See Stone Heart for controversy regarding administration of calcium in<unk><unk>  Immune Fab
Indications
Ventricular dysrhythmias: PVCs most common, Bidirectional VTach is rare (but pathognomonic for<unk> 
Symptomatic bradycardias unresponsive to atropine
Hyperkalemia >5.0 mEq/L secondary to digitalis intoxication
Coingestions of cardiotoxic drugs (beta-blockers, cyclic antidepressants)
Acute<unk>  ingestion of greater than 10 mg in adults or greater than 4 mg in children
Acute<unk>  ingestion with post distribution<unk>  >10 ng/mL (by 6 hours post ingestion)
Chronic<unk>  ingestion leading to steady state serum<unk>  concentrations of >4 ng/ml
Activated Charcoal
Questionable efficacy
Only an adjunctive treatment; NOT an alternative to fab fragment therapy
Consider only if present within 1 hr of ingestion
1 g/kg (max 50 g)<unk>  has high volume of distribution so not readily removed by dialysis
Indications
Ventricular dysrhythmias: PVCs most common, Bidirectional VTach is rare (but pathognomonic for<unk> 
Symptomatic bradycardias unresponsive to atropine
Hyperkalemia >5.0 mEq/L secondary to digitalis intoxication
Coingestions of cardiotoxic drugs (beta-blockers, cyclic antidepressants)
Acute<unk>  ingestion of greater than 10 mg in adults or greater than 4 mg in children
Acute<unk>  ingestion with post distribution<unk>  >10 ng/mL (by 6 hours post ingestion)
Chronic<unk>  ingestion leading to steady state serum<unk>  concentrations of >4 ng/ml
Ventricular dysrhythmias: PVCs most common, Bidirectional VTach is rare (but pathognomonic for<unk> 
Symptomatic bradycardias unresponsive to atropine
Hyperkalemia >5.0 mEq/L secondary to digitalis intoxication
Coingestions of cardiotoxic drugs (beta-blockers, cyclic antidepressants)
Acute<unk>  ingestion of greater than 10 mg in adults or greater than 4 mg in children
Acute<unk>  ingestion with post distribution<unk>  >10 ng/mL (by 6 hours post ingestion)
Chronic<unk>  ingestion leading to steady state serum<unk>  concentrations of >4 ng/ml
Questionable efficacy
Only an adjunctive treatment; NOT an alternative to fab fragment therapy
Consider only if present within 1 hr of ingestion
1 g/kg (max 50 g)<unk>  Immune Fab is the agent of choice for all dysrhythmias!
Cardioversion should only be used as a last resort (may precipitate V-Fib)
Consider lower energy settings (25-50J)
Bradyarrhythmias (symptomatic)
Atropine 0.5 mg IV
Pacing
Avoid transvenous if possible as myocardium is irritated
Ventricular dysrhythmias
Phenytoin
Enhances AV conduction
Phenytoin: 15-20 mg/kg at 50 mg/min
Fosphenytoin: 15-20 mg PE/kg at 100-150 mg/min
Lidocaine
Decreases ventricular automaticity
1-3 mg/kg over several minutes; follow by 1-4 mg/min
Magnesium
Many patients have Hypomagnesemia and labs can be unreliable
2-4 g IV over 20-60 mins
Consider lower energy settings (25-50J)
Atropine 0.5 mg IV
Pacing
Avoid transvenous if possible as myocardium is irritated
Avoid transvenous if possible as myocardium is irritated
Phenytoin
Enhances AV conduction
Phenytoin: 15-20 mg/kg at 50 mg/min
Fosphenytoin: 15-20 mg PE/kg at 100-150 mg/min
Lidocaine
Decreases ventricular automaticity
1-3 mg/kg over several minutes; follow by 1-4 mg/min
Magnesium
Many patients have Hypomagnesemia and labs can be unreliable
2-4 g IV over 20-60 mins
Enhances AV conduction
Phenytoin: 15-20 mg/kg at 50 mg/min
Fosphenytoin: 15-20 mg PE/kg at 100-150 mg/min
Decreases ventricular automaticity
1-3 mg/kg over several minutes; follow by 1-4 mg/min
Many patients have Hypomagnesemia and labs can be unreliable
2-4 g IV over 20-60 mins
The most important predictor of outcome in the setting of<unk> 
Treat with Fab, not with usual meds
Once Fab is given hyperkalemia will rapidly correct
If Fab unavailable and hyperkalemia is life-threatening then treat with:
Dextrose-insulin
Sodium bicarb
Kayexylate
Dialysis
Calcium (controversial: some say dangerous, others say not)
Theoretical concern for inducing "stone heart"; Ca channels open and may lead to cardiac muscle tetany
Chronic<unk>  toxic patients likely have hyperkalemia from renal failure, and calcium administration is likely safe in these patients
Acutely toxic patients will not benefit from calcium, and priority must be placed on administering DigiFab
Once Fab is given hyperkalemia will rapidly correct
Dextrose-insulin
Sodium bicarb
Kayexylate
Dialysis
Calcium (controversial: some say dangerous, others say not)
Theoretical concern for inducing "stone heart"; Ca channels open and may lead to cardiac muscle tetany
Chronic<unk>  toxic patients likely have hyperkalemia from renal failure, and calcium administration is likely safe in these patients
Acutely toxic patients will not benefit from calcium, and priority must be placed on administering DigiFab
Theoretical concern for inducing "stone heart"; Ca channels open and may lead to cardiac muscle tetany
Chronic<unk>  toxic patients likely have hyperkalemia from renal failure, and calcium administration is likely safe in these patients
Acutely toxic patients will not benefit from calcium, and priority must be placed on administering DigiFab
Chronic intoxication
Raise level to 3.5-4
Acute intoxication
Do not treat (likely that potassium level is rapidly rising)
Raise level to 3.5-4
Do not treat (likely that potassium level is rapidly rising)
Treat with 1-2g over 10-20 min
Monitor for respiratory depression
Avoid in patients with:
Renal failure
Bradydysrhythmias/conduction blocks
Monitor for respiratory depression
Avoid in patients with:
Renal failure
Bradydysrhythmias/conduction blocks
Renal failure
Bradydysrhythmias/conduction blocks
Digoxin toxicity
Cardiac
Beta-blocker toxicity
Inferior MI 
Amiodarone pulmonary toxicity
Sick sinus syndrome
Clonidine toxicity
Neurocardiogenic/reflex-mediated