... and now for something, completely academic.

[RustedFox]

Monty Python: "And now for something... completely different."

Matchitis is in late-season form. There are plenty of threads regarding the importance (or lack thereof) of trauma, and tiers in residencies, and all that yah-yah.

Lets discuss something academic, eh ?

Let's talk about... digoxin.

What's you guys' threshold for giving digibind ? I've seen a ton of patients with supratherapeutic dig'j levels, and they're "just fine". I have more "personal data", but I don't wanna pollute the discussion, yet.

G'head.

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[FLTDOC1]

The drug has been around for 200 years. The ability to determine an accurate serum level with a reasonable turn around time has only been available for the last 35 years. Back in the olden days ( before dig levels) the standard way to load digoxin was to give it until the patient started to exhibit symptoms of early toxicity ( nausea, green tinted vision, dizziness, bradycardia) then the dose was decreased.

By definition, almost every pt loaded with digoxin back then met todays requirements for digibind.

 

[dchristismi]

I am far more likely to give dig than digibind. In fact, I don't know that I've ever ordered it. Which puts it behind artemether, which I have actually ordered, but may be the most esoteric ever. Well, tried to. But then learned that you have to get it from the CDC, so the point became moot...

(20 gunner points to the first person who doesn't have to look that one up!)

Hm. Fomepizole. There's another esoteric one. Only gave that once in an oral board practice case. Came close in real life once, but then learned that the guy actually drank isopropyl (or something like that.)

Hm. Sorry to derail. That's what you get after a long painful shift with a bad dog-bite case.
Carry on.

 

[Daiphon]

Monty Python: "And now for something... completely different."

Matchitis is in late-season form. There are plenty of threads regarding the importance (or lack thereof) of trauma, and tiers in residencies, and all that yah-yah.

Lets discuss something academic, eh ?

Let's talk about... digoxin.

What's you guys' threshold for giving digibind ? I've seen a ton of patients with supratherapeutic dig'j levels, and they're "just fine". I have more "personal data", but I don't wanna pollute the discussion, yet.

G'head.

Typical stuff - hyperK, ventricular dysrhythmias, etc... rarely for an isolated elevated serum concentration without other sx - need to check 6h post ingestion due to redistribution effects, so some
"overdoses" are just inappropriately interpreted levels and thus why asymptomatic.

Sometimes I'll give it in a complicated case, just to take dig off the table. Cardiologists get angry with that though...

Hm. Fomepizole. There's another esoteric one. Only gave that once in an oral board practice case. Came close in real life once, but then learned that the guy actually drank isopropyl (or something like that.)
Carry on.

Good call. I use 4MP relatively frequently, but my patient population likes antifreeze.

Little tidbit - fomepizole was approved by the FDA with an N=9 study. That's how much of a game changer for ToxOH it is. d=)

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

 

[BADMD]

What's you guys' threshold for giving digibind ? I've seen a ton of patients with supratherapeutic dig'j levels, and they're "just fine". I have more "personal data", but I don't wanna pollute the discussion, yet.

G'head.

For the chronic patient with an elevated dig level, usually if you fix the kidneys, you fix the level. I'll give Dig fab really only for brady/ventricular dysrhythmias or hyperkalemia that I can't control though other means. It also depends on why they are on dig. If it is for straight up CHF, I have a lower threshold to pull it. If for afib/flutter, I'm more likely to try holding off. With a level, you can also try partial reversal.

 

[BADMD]

Fomepizole. There's another esoteric one. Only gave that once in an oral board practice case. Came close in real life once, but then learned that the guy actually drank isopropyl (or something like that.)

I give it for pretty much any unexplained significant acidosis where there is no alcohol on board. Even with an explanation (specifically an elevated lactic acid), you still have to consider the possibility of ethylene glycol as some analyzers can't differentiate EG from lactic acid. I can get a EG, MeOH back in less than 6 hours and theoretically less than 1, so one dose while things get sorted out is easy.

 

[njac]

I give it for pretty much any unexplained significant acidosis where there is no alcohol on board. Even with an explanation (specifically an elevated lactic acid), you still have to consider the possibility of ethylene glycol as some analyzers can differentiate EG from lactic acid. I can get a EG, MeOH back in less than 6 hours and theoretically less than 1, so one dose while things get sorted out is easy.

You're lucky. All the toxic alcohols are multi day sendouts where I am.

 

[Birdstrike]

I am far more likely to give dig than digibind. In fact, I don't know that I've ever ordered it. Which puts it behind artemether, which I have actually ordered, but may be the most esoteric ever. Well, tried to. But then learned that you have to get it from the CDC, so the point became moot...

(20 gunner points to the first person who doesn't have to look that one up!)

Hm. Fomepizole. There's another esoteric one. Only gave that once in an oral board practice case. Came close in real life once, but then learned that the guy actually drank isopropyl (or something like that.)

Hm. Sorry to derail. That's what you get after a long painful shift with a bad dog-bite case.
Carry on.

I don't think I've ever ordered digibind either. And that's in at least 30,000+ patient interactions. Maybe I have, but forgot. If so, not very many times.

 

[EM2BE]

I've only given digibind once, and that was because of arrhythmia issues. I could see it being used for hyperkalemia as well, but I haven't seen that situation yet. If it's high and they are symptomatic (nausea, vomiting), I would admit to watch levels and hold their dig until symptoms resolve. If they are asymptomatic, hold for a few days and follow up for recheck level and medication adjustment.