1. POISONING BY
CARDIOVASCULAR DRUGS
Ayman Zaaqoq
Lecturer
Department of Forensic Medicine and Clinical Toxicology, ASU
2012-2013

2. CV TOXICITY
CV toxicity
Bradycardia Tachycardia
Calcium
Digoxin Beta-blockers channel Theophylline
blockers

3. CV TOXICITY
INVESTIGATIONS
Investigation
Laboratory ECG
S. drug level Glucose S.K+ KFTs ABG

4. TOXICITY TREATMENT
GENERAL GUIDELINES
Treatment
Stabilization Decontamination Elimination Antidote Supportive
MDAC: dig., Bradycardia,
GL theo Very high level AVB
Ventricular
AC Dialysis: theo Serious C/P dysrhythmias
Huge dose Hyperkalemia

5. TREATMENT OF SERIOUS
DYSRHYTHMIAS
TdP V-tach
 MgSO4 IV  Cardioversion
 Overdrive pacing  NaHCO3 IV
 Cardioversion  Lignocaine
 Phenytoin  Phenytoin
 Esmolol

6. DIGOXIN TOXICITY

7. DIGOXIN TOXICITY
SOURCES
 Pharmaceutical preparations:
Lanoxin®, Cardixin®
 Plants: oleander
 Animals: cane toad

8. DIGOXIN TOXICITY
FORMS
Acute Chronic
 Accidental  Therapeutic error
 Intentional  Decreased elimination

9. DIGOXIN TOXICITY
MECHANISM
Digoxin
Changes
Θ Na+/K+- Vagotonic refractory
ATPase period
↑ intracellular ↑ extracellular ↓ in atria and
Na+ K+ ↑ in AV node
ventricles

10. DIGOXIN TOXICITY
ACTIONS
Digoxin
↓ ↑
↑ inotropy ↑ potassium
chronotropy automaticity

11. DIGOXIN TOXICITY
CLINICAL PICTURE
C/P
Potassium
CV GI Visual
imbalance

12. DIGOXIN TOXICITY
INVESTIGATIONS
Investigation
Laboratory ECG
S.K+ SDC KFTs ABG Glucose

13. DIGOXIN TOXICITY
INVESTIGATIONS
 ECG changes
• Due to digoxin intake
• Due to digoxin toxicity
• Due to potassium
disturbances
• Due to pre-existing cardiac
condition

14. DIGOXIN TOXICITY
TREATMENT
Treatment
Stabilization Antidote Supportive
Decontamination Elimination
(antidote)
Ventricular
GL (?) MDAC Bradycardia, AVB dysrhythmias
AC Hyperkalemia

15. DIGOXIN TOXICITY
ANTIDOTE: DIGIBIND
Indications
Laboratory Clinical History
S.K+ SDC
High Unavailable

16. BETA-BLOCKER
TOXICITY

17. BETA-BLOCKER TOXICITY
MECHANISM
BB
β-receptor Na channel Lipid
blockade blockade solubility

18. BETA-BLOCKER TOXICITY
ACTIONS
BB
↓
↓ inotropy chronotropy
Wide QRS Θ CNS

19. BETA-BLOCKER TOXICITY
CLINICAL PICTURE
C/P
CVs CNS Metabolic

20. BETA-BLOCKER TOXICITY
INVESTIGATIONS
Investigation
Laboratory ECG
Glucose S.K+ KFTs

21. DIGOXIN TOXICITY
TREATMENT
Treatment
Antidote
Stabilization Decontamination Supportive
(Glucagon)
Bradycardia,
GL Wide QRS
hypotension
AC Seizures Hypoglycemia

22. CALCIUM CHANNEL
BLOCKERS

23. CALCIUM CHANNEL
BLOCKERS
 They block slow Ca channels of vascular smooth muscles and
cardiac muscles.
 Acute toxicity is similar to B-blockers
 Treatment is as in B-blockers. In addition, CaCl2 10% 10ml IV
over 10 min for hypotension and myocardial depression.

24. THEOPHYLLINE
TOXICITY

25. THEOPHYLLINE TOXICITY
MODE
Mode of
poisoning
Intentional Dosing errors
Change in the Reduced
Parent error Miscalculation
frequency clearance

26. THEOPHYLLINE TOXICITY
MECHANISM
Theophylline
↓cGMP & Adenosine
cAMP receptor block ↑catecholamines

27. THEOPHYLLINE TOXICITY
C/P
Nausea and
GIT vomiting
Hematemesis Hypovolemic
shock
Irritability, Seizures,
CNS Anxiety
tremors coma
Sinus Ventricular Cardiogenic
CVS tachycardia tachycardia shock
Metabolic
Metabolic Hypokalemia
acidosis

28. THEOPHYLLINE TOXICITY
INVESTIGATIONS
Investigation
Laboratory ECG
S.
Glucose S.K+ KFTs ABG
Theophylline

29. THEOPHYLLINE TOXICITY
TREATMENT
Treatment
Stabilization Decontamination Elimination Antidote Supportive
GL MDAC Hemodialysis Hemoperfusion
Emesis (?)

30. THEOPHYLLINE TOXICITY
TREATMENT
Supportive
treatment
Tachycardia Hypokalemia Hypotension Seizures Vomiting
Supraventricluar Ventricular