Digitoxin intoxication with lethal outcome

A 65-year old woman with known history of reactive depression and failed suicide attempts ingested 7 mg digitoxin at 09.00 h. After vomiting 4 hours later, she reported the drug intake to her husband who thereupon summoned a physician. Arriving at 16.00 h, the physician was informed about the suicide attempt, but failed to initiate any specific measures. After a second doctor's visit at 22.00 h, the patient was rushed to hospital in a moribund state. In spite of a gastric lavage, treatment with activated charcoal and insertion of a transvenous pacemaker, the patient died at 23.45 h with signs of total atrioventricular block. Digitalis fab fragments could not be administered in time. A calculation based on the plasma digitoxin concentration of 212 ng.ml-1 measured at 23.00 h indicated that nearly the entire ingested dose had been absorbed. Thus, neither the vomiting nor the gastric lavage eliminated significant amounts of the drug which had left the stomach without delay. Under these circumstances, the failure to initiate timely therapy with specific digitalis fab fragments ultimately contributed to the lethal outcome.