Digoxin Toxicity?

[jpregulman]

Hey Guys,

I was working the night shift last night and was wondering about this patient. Just some background I was on a BLS staffed ALS truck (as in I had a monitor).

Call came in as an Intox (no idea why) to an assisted living home.

When we got there the pt was AAOx4, standing waiting for us in his room. His C/c was dizziness and blurred vision and denied any ETOH. Pt is a 60 yo Male.

Pt hx: Afib, CVAx2 (most recent 2012), Diabetes II, CHF, Implanted Defibrillator
pt Rx: Digoxin (.125mg), coumadin, ASA, amiodarone
Pts vials were: BP: 84/44, HR: 64, RR: 18, BGL: 75, Pain 0/10

The pt said that he normally had low BP but did not know how low. Pt also complains of being tired and says that he has not eaten much. He said that a BGL of 75 was low for him. His Digoxin was D/C then restarted a few days later (2 days before call). The nurses said they suspected Digoxin toxicity.

I applied a 3 and 12 lead and he was Sinus Bradi (My best guess as I am not allowed to name rhythms)

My differential was: Digoxin toxicity, Hypoglycemia or some heart rhythm I could not identify.


Any idea what was going on with him? Thanks


PS: feel free to use this scenario for teaching!

 

[VFlutter]

Eh I would like to see the 12 lead. He is on a low dose of digoxin, 125mcg, so it is unlikely he became dig toxic in two days unless he significantly overdosed or had acute renal failure. Even if he accidentally took a few extra pills he should not be overtly toxic. How low did his HR get? It sounds like only mild bradycardia. Did you or the nurses check is prescription bottle and see how many he took?

 

[jpregulman]

The nurses kinda gave me the paperwork and disappeared and after I saw his BP i wanted to get to the hospital. His BP was about 58 when I took the 12 lead is why it was sinus bradi

 

[Akulahawk]

I'd want to see the 12 lead. I would also have wanted to see his labs, including Dig level. I'd want to know why the nurses thought he was experiencing Dig toxicity. I don't know about you, but if my HR was in the 60's (or lower) and my BP was something like 58/P or even 84/44 as stated above, I'd think that something else might be wrong that's causing the dizziness and blurred vision other than Dig. From what I understand about digitalis, about the only side effects that has been described that can be attributed to that drug is the blurred vision. I think it is very possible that is having a different problem. To put it simply, I don't think he is having a problem with digitalis toxicity. I think it's something else.

 

[Handsome Robb]

He could be hypotensive from ARF causing hyperK and dig tox but if that's the case that's a real bad day.

I thought sinus Brady was a HR

Why'd the D/C his dig? I'd like to know more about his other history and medications. Without that and a more detailed story we can only speculate.

 

[Akulahawk]

He could be hypotensive from ARF causing hyperK and dig tox but if that's the case that's a real bad day.

I thought sinus Brady was a HR

Why'd the D/C his dig? I'd like to know more about his other history and medications. Without that and a more detailed story we can only speculate.

That's pretty much where we're at, I think. :blink:

 

[FLdoc2011]

How about a physical exam?

 

[Fire51]

What his urine output the last couple days may help to, from what I have read about the drug is it's a diuretic/digitalis . So if he is not having any urine output digoxin can build up that way and cause toxicity. But with out a further history and info it's hard to say that he has digoxin toxicity. I have not studied much into this drug so my knowledge is very limited.

 

[Handsome Robb]

What his urine output the last couple days may help to, from what I have read about the drug is it's a diuretic/digitalis . So if he is not having any urine output digoxin can build up that way and cause toxicity. But with out a further history and info it's hard to say that he has digoxin toxicity. I have not studied much into this drug so my knowledge is very limited.

Hence all the talk about acute renal failure (ARF) and what not

 

[VFlutter]

For a point of reference one of our standard treatments for refractory A fib w/ RVR is 250-500mcg Digoxin IV q4 hrs x 4 doses. Never had a problem with dig toxicity even in patients with AKI/ARF.

 

[MrJones]

...His BP was about 58 when I took the 12 lead is why it was sinus bradi

Would you like to change anything in the above statement?