Digoxin Toxicity — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Life-threatening features?
   Life-threatening features / acute hyperkalemia? (Digoxin toxicity: nausea/vomiting/anorexia, yellow-green vision, delirium; arrhythmias (increased automaticity + AV block, e.g. atrial tachycardia with AV block, bidirectional VT; almost any arrhythmia except a rapidly conducting SVT). Acute hyperkalemia marks severity (K >5.0 raises mortality). Level at ≥6 h (steady state); toxicity can occur at therapeutic levels (precipitated by hypokalemia/hypomagnesemia/renal failure); total levels rise falsely after Fab.)
   • Life-threatening (lethal arrhythmia / acute K >5 / unstable / large ingestion) → Life-threatening → DigiFab
   • No life-threatening features → Not life-threatening · observe
2. [End] Not life-threatening · observe
   ECG monitoring, serial ECGs; correct hypokalemia and hypomagnesemia (worsen toxicity); stop digoxin, check renal function and precipitants; activated charcoal (early). Give Fab immediately if a lethal arrhythmia/hyperkalemia/hemodynamic instability develops.
3. [End] Life-threatening → DigiFab
   Digoxin-specific antibody fragments (DigiFab) are the definitive antidote — indications: life-threatening ventricular arrhythmia, progressive bradycardia or high-grade AV block unresponsive to atropine, acute hyperkalemia >5.0–5.5, hemodynamic instability/shock, acute level >10–15 ng/mL or large ingestion (>10 mg in an adult). Each vial binds ~0.5 mg; empiric 10–20 vials for acute severe/arrest, fewer for chronic toxicity. Do not give calcium for digoxin-related hyperkalemia ('stone heart' concern); avoid transcutaneous/transvenous pacing (precipitates arrhythmia); atropine 0.5 mg for bradycardia; magnesium/lidocaine/phenytoin for ventricular arrhythmia before Fab. Correct hypokalemia/hypomagnesemia, watch for a sharp potassium drop after Fab.

Source guidelines & references

• DigiFab (digoxin immune Fab) prescribing information; LITFL/UpToDate digoxin toxicity

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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