Electrocardiographic Manifestations and Emergency Management of Digoxin Toxicity: A Case Series from a Resource-limited Emergency Department

Background: Digoxin remains widely prescribed in low-and middle-income countries despite its narrow therapeutic index and potential for life-threatening toxicity.Digoxin-specific antibody fragments (DigiFab) are often unavailable in resource-limited emergency settings.Objectives: To describe the electrocardiographic (ECG) spectrum of digoxin toxicity and characterize emergency management outcomes in patients treated without DigiFab in a resource-limited environment.Materials and methods : A descriptive observational case series of 15 consecutive adult patients presenting with suspected digoxin toxicity to a tertiary-care emergency department (ED) over 24 months.Clinical features, ECG patterns, laboratory findings, management strategies, and outcomes were analyzed descriptively.Diagnosis was based on documented digoxin exposure with compatible ECG findings and either elevated serum digoxin levels (>2.0 ng/mL) or strong clinical-ECG correlation when laboratory values were unavailable.No inferential statistical testing was performed.Results: Fifteen patients (mean age: 48 ± 14 years; 73% female) demonstrated diverse ECG manifestations including bidirectional ventricular tachycardia (n = 1), polymorphic ventricular tachycardia (n = 1), atrial fibrillation with complete atrioventricular (AV) block (n = 3), atrial fibrillation with severe bradyventricular response (n = 4), ventricular bigeminy (n = 3), frequent ventricular ectopy with digitalis effect (n = 2), and isolated digitalis effect (n = 1).Rheumatic heart disease was present in 10 patients (67%).Chronic kidney disease was observed in four (27%), and five patients (33%) were receiving interacting medications.Serum digoxin levels were available in 10 patients (67%) and were >2.0 ng/mL in eight.Conventional rhythm-directed therapy was associated with clinical and ECG stabilization in 13 patients.Two patients developed cardiogenic shock; one patient died during hospitalization.Intensive care unit (ICU) admission was required in three patients (20%), and temporary pacing was performed in two.Conclusion: Digoxin toxicity produces a heterogeneous ECG spectrum.In this small observational series, structured rhythm-directed therapy in the absence of DigiFab was associated with stabilization in most patients.These findings are descriptive and hypothesis-generating; the proposed management algorithm is expert-opinion-based and unvalidated.