Extra Corporeal Life Support in Life-Threatening Digoxin Overdose: A Bridge to Antidote

Digoxin poisoning is a potentially life-threatening overdose that may result in refractory atrioventricular block and ventricular arrhythmias. The efficacy of digoxin-specific Fab fragments in controlling all manifestations of digoxin toxicity was consistently evidenced. However, specific Fab fragments are very expensive meanwhile digoxin poisoning is very rare. The likelihood of occurrence of a severe digoxin overdose in a setting where specific Fab fragments are not available is very high. We report a case of poisoning with 22.5 mg of digoxin in a previously healthy 50-year-old male who experienced the onset of an atrioventricular block followed by a refractory electromechanical dissociation. The installation of an arteriovenous extracorporeal support prevented further development of a multi-organ failure in this patient in refractory cardiac arrest while allowing for the supply of Fab fragments, as well as the infusion of that expensive antidote over a period of time, resulting in the optimization of the Fab fragments' binding capacity. This case report along with another one support the addition of life-threatening digoxin poisonings as a possible cause of refractory electromechanical dissociation. Digoxin-specific Fab fragments should be considered as first-line treatment. However, in case of sudden hemodynamic compromise while Fab fragments are not immediately available, arterio-veinous extracorporeal life support might be life-saving, enabling a “bridge to antidote” along with the infusion of digoxin-specific Fab fragments using the most efficient dosage regimen.