MBBS OSCE · Emergency & Toxicology

OSCE — Digoxin Toxicity

Eight-minute OSCE station on Digoxin Toxicity: focused history, examination priorities, investigations, emergency and definitive management.

8 min stationVerification in progress
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NEET-PGINICETUSMLEPLAB

Brief (to candidate)

You will assess a patient with a presentation consistent with Digoxin Toxicity. You have 8 minutes to take a focused history, outline examination, investigations, and management including red flags. [1]

Clinical context

Digoxin toxicity is the clinical syndrome of excessive cardiac glycoside effect from Na+/K+ ATPase inhibition. Features: gastrointestinal (anorexia, nausea, vomiting, diarrhoea), neurological (headache, confusion, lethargy), visual (blurring, halos, colour change) and cardiac arrhythmias. PVCs are the commonest arrhythmia; bidirectional VT is pathognomonic. Most cases are chronic toxicity as renal function deteriorates. Treat life-threatening features with digoxin-specific Fab. Chan indications: life-threatening tachy-bradyarrhythmias, potassium over 6 mmol/L, or haemodynamic instability with digoxin over 2 microg/L. Andrews 2023: VT/VF, symptomatic high-degree AV block, potassium over 6.5 mmol/L, or hypotensive end-organ dysfunction. [1][2][3]

Candidate tasks

  1. Clarify onset, severity, associated features, and red-flag symptoms.
  2. State focused examination priorities.
  3. List first-line investigations (digoxin before Fab, potassium, magnesium, calcium, renal function, ECG).
  4. Give immediate resuscitation steps (stop the drug; monitoring; Fab if life-threatened).
  5. Outline definitive management with sourced regimens: Chan 80 mg acute bolus / 1 to 3 vials chronic; Andrews 5-vial arrest dose. Do not invent atropine or lidocaine milligrams.
  6. Name complications (post-Fab hypokalaemia uncommon under 10 per cent; recrudescence infrequent; uninterpretable total immunoassay) and disposition.
  7. Mention one special-population modifier (elderly/renal — both drug and Fab half-lives exceed 100 hours in renal failure). [1][2]

Examiner checklist

DomainPass behaviours
DefinitionClinical diagnosis; levels do not correlate consistently
AssessmentGI + neuro + visual + cardiac; effect vs toxicity
InvestigationsLevel before Fab; at least 6 h after last dose for an accurate number; do not delay Fab if life-threatened
Emergency careStop digoxin; Fab for Chan/Andrews life-threatening criteria
Definitive careSourced Fab dosing, not (level × kg)/100 as the default
SafetyBidirectional VT — pathognomonic; give Fab
SafetyDo not use dialysis to remove digoxin; conservative avoidance of IV calcium
CommunicationClear plan and safety-netting

Model outline

Lead with the working diagnosis and life threats. Resuscitate before waiting for a level if unstable. Use Chan/Andrews Fab criteria and Chan practical vial counts. Document that the post-Fab total immunoassay is uninterpretable. A safe candidate is specific, sourced, and never delays Fab for a number. [1][2]

References3Show
  1. [1]Andrews P, Anseeuw K, Kotecha D, et al. Diagnosis and practical management of digoxin toxicity: a narrative review and consensus Eur J Emerg Med, 2023.PMID 37650725
  2. [2]Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity Clin Toxicol (Phila), 2014.PMID 25089630
  3. [3]Regina AC, Hai O. Cardiac Glycoside and Digoxin Toxicity StatPearls, 2026.PMID 29083729
OSCE — Digoxin Toxicity · MBBS OSCE · NeetVellum