UMEM Educational Pearls

Title: Lily of the Valley

Category: Toxicology

Keywords: Digoxin, Cardioactive Steroids, Digitoxin, Digoxin-specific Fab Fragment (PubMed Search)

Posted: 10/1/2014 by Kishan Kapadia, DO
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Cardioactive steroids are among the many treatments used for CHF, and for the control of ventricular response rate in atrial tachydysrhythmias. There are many sources of cardioactive steroids:

Pharmaceutial: Digoxin, Digitoxin

Plants: Oleander, Yellow Oleander, Foxglove, Lily of the Valley, Dogbane, Red Squill

Animal: Bufo marinus toad

It is a potent Na+-K+-ATPase inhibitor and can lead to hyperkalemia in acute ingestion with associated signs and symptoms of N/V, abdominal pain, bradycardia and possibly, hypotension.

Toxicity should be suspected with bidirectional ventricular tachycardia or atrial tachycardia with high-degree AV block

Therapeutic range of digoxin of 0.5 - 2.0 ng/mL is helpful but not a sole indicator of toxicity

Indication for antidote (Digoxin-specific Antibody Fragments) include:

1) Digoxin-related life-threatening dysrhythma

2) Serum K+ > 5.0 mEq/L in acute ingestion

3) Serum digoxin concentration >15ng/mL at any time, or >10 ng/mL 6 hours postingestion

4) Ingestion of 10 mg in adult; 4 mg in pediatric

5) Poisoning by non-digoxin cardioactive steroid

References

Goldfrank's Toxicologic Emergencies, 9th edition