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Digoxin
Digitalis Glycosides exert positive inotropic effects through improved availability of calcium to myocardial
contractile elements, thereby increasing cardiac output in CHF.
In CHF, digoxin improves the symptoms of CHF but
does not alter long-term mortality. Antiarrhythmic actions of digoxin are caused by an increase in AV nodal
refractory period via vagal tone, sympathetic withdrawal, and direct mechanisms.
Digoxin also exerts a moderate, direct vasoconstrictor action on arterial venous smooth muscle.
Missed Doses: Take this drug at regular intervals. If you miss a dose and is has been less than 12 hours since
your dose was due, take it as soon as you remember. If it is about time for the next dose, take the dose only. Do
not double dose or take extra.
Serum Levels: Therapeutic: 0.5 – 2.0 g/L
Adverse Reactions: Arrhythmic, listed by decreasing prevalence, are premature ventricular beats, second- and
third-degree heart blocks, AV junctional tachycardia, atrial tachycardia with block, ventricular tachycardia, and
SA
nodal block. Visual disturbances are related to serum level and occur in up to 25% of patients with digoxin
intoxication. They include blurred vision, yellow or green tinting, flickering light or halos, or red-green color
blindness. GI symptoms occur frequently and include abdominal discomfort, anorexia, nausea, and vomiting.
CNS
side effects occur frequently but are nonspecific, such as weakness, lethargy, disorientations, agitation, and
nervousness. Hallucinations and psychosis have been reported. Rare reactions include gynecomastia,
hypersensitivity, and thrombocytopenia.
Contraindications: hypertrophic obstructive cardiomyopathy; suspected digitalis intoxication; second- or
third- degree heart block in the absence of mechanical pacing; atrial fibrillation with accessory AV pathway;
ventricular fibrillation.
Drug Interactions: Beta-blockers can worsen CHF or digoxin-induced bradycardia. Potassium loss caused by
amphotericin B or diuretic can contribute to digoxin toxicity. Spironolactone can decrease digoxin renal
elimination.ACE inhibitors, amiodarone, bepridil, diltiazem, nitredipine, quinidine, and verapamin can increase
digoxin levels.Oral antacids, kaolin-pectin, oral neomycin, and sulfasalazine can reduce digoxin absorption.
Paremeters to Monitor: Obtain serum levels only when compliance, effectiveness, or systemic availability is
questioned or toxicity is suspected. Monitor HR, ECG for digoxin-induced arrhythmias, subjective complaints
oftoxicity, and renal function. Monitor serum electrolytes (especially potassium) frequently initially and then q
1-2months when stabilized.
Toxicity: Treatment of severe or life-threatening digoxin toxicity should include IV Digoxin Immune Fab
(Digibind). About 40 mg (one vial) of digoxin-specific Fab fragments binds 0.6 mg of the glycoside. Exact
dosage can be calculated based on estimated total body stores.

HEPARIN V/S WARFARIN

Heparin Warfarin
 Structure
Large anionic polymer, acidic Small lipid-soluble molecule

Route of Administration Parenteral (IV, SQ) Oral

Site of action Blood Liver

Slow, limited by half-lives of

Onset of action Rapid (seconds)
normal clotting factors

Impairs the synthesisof vitamin K-

dependent clottingfactors II, VII,
Mechanism of action Activates antithrombinIII
IX,and X (Vitamin K

Duration of Action Acute (hours) Chronic (weeks or months)

Inhibits coagulation (In vitro) YES NO

Treatment of acute Protamine Sulfate IV vitamin K and

overdose fresh frozen plasma

Monitoring aPTT (intrinsic pathway) PT (extrinsic pathway)

Normal Values aPTT: 20-26seconds With heparin PT 9.6 - 11.8 seconds (male adult);
therapy: 1.5 and 2.5 and 9.5 - 11.3 (female adult) With
times normal warfarin therapy: 1.5-2 times
normal

NURSING UPDATES ON ANTIDOTES

Toxin Antidote / Treatment

Acetaminophen (Paracetamol) N-acetylcysteine

Salicylates Alkalinize urine, dialysis

 Anticholinesterases, organophosphates Atropine, Pralidoxime

Antimuscarinic, anticholinergic agents Physostigmine salicylate

Beta blockers Glucagon

Digitalis Stop digitalis, normalize K; lidocaine,

anti-dig FAB fragments ( Digitoxin)
Digitalis Immune FAB

Iron (Ferrous Sulfate) Deferoxamine

Lead CaEDTA, dimercaprol, succimer,

penicillamine

Arsenic, mercurym gold Dimercaprol (BAL), succimer

Copper, arsenic, gold Penicillamine

Cyanide Nitride, Hydroxocobalamin

Methemoglobin Methelyn blue

Carbon Monoxide 100% O2, hyperbaric O2

Methanol, ethylene glycol Ethanol, dialysis, fomepizole

(antifreeze) antagonist)

Opioids, Narcotic Analgesics: Naloxone Hydrochloride (Narcan),

Demerol and Morphine Sulfate Naltrexone

Benzodiazepines Flumazenil (Romazicon)

Tricyclic antidepressants NaHCO3 (nonspecific)

(Anafranil, Tofranil)

Anticoagulant: Heparin Protamine Sulfate

Anticoagulant: Warfarin Vitamin K, fresh frozen plasma

Thrombolytics: t-PA, Aminocaproic Acid ( Amicar)

(Streptokinase, Urokinase)
 Lithium Carbonate (Eskalith) Sodium Bicarbonate

Calcium Channel Blocker Calcium

(Verapamil)

Magnesium Sulfate Calcium Gluconate

The Definitive List of Antidotes on Common Medications

1. ANTICOAGULANTS - mechanism of actions -> it is a substance that prevents coagulation:

Heparin - Protamine Sulfate (in Heaven there is Peace)

Warfarin - Vitamin K (In War there is Killing)

2. Narcotic Analgesics: Morphine and Demerol - Naloxone Hydrochloride (Narcan)

3. Atropine Sulfate (Anticholinergic) - Pilocarpine (Cholinergic)

4. THROMBOLYTICS- which acts on dissolving the clots: Streptokinase, Urokinase - Aminocaproic Acid
( Amicar)

5. Calcium Channel Blocker (Verapamil) - Calcium

6. Paracetamol (Acetaminophen) - NAC (N-Acetylcysteine)

7. Digoxin - Digitoxin Immune Fab (Digibind)

8. Tricyclic Antidepressants (Anafranil, Tofranil) - Sodium Bicarbonate

9. Magnesium Sulfate - Calcium Gluconate (Just remember MCdo)

10. Cyanide Poisoning - Sodium Nitrate

11. Iron (Ferrous Sulfate) - Deferoxamine

12. Carbon Monoxide Poisoning - Oxygen

13. Benzodiazepines - Flumazenil (Romazicon)

14. Lithium Carbonate (Eskalith) - Sodium Bicarbonate