Acute massive digoxin overdose: survival without use of digitalis-specific antibodies.

Acute massive digoxin overdose may result in life-threatening arrhythmias, with reported mortality of up to 20% prior to the introduction of digitalis-specific antibodies. Digitalis-specific Fab antibody fragments remain under experimental protocol and are not widely available. Interpretation of serum digoxin levels and indications for the use of Fab are not clearly established. The authors report a case of massive digoxin overdose in an 18-month-old child with the highest reported digoxin level (48 ng/ml) with which a victim survived without the need for Fab administration. She developed only mild manifestations of digitalis intoxication, and her serum potassium never exceeded 5.2 mEq/l. Her course may be explained by the distribution kinetics of digoxin, which follows a two-compartment model, and the relative resistance of children to digitalis intoxication. This case emphasizes the need for better criteria than the digoxin level for the administration of Fab. The serum potassium concentration, which is usually elevated in acute type digitalis intoxication, may be a better predictor of the need for Fab in acute massive digitalis ingestion.