ICU · Toxicology
Digoxin toxicity in the ICU
Also known as Digoxin poisoning · Cardiac glycoside toxicity · Digoxin Fab antibody fragments (DigiFab) · Digoxin-specific antibody · Cardiac glycoside poisoning · Digitalis toxicity · Xanthopsia
Digoxin toxicity is excessive cardiac glycoside effect from Na+/K+ ATPase inhibition. Features: gastrointestinal, neurological/visual, and cardiac arrhythmias. PVCs are the commonest arrhythmia; bidirectional VT is pathognomonic. Most cases are chronic as renal function deteriorates. Treat life-threatening features with digoxin-specific Fab. Chan: tachy-bradyarrhythmias, potassium over 6 mmol/L, or haemodynamic instability with digoxin over 2 microg/L. Andrews 2023: VT/VF, symptomatic high-degree AV block, potassium over 6.5 mmol/L, or hypotensive end-organ dysfunction.
Checked against its sources on 5 Sept 2026
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Red flags
- Bidirectional ventricular tachycardia is pathognomonic for cardiac glycoside toxicity — give Fab
- Life-threatening tachy- or bradyarrhythmia, potassium over 6 mmol/L (Chan) or over 6.5 mmol/L (Andrews 2023), or shock with an elevated digoxin concentration — give digoxin Fab
- Atrial tachycardia with AV block is a characteristic digitalis pattern, not the pathognomonic rhythm
- Do not use dialysis to remove digoxin; IV calcium remains exam-conservative to avoid first-line, even though modern series have not shown a short-term mortality signal
- Post-Fab total serum digoxin is uninterpretable — do not re-dose on the total level
Meet the patient
An 82-year-old woman on digoxin for permanent atrial fibrillation arrives with four days of nausea, vomiting, and yellow visual halos. She was started on clarithromycin a week ago for pneumonia. Heart rate 48 and irregular; potassium 5.8; digoxin level 9.2 ng/mL; ECG shows atrial tachycardia at 160 with 2:1 AV block.[1][22]
Two questions decide her management: is this chronic or acute toxicity? (chronic — elderly, renal impairment, new interacting macrolide) and why is Fab indicated? The life-threatening arrhythmia (atrial tachycardia with 2:1 block, HR 48) plus an elevated level — not the potassium of 5.8, which sits below Chan's over-6 and Andrews' over-6.5 cut-offs.[2][1][20]
References28ShowHide
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