• Gastrointestinal: anorexia, nausea, vomiting and
abdominal pain.
• Visual: blurred vision, xanthopsia (yellow vision)

65
Q

What are the ECG features of digoxin toxicity?

A 
The following ECG changes can occur:
•	Bradycardia
•	Prolongation of the PR interval
•	Prolongation of the QRS duration
•	Downsloping ST depression / “reverse tick” (digoxin 
         effect)
•	AV block or dissociation
•	Ventricular ectopics
•	Ventricular arrhythmias

Memory Aid:
Downward sloping ST Depression

( dont confuse with downward sloping Coved shape ST elevetion in Brugada Syndrome ECG )

66
Q

How do you manage digoxin toxicity?

FRCEM Exam prep SAQ

A

Digoxin toxicity should be managed as follows:
• Stop the digoxin
• Involve the cardiology team and/or the Poisons
Information Service
• Monitor pulse, blood pressure and cardiac rhythm
• Check urea and electrolytes, magnesium, and
digoxin levels
• Correct serum potassium
• Correct serum magnesium
• Monitor ECG and treat arrhythmias as appropriate

Only in severe poisoning - treat with antidote: digoxing specific anti-body FAB

FRCEM Final SAQ (16 decks)

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