Digoxin Toxicity, Foxglove Poisoning, Yellow-Green Vision Halos, ndi Arrhythmia Triage¶

Digoxin (yogulitsidwa pansi pa mayina amtundu monga Lanoxin ndi Digitek) ndi glycoside yamtima yomwe idachokera ku foxglove chomera (Digitalis lanata ndi Digitalis purpurea) ndipo amalamulidwa kuti azitha kuwongolera kugunda kwa mtima wamtima mu atria fibrillation komanso kuwongolera kugunda kwa mtima kwa mtima kulephera kwa mtima. Chifukwa digoxin ili ndi imodzi mwazolemba zochepetsetsa kwambiri pamankhwala azachipatala, malire pakati pa mulingo wochizira wamagazi (0.5 to 0.9 ng/mL kwa kulephera kwa mtima; mpaka 1.2 ng/mL kwa atria fibrillation) ndipo mulingo wapoizoni wowopseza moyo ndi wowonda kwambiri. Poyizoni wapamtima wa glycoside wofananira kapena wowolowa manja amapezekanso muzomera zodzikongoletsera komanso mankhwala azikhalidwe, kuphatikiza foxglove, wamba ndi oleander wachikasu (Nerium oleander ndi Thevetia peruviana), kakombo waku chigwa (Convallaria majalis), , ad squill okalamba monga Chan Su kapena Love Stone). Ngati mukukayikira kuti wina wamwa kwambiri digoxin, wayamba kukhala ndi chiwopsezo chambiri panthawi yakudwala, kapena wamwa chomera cha mtima glycoside, imbani nambala yanu yazadzidzi (911 ku United States ndi Canada, 112 kudutsa European Union, 999 ku United Kingdom) manambala angozi chikwatu nthawi yomweyo, ndikuwunikanso poyizoni thandizo loyamba, zovuta zadzidzidzi za potaziyamu,ndi kutsitsimula mtima kwa mtima (CPR).

Poyizoni wa Digoxin umapezeka m'njira ziwiri zosiyana zachipatala: kumwa mowa mopitirira muyeso (kumeza mapiritsi angapo kapena zomera zapoizoni nthawi imodzi, zomwe zimayambitsa kusanza kwambiri komanso kuyika moyo pachiswe hyperkalemia [potaziyamu wamagazi] m'maola ochepa) ndi kuopsa kwachiwopsezo (kofala kwambiri mwa okalamba omwe digoxin yawo ya tsiku ndi tsiku imakula mpaka kuwonongeka kwa impso, kuwonongeka kwa impso, kuwonongeka kwa impso. hypokalemia [kuchepa kwa potaziyamu m'magazi], kapena mankhwala omwe angoperekedwa kumene monga amiodarone, verapamil, diltiazem, kapena clarithromycin). Kuzindikira nseru koyambirira, kusokonezeka, ndi ma halos owoneka obiriwira achikasu (xanthopsia) amalola magulu achipatala kuti apereke Digoxin Immune Fab (Digibind kapena DigiFab) isanaphe bidirectional ventricular tachycardia kapena kutsekeka kwa mtima kwathunthu kumachitika.

Chitani izi tsopano¶

1. Imbani zithandizo zachipatala zadzidzidzi ndikuwongolera poizoni nthawi yomweyo: Imbani 911 (US ndi Canada), 112 (EU), kapena 999 (UK) ngati munthu amene wamwa digoxin (kapena wina amene wameza foxglove, oleander, kapena kakombo wa m'chigwa) ayamba nseru, kusanza, chizungulire, chisokonezo, kuphulika kwa maso kapena kusintha kwa mtundu, palpitar palpita. Ku United States, funsaninso Poison Control pa 1-800-222-1222 kuti katswiri wa poizoni azitha kugwirizanitsa Digoxin Immune Fab (DigiFab) kupezeka ndi chipatala cha pharmacy.
2. Musamwenso mlingo wina wa digoxin ndipo sonkhanitsani mabotolo onse amankhwala: Musalole kuti munthuyo amwenso digoxin, okodzetsa (mapiritsi amadzi monga furosemide kapena hydrochlorothiazide), kapena mankhwala ogunda mtima. Sonkhanitsani botolo lililonse lamankhwala, chowonjezera chogulitsira, ndi zodulira kapena mbewu zilizonse zomwe zikukhudzidwa kuti madotolo azadzidzidzi athe kuzindikira momwe mankhwala amagwiritsidwira ntchito ndikuwerengera kuchuluka kwake.
3. Dziwani nthawi yeniyeni ya mlingo womaliza wa digoxin: Chifukwa digoxin imatenga 6 mpaka 8 maola kuti igawike kuchokera m'magazi kupita ku minofu ya mtima ndi ya chigoba, kuyesa kwa magazi kwa serum digoxin kotengedwa mkati mwa maola 6 a piritsi lodziwika bwino tsiku lililonse kudzawoneka mokwezeka monyenga ("zopangidwa pambuyo pogawa"). Kuwuza namwino wanthawi zonse ola lenileni lomwe piritsi lomaliza linamezedwa kumathandiza madokotala kutanthauzira mulingo wa digoxin mu seramu molondola.
4. Musungeni munthuyo ali chigonere ndipo ali chete: Kulimbitsa thupi kumawonjezera chifundo cha catecholamine (epinephrine ndi norepinephrine), yomwe imathandizira minofu yamtima yodzaza ndi calcium mu kawopsedwe ka digoxin ndipo nthawi yomweyo imatha kuyambitsa kufa kwa ventricular fibrillation kapena bidirectional ventricular tachycardia. Pitirizani kupuma mwakachetechete mpaka azachipatala afika.
5. Osayambitsa kusanza: Osayesa kupangitsa wodwala kunjenjemera kapena kusanza kunyumba. Kugwedeza mwamphamvu kumapangitsa mitsempha ya vagus, kutulutsa acetylcholine pa node ya digoxin-poisoned atrioventricular (AV) node, yomwe imatha kuyambitsa kutsekeka kwa mtima wathunthu kapena kumangidwa kwa sinus (asystole).
6. Chenjezani azachipatala ndi ogwira ntchito m'chipatala ngati wodwala akumwa digoxin asanapatsidwe kashiamu ya IV: Ngati wodwalayo ali ndi potaziyamu wochuluka m'magazi (hyperkalemia) pakuyezetsa magazi kwawo koyamba m'chipatala, onetsetsani kuti gulu ladzidzidzi likudziwa mwamsanga kuti wodwalayo wamwa digoxin kapena wamwa mankhwala a mtima wa glycoside, monga mankhwala ovomerezeka a calcium m'mitsempha ya hyperkalemia nthawi zambiri amapeŵedwa kapena kusinthidwa ndi mankhwala a Immuxin.

Mtengo wosankha: Acute vs. chronic digoxin ndi mtima wa glycoside triage¶

flowchart TD
    Start["Oganiziridwa kuti Digoxin kapena Plant Cardiac Glycoside Toxicity (Foxglove, Oleander, Lily of the Valley)"] --> CallEMS["Imbani 911 / 112 / 999 ndi Kuwongolera Poizoni Wachigawo; Pitirizani Kupumula Moleza Mtima"]
    CallEMS --> PatternSplit{"Tsimikizirani Chitsanzo Chowonetsera Zachipatala"}

    PatternSplit -->|Acute Overdose: Single Large Ingestion of Pills or Toxic Plant| AcutePath["Acute Pathophysiology: Kutsekeka Kwapampu Kwadzidzidzi Na+/K+ -ATPase Pampu"]
    PatternSplit -->|Chronic Toxicity: Gradual Accumulation on Daily Prescription| ChronicPath["Chronic Pathophysiology: Yoyambitsidwa ndi Kuchepa kwa Renal, Kutaya madzi m'thupi, Diuretics, kapena Kugwiritsa Ntchito Mankhwala"]

    AcutePath --> AcuteLabs["Zofunika Zowawa Kwambiri: Mseru / Kusanza Koyambirira, Kulemba HYPERKALEMIA (Serum K +> 5.0 mpaka 5.5 mEq / L), Bradycardia / AV Block; Seramu ya Digoxin Yokwera Kwambiri (Kupatula Chomera Chopanda Digoxin)"]
    ChronicPath --> ChronicLabs["Zochitika Zazikulu Zakale: Masiku a Anorexia / Nausea, Delirium, Yellow-Green Vision Halos (Xanthopsia), Nthawi zambiri HYPOKALEMIA kapena HYPOmagnesemia kuchokera ku Diuretics; Mitsempha ya Ventricular Arrhythmias pa Miyezo Yochepa ya Digoxin (> 2.0 ng/mL)"]

    AcuteLabs --> CheckFab{"Kodi Wodwala Amakwaniritsa Zofunikira za Digoxin Immune Fab (DigiFab / Digibind) Antidote?"}
    ChronicLabs --> CheckFab

    CheckFab -->|1. Any Life-Threatening Ventricular or Brady-Arrhythmia / Shock| GiveFab["ONANI MALO OGWIRITSA NTCHITO DIGOXIN MMMUNE FAB NTHAWI YOMWEYO"]
    CheckFab -->|2. Acute Overdose with Serum Potassium > 5.0 to 5.5 mEq/L| GiveFab
    CheckFab -->|3. Acute Ingestion > 10 mg (Adult) / > 4 mg (Child) or Steady-State Level > 10-15 ng/mL| GiveFab
    CheckFab -->|4. Symptomatic Chronic Toxicity with Arrhythmia or Hemodynamic Instability| GiveFab

    GiveFab --> PostFabRules["Ulamuliro wa Post-Fab ICU: Yang'anirani Potaziyamu ya Seramu Mosamala (Kusuntha Mofulumira Kubwerera M'maselo Kumayambitsa Hypokalemia); OSAYANG'ANIRAnso Miyezo Yonse ya Seramu ya Digoxin (Kumangirira Nsalu Monama Kumakweza Mayeso)"]

Pathophysiology: Momwe Cardiac Glycosides Imayitsira Poizoni Mtima, Ubongo, ndi Maso¶

Kumvetsetsa momwe digoxin imagwirira ntchito pamlingo wa ma cell kumafotokoza chifukwa chake imayambitsa kuphatikiza kuchuluka kwa potaziyamu m'magazi (hyperkalemia), **kutsekereza pang'onopang'ono **, hyper-excitable ventricular arrhythmias, ndi mawonekedwe achikasu obiriwira:

1. Kuletsa kwa sodium-potaziyamu ATPase (Na+/K+-ATPasepompo¶

Selo lililonse la minofu yamtima, minyewa, ndi retinal photoreceptor zimadalira nembanemba sodium-potaziyamu ATPase (Na+/K+-ATPase) mpope kupopera 3 ma ion sodium (Na+) KUCHOKERA mu selo posinthanitsa ndi kupopa 2 potaziyamu ma ion (K+) MU cell motsutsana ndi ma gradient awo.

Pamene digoxin kapena chomera mtima wa glycoside umangirira ku extracellular alpha-subunit ya Na+/K+-ATPase pampu ndikuyiletsa, zochitika ziwiri zowopsa zimachitika nthawi imodzi:

1. Mulu wa Potaziyamu Wowonjezera (Acute Hyperkalemia):
2. Chifukwa chigoba cha minofu ndi maselo amtima sangathenso kupopera ayoni a potaziyamu ** mu ** maselo, potaziyamu amakhalabe kunja kwa magazi.
3. Mu kuchulukirachulukira, mlingo wa serum hyperkalemia ndiye choyezera cholondola kwambiri cha kuchuluka kwa kuchuluka kwa shuga m'magazi. Na+/K+-ATPase mapampu ali ndi poizoni mthupi lonse. Asanatulutsidwe mankhwala oletsa antibody a Digoxin Immune Fab, pafupifupi 100 peresenti ya odwala omwe anali owopsa kwambiri a digoxin omwe seramu yawo ya potaziyamu idaposa 5.5 mEq/L (mmol/L) adamwalira, pomwe omwe anali ndi potaziyamu pansi pa 5.0 mEq/L adapulumuka.
4. Intracellular Sodium ndi Calcium Overload (Kuchedwa Afterdepolarizations and Arrhythmias):
5. Chifukwa sodium simatulutsidwanso mu mtima wa myocyte, **intracellular sodium (Na+) imakwera motsetsereka **.
6. Sodium yapamwambayi imathetsa gradient yomwe ikufunika ndi Sodium-Calcium Exchanger (NCX), yomwe nthawi zambiri imagwiritsa ntchito kutuluka kwa sodium m'kati kuti ikankhire kashiamu kunja kwa selo.
7. Chifukwa chake, ** intracellular calcium (.Ca2+) amaunjikana ku mlingo wapoizoni** mkati mwa sarcoplasmic reticulum ya minofu ya mtima. Mlingo wochizira, kukwera pang'ono kwa calcium mu intracellular pang'onopang'ono kumalimbitsa kugunda kwa mtima (positive inotropy). Poizoni, sarcoplasmic reticulum imadzaza kwambiri ndi calcium ndipo imangotaya mafunde a calcium mu cytoplasm panthawi ya diastole.
8. Kutayikira kwa calcium komweko kumayambitsa mafunde a sodium mkati mwakanthawi kochepa omwe amapanga Delayed Afterdepolarizations (DADs) pamtima kuchitapo kanthu, kutulutsa ma ectopic ventricular contractions, paroxysmal atrial tachycardia, ndikupha bidirectional ventricular tachycardia.
9. Toni Yambiri Ya Vagal (Parasympathetic) (AV Nodal Block):
10. Digoxin nthawi imodzi imathandizira ma baroreceptors amitsempha ndikuyambitsa minyewa yapakati ya vagus, kusefukira kwa **sinoatrial (SA) node ** ndi **atrioventricular (AV) node ** ndi acetylcholine.
11. Choncho, mtima wapoizoni wa digoxin umasonyeza chododometsa chakupha: ** kuponderezedwa automaticity ndi chotchinga kwambiri mu SA ndi AV nodes (bradycardia ndi heart block)** kuphatikizapo **kukwiya kwambiri ndi kuwombera modzidzimutsa mu atria, His-Purkinje fibers, ndi ventricles (ectopic tachyarrhythyarrhythmia)*.

2. Chifukwa Chake Potaziyamu Yochepa (Hypokalemia) Imapangitsa Ngakhale Mlingo Wachibadwa Wa Digoxin Kukhala Wapoizoni¶

Potaziyamu ions (K+) ndi mamolekyu a digoxin amapikisana mwachindunji ndi malo enieni omwe amamangiriza kunja kwa Na+/K+-ATPase pompa: - Wodwala akamamwa mlingo wa tsiku ndi tsiku wa digoxin wayamba lupu kapena thiazide diuretic (monga furosemide [Lasix], bumetanide, torsemide, kapena hydrochlorothiazide) kapena akutsegula m'mimba/kusanza, potaziyamu m'magazi ake amatsika (hypokalemia), K+ < 3.5 mEq/L). - Pokhala ndi ayoni ochepa a potaziyamu m'magazi kuti apikisane ndi digoxin pamalo omangira mpope, digoxin yochulukirapo imamanga ndikulepheretsa Na+/K+-ATPase mapampu, kuyambitsa poizoni wa digoxin woyika moyo ngakhale wodwalayo atayezedwa mu seramu ya digoxin ali mkati kapena mocheperapo kuposa "zabwinobwino" zochizira (1.2 to 2.0 ng/mL). - Hypomagnesemia (kuchepa kwa magnesium, komwe kumayambitsidwanso ndi okodzetsa) ndi hypercalcemia (kashiamu yapamwamba, yomwe imapangitsa kuti calcium ichuluke kwambiri) mofananamo imathandizira digoxin arrhythmias.

Kuchuluka Kwambiri Kwambiri vs. Chronic Digoxin Poizoni: Kuyerekeza Mbali ndi Mbali¶

Madokotala azadzidzi amachitira achimake ndi osakhalitsa poizoni wa digoxin mosiyana chifukwa mbiri yawo ya electrolyte, nthawi yazizindikiro, ndi milingo ya serum digoxin imachita mosiyana:

Kugwiritsa Ntchito Mankhwala Odziwika Kwambiri ndi Zoyambitsa Zachipatala Zomwe Zimayambitsa Poizoni Wosatha¶

Oposa 80 peresenti ya ogonekedwa m'chipatala chifukwa cha kawopsedwe wa digoxin amapezeka mwa odwala omwe sanamwe mapiritsi owonjezera; m'malo mwake, kuthekera kwa thupi lawo kuchotsa digoxin mwadzidzidzi kudatsekedwa ndi imodzi mwa njira ziwiri:

1. Kuvulala Kwambiri kwa Impso (AKI) ndi Kutaya madzi m'thupi (Kusefera kwa Glomerular Kutsekedwa):
2. Pafupifupi **70 peresenti mpaka 80 peresenti ya digoxin imatulutsidwa mosasinthika ndi impso ** kudzera mu kusefera kwa glomerular ndi katulutsidwe ka tubular.
3. Wachikulire akayamba matenda a kutentha kwa chilimwe, viral gastroenteritis (chimfine cha m'mimba), matenda a mkodzo / sepsis, kapena amayamba NSAID (ibuprofen, naproxen) kapena ACE inhibitor / ARB pamene voliyumu yatha, glomerular filtration rate (GFR) imatsika ndi digoxin m'magazi mofulumira.
4. P-Glycoprotein (P-gp) Efflux Pump Inhibitors (Kuyanjana kwa Mankhwala ndi Mankhwala):
5. Mkati mwa matumbo ndi aimpso proximal tubules, puloteni yonyamula efflux yotchedwa P-glycoprotein (P-gp) imatulutsa digoxin m'thupi kuti ilowe m'matumbo ndi mkodzo.
6. Kuyambitsa mankhwala aliwonse omwe amalepheretsa P-glycoprotein kumachepetsa kuchotsedwa kwa digoxin kwa aimpso ndi matumbo ndi 30 peresenti mpaka 60 peresenti, zomwe zimapangitsa kuti serum digoxin ichuluke **kuwirikiza kawiri mkati mwa masiku ** pokhapokha mlingo wa digoxin udulidwe pakati:
   • Antiarrhythmics: Amiodarone, dronedarone, quinidine, propafenone, ndi flecainide.
   • Ma Calcium Channel Blockers: Verapamil ndi diltiazem (omwe amawonjezeranso kutsekeka kwa ma nodal AV pamwamba pa kukwera kwa digoxin, kupangitsa kuti mtima wathunthu utsekedwe).
   • Macrolide Antibiotics ndi Antifungals: Clarithromycin, erythromycin, ndi itraconazole (macrolides amathetsanso mabakiteriya a m'matumbo monga Eggerthella lenta omwe nthawi zambiri amalepheretsa digoxin m'matumbo).
   • Zina za P-gp Inhibitors: Cyclosporine, tacrolimus, ranolazine, ritonavir/nirmatrelvir (Paxlovid), ndi carvedilol.

Kuzindikira Ma signature a Digoxin Owoneka, Mitsempha, ndi ECG¶

1. Xanthopsia (Chizindikiro cha "Van Gogh" Yellow-Green Halo) ndi Zizindikiro za Neuro-Gastrointestinal¶

Chifukwa ma retinal photoreceptors (makamaka ma cones ozindikira mitundu) amakhalabe ndi mdima wakuda pogwiritsa ntchito kachulukidwe kwambiri. Na+/K+-ATPase mapampu, kuletsa kwa digoxin kwa mapampu a retina kumatulutsa zizindikiro zowoneka bwino zomwe nthawi zambiri zimawonekera **** kugunda koopsa kwa arrhythmia kusanachitike: - Chromatopsia ndi Xanthopsia: Zinthu, makoma, ndi nkhope zimatsukidwa mu **chikasu, chobiriwira-chikasu, kapena choyera chachisanu **, ndipo nyali zowala (nyale, nyali zakutsogolo, zowonera pa TV) zazunguliridwa ndi kunyezimira kwachikasu-wobiriwira kapena oyera korona/halos. - Scotomas Yowoneka Bwino: Madontho akhungu onyezimira, magalasi owoneka bwino, kapena kulephera kuwerenga zilembo zabwino. - Neurological Delirium ("Digoxin Encephalopathy"): Kwa okalamba, kawopsedwe ka digoxin kaŵirikaŵiri amafanana ndi kusokonezeka kwa ubongo, sitiroko, kapena matenda amisala, kusonyeza maloto owopsa, ziwonetsero, mphwayi, chisokonezo, kunjenjemera, kapena kupweteka kwapankhope kwa trigeminal neuralgia.

2. Classic Electrocardiogram (ECG) Zopeza: "Digoxin Effect" vs. True Digoxin Toxicity¶

Digoxin imatha kutulutsa mtundu uliwonse wamtima womwe umadziwika kupatula ma tachyarrhythmias ochitika mwachangu (chifukwa digoxin imachepetsa nodi ya AV). Madokotala akuyenera kusiyanitsa kusintha kosavulaza kwa ECG kuchokera ku ma arrhythmias oopsa:

• The "Digoxin Effect" (Scooped ST Segments / "Salvador Dali Mustache"): OSATI Chizindikiro cha Poizoni Yekha:
• Downsloping, "scooped" ST-segment depression (yofanana ndi reverse checkmark kapena masharubu a Salvador Dali), mafunde amtundu wa T flattened kapena inverted, ndi **fupikitsa nthawi ya QT ** zimachitika mwa odwala ambiri omwe amamwa mankhwala a digoxin chifukwa cha kuthamanga kwa ventricular repolarization kuchokera ku intracellular calcium. Payokha, "digoxin effect" imangotsimikizira kuti wodwalayo akumwa digoxin; sichimatsimikizira kuti ** sichikuwonetsa poizoni.
• Pathognomonic Arrhythmias of True Digoxin Toxicity:
• Kudumpha Kwapang'onopang'ono kwa Ventricular (PVCs) ndi Ventricular Bigeminy: Mitsempha yodziwika bwino kwambiri ya poizoni wa digoxin (kugunda kulikonse koyenera kumatsatiridwa ndi kugunda kwa ventricular msanga).
• Paroxysmal Atrial Tachycardia (PAT) yokhala ndi Variable kapena 2:1 AV Nodal Block: Imaphatikiza kuchulukirachulukira kwa atria (mulingo wa atrium 150 mpaka 250 bpm) ndi ma vagally kuponderezedwa ndi AV nodal conduction.
• "Regularized" Atrial Fibrillation (Complete AV Block with an Accelerated Junctional Escape Rhythm): Wodwala yemwe ali ndi matenda a atrial fibrillation nthawi zambiri amakhala ndi kugunda kwa mosakhazikika. Ngati wodwala wa digoxin chifukwa cha fibrillation ya atrial mwadzidzidzi ayamba kugunda kokhazikika (mwina pang'onopang'ono pa 40 mpaka 60 bpm kapena kuthamangira pa 65 mpaka 100 bpm), ndi chizindikiro chofiira cha chida chonse chachitatu cha AV block pomwe mphambano ya AV yatenga ngati njira yopulumukira.
• Bidirectional Ventricular Tachycardia: Kakomedwe kosowa kwambiri, koopsa, komanso koopsa koopsa komwe kumawoneka kokha pakupha kwambiri kwa mtima wa glycoside (komanso banja la catecholaminergic polymorphic VT), pomwe olamulira a QRS amasinthira kumenya-kumenya ndi 180 CG ndi 120 kumanzere kumanzere kumanzere. morphology).

Non-Pharmaceutical Cardiac Glycosides: Foxglove, Oleander, Lily of the Valley, ndi Toad Venom¶

Odyera, olima dimba, ana, ndi ziweto nthawi zambiri amadwala poyizoni wa mtima wa glycoside kuchokera ku zomera ndi poizoni wachilengedwe omwe amafanana ndi digoxin:

Kupulumutsidwa Kotsimikizika Pachipatala: Digoxin Immune Fab (DigiFab / Digibind) ndi ICU Protocols¶

1. The Definitive Antidote: Digoxin Immune Fab (Zidutswa za Ovine Anti-Digoxin Antibody)¶

Digoxin Immune Fab (yogulitsidwa ngati DigiFab kapena Digibind) imakhala ndi zidutswa zotsukidwa zomangira ma antigen (Fab) zochokera ku nkhosa zotetezedwa ndi digoxin. Mukalowetsedwa m'mitsempha yopitilira mphindi 30 (kapena kuperekedwa ngati **kukankhira mwachangu kwa IV bolus ** pakumangidwa kwa mtima kapena kugwa komwe kuli pafupi): - Zidutswa za antibody za Fab zili ndi mgwirizano wa digoxin womwe uli 10 mpaka 100 kuwirikiza ka 100 kuposa kuyanjana kwa digoxin kwa munthu. Na+/K+-ATPase mpope. - Zidutswa za nsalu nthawi yomweyo zimamanga digoxin yaulere m'magazi, ndikupanga kutsika kwambiri komwe **kumakoka mamolekyulu a digoxin kuchokera pamtima ndi m'mitsempha. Na+/K+-ATPase mapampu **, kubwezeretsa ntchito yapampu yanthawi zonse mkati mwa 20 mpaka mphindi 60 ndikulola impso kuti zitulutse zovuta zosavulaza za Fab-digoxin mumkodzo.

Zizindikiro Zovomerezeka za Immediate Digoxin Immune Fab Administration:¶

Madokotala akuchipatala amapereka Digoxin Immune Fab nthawi yomweyo ALIYENSE mwa izi: 1. Tachyarrhythmia kapena bradyarrhythmia yoopsa: Kuphatikizapo ventricular tachycardia, ventricular fibrillation, bidirectional VT, AV block yachiwiri kapena yachitatu digiri ya AV, kapena bradycardia yodziwika bwino yosalabadira atropine. 2. ** Hyperkalemia (Serum Potassium > 5.0 to 5.5 mEq/L) mu overdose pachimake**: Chifukwa seramu potaziyamu pamwamba 5.0 to 5.5 mEq/L mu pachimake digoxin poyizoni kulosera kuyandikira kupha mtima kumangidwa. 3. Kusakhazikika kwa Hemodynamic / Cardiogenic shock: Hypotension kapena hypoperfusion ya ziwalo zomaliza zomwe zimachitika chifukwa cha kawopsedwe ka digoxin. 4. Kulowetsedwa kwakukulu kapena kuchulukirachulukira kwa seramu (ngakhale arrhythmias isanayambe): Kudziwikiratu kulowetsedwa kwa kuposa 10 mg mwa munthu wamkulu (kapena kuposa 4 mg [kapena> 0.1 mg/kg] mwa mwana), KAPENA kuchuluka kwa serum digoxin ng 0m1 kupitirira mulingo uliwonse* 0m1* woposa 4 mg/kg* ** wamkulu kuposa 2.0 ng/mL ** mwa wodwala yemwe ali ndi ziwopsezo zowopsa).

Mlingo wa Digoxin Immune Fab (Botolo Iliyonse = 40 mg ya Fab, Yomanga 0.5 mg ya Digoxin):¶

• Chidziwitso Chodziwika cha Serum Digoxin Concentration (Yosatha Kapena Kugawika Kwambiri Kwambiri): Chulukitsani Serum Digoxin Concentration (ng/mL) mwa Patient Weight (kg) ndi kugawa ndi 100 kuwerengera kuchuluka kwa mbale. (Zindikirani: Maupangiri ambiri a toxicology tsopano amathandizira kuyambira 1 mpaka 2 Mbale [40 mpaka 80 mg] mu kawopsedwe wosakhazikika komanso kubwereza 1 mpaka 2 Mbale mumphindi 60 ngati pakufunika, kuti mupewe kutulutsa mwadzidzidzi kugunda kwa mtima kwamtima kapena kukulitsa kulephera kwa mtima).
• Kumwa Mapiritsi Aakulu Odziwika (Mamiligalamu Omezedwa Odziwika, Oyembekezera): Chulukitsani Total Digoxin Ingested (mg) mwa 0.80 (bioavailability) ndi kugawa ndi 0.5 mg bound per vial (kapena chulukitsa mg ingested by 1.6).
• Mlingo Wowopseza Moyo Wamphamvu (Kumangidwa Kwa Mtima, Mlingo Wosadziwika, kapena Poizoni wa Glycoside wa Chomera/Chule):
• Kuchuluka Kwambiri Kwambiri / Chomera kapena Toad Glycoside Poisoning: Perekani 10 mpaka 20 Mbale (400 mpaka 800 mg) IV mwamphamvu.
• Kusakhazikika kwa Digoxin Poizoni (Mbale Ukadalibe): Perekani 3 mpaka 6 Mbale (120 mpaka 240 mg) IV mwamphamvu (kapena **1 mpaka 2 Mbale ** ngati m'malire mokhazikika).

2. Malamulo Atatu Ovuta Kwambiri a ICU ndi Mavuto mu Digoxin Poisoning¶

3. Chithandizo Chothandizira cha Arrhythmias ndi Electrolytes Pamene Mukukonzekera Nsalu¶

• Kuwonongeka kwa M'mimba: Kupereka Mlingo Umodzi wa Makala (1 g/kg mpaka 50 g) ngati wodwala apereka mkati mwa 1 mpaka maola 2 atamwa piritsi lowopsa kapena chomera ndipo ali maso ndikuteteza njira yawo yodutsa mpweya. (Makala opangidwa ndi mlingo wambiri amathanso kusokoneza kubwereza kwa digoxin ndi digitoxin ngati DigiFab palibe).
• Kuwongolera Hypokalemia ndi Hypomagnesemia Nthawi yomweyo mu Poizoni Yosatha: Ngati wodwala yemwe ali ndi kawopsedwe ka digoxin ali ndi potaziyamu yochepa (< 3.5 to 4.0 mEq/L) kapena otsika magnesiamu, perekani IV Potaziyamu (yolunjika 4.0 mpaka 4.5 mEq/L, pokhapokha ngati palibe chipika chapamwamba cha AV kapena kulephera kwa aimpso) ndi **IV Magnesium Sulfate (2 magalamu pa 15 mpaka 20 mphindi) **. Magnesium ndi cofactor kwa thupi Na+/K+-ATPase mpope ndikupondereza digoxin-induced ventricular ectopy ngakhale serum magnesium ndi yabwinobwino.
• Bradycardia ndi AV Block: Perekani Atropine (0.5 mpaka 1 mg IV) kuti atseke kutsekemera kochuluka kwa vagal pamene DigiFab ikupangidwanso. Pewani mawaya a pacemaker ngati kuli kotheka: kulumikiza waya woyenda m'mphuno yakumanja yomwe ili ndi calcium yodzaza ndi digoxin-poizoni nthawi zambiri kumayambitsa kukana mitsempha yamagazi. Gwiritsani ntchito Digoxin Immune Fab m'malo mwake.
• Ventricular Tachyarrhythmias: Pamene mukuyembekezera DigiFab, Lidocaine (1 to 1.5 mg/kg IV) kapena Phenytoin (15 mg/kg IV slowly at <= 25 to 50 mg/min) ndi antiarrhythmics omwe amakonda kwambiri chifukwa amapondereza kuchedwa kwa depolarizations ndipo makamaka amapangitsa AV nodal conduction popanda kukhumudwitsa contractility. Pewani procainamide, quinidine, beta-blockers, ndi calcium channel blockers (zomwe zimaipitsa AV block ndi kulephera kwa pampu).
• Pewani Kuwotcha kwa Magetsi Pokhapokha Mukumangidwa Mopanda Mphuno: Kupereka kugwedezeka kwamagetsi kolumikizana kwa wodwala wa poizoni wa digoxin wokhala ndi fibrillation ya atrial kapena supraventricular tachycardia nthawi zambiri kumasintha mtima kukhala inreversible ventricular fibrillation kapena asystole. Ngati kugunda kwamtima sikungalephereke chifukwa cha kusakhazikika kowopsa DigiFab isanafike, gwiritsani ntchito kutsika kwamphamvu komwe kungatheke (10 mpaka 25 Joules) mutatha kuchiza ndi lidocaine ndi magnesium.
• Chifukwa chiyani Hemodialysis Singathetse Digoxin: Chifukwa digoxin ili ndi kuchuluka kwa kugawa (5 to 8 L/kg) yokhala ndi 90 peresenti yomangika mkati mwa minyewa ya chigoba ndi mtima, hemodialysis ndi hemoperfusion SANGATHE kuchotsa digoxin m'thupi (dialysis imagwiritsidwa ntchito pothana ndi hyperkalemia yoopsa kapena kuchuluka kwamadzimadzi mu aimpso kulephera).

Nambala zangozi zachigawo ndi ndondomeko za bungwe¶

Mafunso omwe amafunsidwa pafupipafupi¶

Chifukwa chiyani anthu omwe ali ndi kawopsedwe ka digoxin amawona ma halo achikasu kapena obiriwira mozungulira magetsi (xanthopsia)?¶

Ma cell a cone ozindikira mitundu mu retina yamunthu amadalira pampope yomweyo ya sodium-potaziyamu ATPase (Na+/K+-ATPase) yomwe digoxin imalepheretsa mu minofu ya mtima. Digoxin ikachuluka m'thupi, imatsekereza mapampuwa mu retina, ndikusokoneza momwe ma cell a cone amasinthira pambuyo pozindikira kuwala. Izi zimayambitsa kusawona bwino, kukhudzika kwa kuwala kowala, komanso kusinthika kwapang'onopang'ono kotchedwa xanthopsia, komwe magetsi amawoneka atazunguliridwa ndi ma halo onyezimira achikasu, obiriwira, kapena oyera ndipo zinthu zimatengera mtundu wachikasu wobiriwira.

Chifukwa chiyani wachibale wanga adayamba kupha poizoni wa digoxin ngakhale sanamwe mapiritsi owonjezera?¶

Pafupifupi 70 mpaka 80 peresenti ya digoxin imasefedwa kunja kwa thupi osasinthidwa ndi impso. Ngati wachikulire amene amamwa mapiritsi awo a tsiku ndi tsiku a digoxin amayamba kutaya madzi m’thupi pang’onopang’ono kuchokera m’mimba, kutentha kwa chilimwe, kuchepa kwa madzimadzi, kapena matenda a mkodzo, kapena atapatsidwa mankhwala atsopano monga amiodarone, verapamil, diltiazem, clarithromycin, kapena ibuprofen, impso zawo zimasiya mwadzidzidzi kuchotsa digoxin pamlingo wabwinobwino. M’masiku oŵerengeka chabe, mlingo wawo watsiku ndi tsiku wanthaŵi zonse umachulukana kufika ku mlingo wapoizoni m’mwazi ndi m’minyewa yamtima, makamaka ngati diuretic (mapiritsi amadzi) atsitsanso potaziyamu m’mwazi wawo.

Chifukwa chiyani potaziyamu wokwera m'magazi (hyperkalemia) ndi wowopsa mukamwa mowa kwambiri wa digoxin, pomwe potaziyamu wamagazi (hypokalemia) ndi wowopsa mukamagwiritsa ntchito digoxin?¶

Kumwa mowa mopitirira muyeso (kumeza botolo la mapiritsi a digoxin nthawi imodzi), kuthamanga kwakukulu kwa digoxin kumatseka mamiliyoni a mapampu a sodium-potaziyamu m'minyewa yam'thupi nthawi imodzi, kulepheretsa potaziyamu kulowa m'maselo ndikupangitsa kuti potaziyamu m'magazi achuluke kwambiri (hyperkalemia). Mosiyana ndi zimenezi, munthu amene amamwa digoxin ya tsiku ndi tsiku m’miyezi ingapo, potaziyamu ndi digoxin zimapikisana pa malo enieni amene amamangiriza pa mapampu a mtima: ngati madzi okodzetsa kapena kutsekula m’mimba kumayambitsa potaziyamu yochepa m’magazi (hypokalemia), palibe potaziyamu wotsala kuti atseke digoxin kuti isamangike, kulola ngakhale mlingo wabwinobwino wa digoxin kulepheretsa mtima kugunda mopitirira muyeso ndi kuyambitsa kusokonezeka kwa mtima.

Chifukwa chiyani madokotala amadikirira osachepera maola 6 atamwa mapiritsi a digoxin tsiku lililonse asanajambule mulingo wamagazi wa digoxin?¶

Mukameza piritsi la digoxin, limalowa m'magazi mkati mwa maola 1 mpaka 2, koma zimatengera maola 6 mpaka 8 kuti mankhwalawa agawike pang'onopang'ono kuchokera m'magazi ndikumanga ku zolandilira zomwe akufuna mkati mwa mtima ndi minofu ya chigoba. Ngati labu atenga magazi pakangotha ​​maola awiri kapena atatu atamwa mapiritsi atsiku ndi tsiku, kuyezetsa magazi kumawonetsa kuchuluka kwa "pre-distribution" mu seramu ngakhale kuti minyewa yapamtima ndi yabwinobwino. Komabe, pakagwa mwadzidzidzi kwambiri, madokotala amajambulabe ma laboratory oyambira nthawi yomweyo pafupi ndi potaziyamu ndi ECG pomwe amakumbukira kugawa kwa maola 6.

Kodi kudya foxglove, oleander, kapena kakombo wakuchigwa kuchokera m'dimba kungayambitse poizoni wamtima womwewo ngati mapiritsi a digoxin?¶

Inde. Foxglove (Digitalis purpurea), common oleander (Nerium oleander), yellow oleander (Thevetia peruviana), ndi kakombo wa m'chigwa (Convallaria majalis) zonse zili ndi cardiac glycosides yachilengedwe yomwe imawononga pampu ya sodium-potaziyamu yamtima mofanana ndi digoxin. Kumeza masamba, maluwa, mbewu, tiyi wamasamba opangidwa kuchokera kumasamba odyetsedwa molakwika ndi comfrey kapena adyo wakuthengo, kapena kumwa madzi kuchokera mumphika wamaluwa womwe umakhala ndi kakombo wachigwa kapena tsinde la oleander kungayambitse kutsekeka kwamtima, hyperkalemia, ndi kufa kwa arrhythmias komwe kumafunikira chisamaliro chachikulu chachipatala ndi Digoxin Immune Fab Antidotherapy.

Maupangiri ogwirizana¶

• Zovuta zadzidzidzi za potaziyamu: Kumangidwa kwa mtima kwa hyperkalemic ndi hypokalemic paralysis
• Beta-blocker ndi calcium channel blocker overdose triage
• Kudya bowa wakuthengo, amatoxin, ndi kumeza mbewu zapoizoni
• Thandizo loyamba la poyizoni ndi kuwongolera poyizoni
• Cardiopulmonary resuscitation (CPR) ndi AED guide

Magwero ndi malangizo ovomerezeka¶

• American Heart Association (AHA): 2023 Focused Update and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Management of Critical Poisoning (Digoxin ndi Cardiac Glycosides).
• American Association of Poison Control Centers (AAPCC) & American College of Medical Toxicology (ACMT): Clinical Practice Guidelines for the Diagnosis and Management of Acute and Chronic Digoxin Toxicity and Digoxin Immune Fab Utilization.
• National Poisons Information Service (NPIS, United Kingdom): TOXBASE Clinical Management of Digoxin, Digitalis, and Cardiac Glycoside Poisoning.
• EXTRIP (Machiritso Owonjezera mu Poizoni) Gulu la Ntchito: Kubwereza Mwadongosolo ndi Malangizo a Chithandizo cha Extracorporeal mu Digoxin Poisoning.
• World Health Organization (WHO): Kusamalira Poizoni ndi Poizoni Zachilengedwe ndi Zomera za Cardiac Glycoside (Yellow Oleander ndi Foxglove).

*Bukhuli ndi lofuna kudziwa zambiri ndipo sililowa m'malo mwa kuwunika kwachipatala, kukaonana ndi Poison Control, kapena chithandizo chadzidzidzi chachipatala. Chifukwa poizoni wa mtima wa glycoside ukhoza kupita patsogolo mwachangu mpaka kumaliza kutsekeka kwa mtima kapena kutsekeka kwa ventricular, timalimbikitsa mwamphamvu kutenga chithandizo chovomerezeka cha manja ndi maphunziro a CPR kudzera ku International Federation of Red Cross ndi Red Crescent Societies (IFRC), gulu lanu la Red Cross, St John Ambulance, kapena wopereka chithandizo chapafupi.