You are at the end of your shift and you get called from radiology department that they have a 90 years old man waiting in CT scan who have a heart rate of 28 BPM and they ask to send the patient to ED for further assessment .
He arrived at your ED, maintaining his airway and breathing, with the following vitals: T: 36.9 , RR: 20 , Spo2: 98% in R.A, BP: 151/75, HR:27, blood sugar:7 mmol/l
ECG is attached
Q1: What is your DD and how you will proceed?
Q2: What you will give this patient?
Old and Slow Cont.
Excellent comments and discussion from all, and if i have a price it will go for Yasmeen ,I liked the initial part of her discussion mostđ! , specially considering non tox causes
More information about the patient :
This is 90 years old man with PMH: dementia, HTN, IHD ,AF on digoxin ,atenolol , hearing impairment and bedbound since months. He was brought in for booked appointment of CT brain for dementia work up and found to be bradycardia
Deny any h/o vomiting or abdominal pain . There is h/o of change in behavior for last 3 months ( screaming at night and become fully dependent on family )but no LOC
No fever or respiratory symptoms, no chest pain
He is not in regular follow up and his family give him his medication and not h/o acute overdose
***************************
Exam : Unremarkable apart from irregular pulse
CT brain: NAD
Lab results was significant for Renal function: sodium 129,creatinine : 122, potassium 4.4,Urea: 12.4, chloride :93, bicarb: 13 ,Troponin : 124 ,Digoxin : 3.5
ECG : showed AF with slow ventricular response rate and bifascicular block(His baseline ECG is AF with ventricular response of 55-60 and bifascicular block
In Summary :
Old , bed bound with isolated stable bradycardia , chronic dig toxicity in context of AKI
responded to atropine and IVF hydration and went back to his baseline
Digbind was not given as it was not really indicated at this point
Q.What is the difference between acute and chronic digoxin Toxicity?
Q. Management of acute vs chronic digoxin ?
Management of acute digoxin toxicity ?
Bradyarrhythmias
o digibind is the definitive treatment( if indicated )
o Treat like any other bradycarrythemia (atropine ,adrenaline & pacingârarely effectiveâ)
¡ Tachyarrhythmias
o digibind is the definitive treatment ( if indicated)
o could try MgSO4 ,Lidocaine âoften refractory to cardioversionâ
¡ Hyperkalemia
o Insulin and glucose, bicarbonate (salbutamol may aggravate automaticity)
o Calcium is traditionally contra-indicated due to the risk of precipitating a âstone heartâ
Management of chronic digoxin toxicity ?
¡ AS for acute digoxin toxicity ,Supportive care and cardiac monitoring
¡ Renal replacement therapy may be indicated in the context of renal failure and hyperkalemia
¡ Digbind is the definitive treatment ( if indicated)
Q. What are the indication for Digbind ?
References:
1- https://litfl.com/digoxin-toxicity-ccc/
2- .Emergency department management of calcium-channel blocker, beta blocker, and digoxin toxicity. Published in Emergency medicine practice 2014
3- Rosen 9TH edition
Dx:
- chronic digoxin toxicity
-CCB/BB to be considered as well
- intracranial hemorrhage still possible. cushing reflex( high BP with low HR )
- want more Hx about the pt background and his regular medications. and to send labs including electrolytes and coagulation profile , digoxin level
Treatment :
- if digixi toxicity will give defibine
-if intracranial bleed , to be started on measures to reduc ICP , and warfarin reversal if indicated
Elderly who is relatively asymptomatic , accidental finding of bradycardia , this clinical content all points to a chronic process.
DDx : tox related causes :
* chronic digoxin toxicity ( the ECG findings is suggestive of digoxin use \ toxicity)
* B blockers ( although pt Expected to be more sick and more of hypotension and hypoglycemia expected)
* CCB ( as in BB usually pt with such toxicity will be quit sick , BP expected to be affected as well)
Alot of other drugs can cause bradycardia thus PMH of the pt need to be explore more.
non tox related causes :
*IHD : pt usually stmptomatic / sick looking
*electrolytes imbalance * sepsis : which is less likely here as pt was relatively fine
* arrythemia and conductive pathology : it is less likely to be new onset in this age
how to proceed:
resuscitate the pt with fluid as tolerated
attach to defeb
send : digoxin level ( preferred 6 hrs after last dose) , K level , UE , paracetamol and aspirin level
CBC and ABG / lactate
how to manage :
if Hx support the thought about Digoxin this start him on digibind 5-10 vial)
correct hypokalemia
correct other electrolytes
Renal replacement therapy if needed
This ECG is showing AF with slow ventricular rate. ( absence of p waves, irrigular RR rhythm and ventricular rate of 25 bpm ). There is reverse tick sign ( aka salvador moustache sign ) seen in v1- v3 in this ECG will give the clue that this patient is on digoxin. this sign, however reflects chronic digoxin use and DOES NOT mean digoxin toxicity.
This elderly is probably known AF on chronic use of digoxin came with digoxin toxicity based on the dysrhythmia ( slow ventricular response due to decreased AV conduction ) which is an indication for digifab administration regardless of the level of digoxin.
- Consider other DDx for bradydysrythmias: ACS, Valvular disease, BB toxicity, CCB toxicity.
Next step ?
- Stabilize, ABC
- IV access with metabolic panel and digoxin level.
- IV crystalloid
- Administer Digifab 10 vials stat
- Frequent reassessments with continuous ECG monitoring
AF with slow ventricular rate. V2-3 show Salavdor Dali sign suggestive of digitalis toxicity. Shift the patient to resus, connect him to a cardiac monitor and oxygen. Send Digoxin level, UE, and CBC.
Digibind is the antidote.
A1: ECG is showing Af with very slow rate and reverse tick sign favoring digitalis toxicity. Other DDx: hyper/hypokalemia, hypothermia, hypothyroidism
I need further hx , PMH and medication hx
I need to know how is the patient clinically and what symptoms he has. I need to send for basic work up including UE, digoxin level in addition to serial ECG
A2: Digibind