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because of its narrow therapeutic index , there is a high probability of accidental overdose leading to toxicity .
moreover , as it is widely and easily available , it has got a significant abuse potential and may be used for suicidal purposes . recently
, digoxin - specific antibody ( fab ) fragments have been shown to be effective in safely and quickly eliminating digoxin from blood and reduce mortality and hence , have become the mainstay of therapy in patients with digoxin toxicity . however , it is not widely available , especially in countries like india , where only conservative symptomatic therapy may be offered to patients with digoxin toxicity . due to high mortality associated with severe digoxin toxicity
we present a case of suicidal ingestion of large quantities of digoxin which was effectively managed by using resin hemofilteration in the absence of fab fragments .
a 30 year old female presented to casualty with an alleged history of ingestion of 70 tablets of 0.25 mg digoxin ( total dose 17.5 mg ) one hour prior to presentation .
immediate gastric lavage was done and activated charcoal 100 gm was given through nasogastric tube .
on examination , she was conscious , oriented , afebrile , and had a heart rate of 102/ minute , bp of 106/70 mmhg , respiratory rate of 20/ minute , and was maintaining oxygen saturation of 99% on room air .
all routine laboratory tests were sent along with serum digoxin levels and urine toxicology screen .
initial investigations revealed serum digoxin levels of 12.63 ng / ml ( normal range 0.8- 2.0 ng / ml ) , serum calcium 8.3 mg / dl , potassium 4.6 mmol / l , sodium 137 mmol / l , magnesium 3.13 mg / dl , and a normal hemogram , liver and renal function tests .
she had persistent vomiting and also developed diplopia , blurring and yellowing of vision within two hours of admission along with intermittent episodes of bradycardia along with hypotension ( systolic bp up to 70 mmhg ) .
electrocardiographs initially showed variable and prolonged pr [ figure 1 ] with atrial ectopics , which subsequently converted into complete heart block .
prophylactically transcutaneous pacing was applied to gain time for temporary pacemaker insertion as the patient continued to have episodes of symptomatic bradycardia ( heart rate going down up to 30/minute ) .
immediate cardiology opinion was taken and temporary pacemaker was inserted [ figure 2 ] . in view of high serum digoxin levels ,
presence of bradyarrhythmias with hypotension and nonavailability of fab fragments , hemoperfusion with resin - based cartridge ( ha280 resin hemoperfusion cartridge , jafron biomedical co. ltd . , china ) was done over 4 hours after taking nephrology opinion and written informed consent from the attendants .
lack of adequate literature about safety and efficacy of the procedure were carefully explained to the attendants .
patient was closely observed and platelets , coagulation profile , serum electrolytes and digoxin levels [ table 1 ] were monitored regularly .
patient tolerated the procedure well and there were no associated side effects , fall in platelet levels or procedure - related complications .
electrocardiograph showing prolonged and varying pr interval ( arrows ) chest x - ray showing external pacing pads ( black arrows ) and temporary internal pacemaker ( white arrow ) serum digoxin levels during resin hemoperfusion patient showed gradual symptomatic improvement with clearing of vision and resolution of nausea and vomiting within 4 hours of resin hemoperfusion .
her heart rate also improved and her atrioventricular block also got corrected over the next 24 hours .
serum digoxin levels dropped to 3.06 ng / ml after 24 hours and to 2.56 ng / ml after 36 hours of resin hemoperfusion .
temporary pacemaker was kept in situ , on demand mode , for 24 hours after complete resolution of symptoms and serum digoxin levels coming in nontoxic range .
serum digoxin levels below 0.8 ng / ml are considered subtherapeutic whereas , levels more than 2.0 ng / ml may be toxic . toxic manifestations include cardiac and non - cardiac manifestations .
electrocardiographic changes may include premature ventricular contractions , atrial fibrillation or flutter , nonparoxysmal atrioventricular junctional tachycardia or atrioventricular blocks .
noncardiac symptoms may include nausea , vomiting , lethargy , anorexia , headache or confusion .
rarely , patients may develop visual disturbances including diplopia , blurred or yellow vision , as in the present case .
if the patient presents within 4 hours of drug ingestion , immediate gastric lavage may be done .
activated charcoal ( 100 gm ) may be given per oral even if the patients presents outside the 4 hours window , to improve gastrointestinal clearance .
immediate management of cardiac manifestations primarily includes management of heart block with repeated doses of atropine .
specific therapy of digoxin toxicity aimed at rapidly reducing serum digoxin concentration involves transfusion of fab fragments . but the criteria for using digoxin specific antibody fragments are unclear and serum digoxin level alone may not be a good indicator .
however , patients with life - threatening arrhythmias like multifocal ectopic beats , atrioventricular conduction disorders ( grade 2 and 3 block ) , ventricular tachycardias and relapsing ventricular fibrillation should be considered for therapy with fab fragments .
as fab fragments are not widely available alternative measures to rapidly reduce digoxin concentration have been tried.[710 ] digoxin has a molecular weight of 780.95 g / mol and is insoluble in water .
peak serum concentrations of digoxin , after oral ingestion , occur at 30 to 90 minutes .
only 25% of digoxin plasma is bound to protein and it is mainly excreted through kidneys and has a serum half - life of 36 - 48 hours in adults with normal renal function .
however , digoxin can be effectively removed by hemoperfusion with charcoal or resin filters.[810 ] resin hemoperfusion has been shown to be useful in managing patients with various intoxications including tricyclic antidepressant , chloral hydrate , and mushroom poisoning .
even though there are reservations regarding its use in digoxin overdose , resin hemoperfusion may be tried for drugs like digoxin , which have a high lipid solubility and it has been used successfully in a few cases.[911 ] hence , resin hemofilteration may be successfully and safely used as an alternative therapy , in conjunction with other supportive measures , to manage patients with digoxin toxicity especially when fab fragments are unavailable .
owing to its wide and easy availability , digoxin has got a significant abuse potential and may be used for suicidal purposes . digoxin - specific antibody ( fab ) 
 fragments have become the mainstay of therapy for severe digoxin toxicity and have significantly helped in reducing mortality . 
 however , due to its high cost and limited availability alternative measures may need to be used to manage severe intoxications especially in countries like india , where fab fragments are unavailable . here 
 , we present a case of a young female who presented to our casualty with alleged history of consumption of 17.5 mg of digoxin tablets . 
 after admission to icu , she developed atrioventricular blocks with hemodynamic instability which had to be managed with temporary pacemaker . 
 her serum digoxin levels were high ( 12.63 ng / ml ) and in the absence of fab fragments , resin hemoperfusion was done which drastically reduced the serum digoxin levels and reverted the symptoms .