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Interesting Case Presentation

PI

• • • • A 85 y/o woman presented to ED of Rasul hosp. by EMS with chief complaint of chest pain & generalized abdominal pain since a day before.

She complained also of nausea & vomitting Chest pain was dull in Lt hemi-thorax, not sharp, not squeezing, non radiating Abdominal pain was generalized, dull, non crampy, has had bowel movement, one episode of vomiting mentioned

• • • • • • •

Ph. Ex

Was oriented, GCS=15/15 Appearance: ill, not toxic PR=70/min BP=165/75 ( RR=16/min Sp o2 =90% Head & Neck: pale conjunctive, JVP, no mass Chest: clear lungs, no rale irregular heart beats, no murmur, Abd: Soft, generalized tenderness, no distention, no rebound Extrem: No edema, no cyanosis, normal irregular pulses, force: 5/5

• • PMH: HTN, IHD, CKD, COPD (hospitalized for COPD exacerbation 6 months ago) DH: Amlodipine Nitrocontin Losartan Triamterene-h Digoxin Atorvastatin ASA

Problem list

• An old woman presented to the ED by EMS with: Lt hemi-thorax dull pain Generalized abdominal pain Nausea- vomiting Irregular pulses since a day before

How to approach this patient

ED work-up

• • • • • • • • • • • EKG Lab test, including BS, Troponin, Amylase, ABG, Bil CXR (upright) Abd X-ray (upright, supine) Bedside US(Aort diametr,heart) Abd/Peivic US (including IVC) Internal med consult Surgery consult Digoxin level IV fluid N/S 500 ml IV stat Cardiac monitoring,POM

• • • • • • • • • • • • • • Lab WBC=7700 (PMN: 74%) Hb= 11.4

MCV= 85 PLT= 219000 Troponin: - K= 5.8 Na= 134 BUN= 59 Cr= 3.12

CPK= 100 Alk-Ph= 103 AST=11 ALT=22 Bil T= 1.46 Bil D= 0.32

Amylase= 89 Ca=8.86

ABG: pH=7.40 HCO3= 10.6 CO2= 17 PT= 14 PTT= 35 INR= 1.1

Abd US

Bedside US

• • • • No pericardial effusion No free abdomino pelvic fluid Abd aortic diameter: normal EF= 55%

Int. Med. consult

• • • • • • Full ACS order(heparin) Cardiac monitoring, POM Surgery consult Cardiology consult for echocardiography Check serum level of: Mg, Digoxin Hyperkalemia management: Glucose 50% 2 vial IV stat 8 unit Regular Insuline Kayexalate 30 gr in 100cc tap water PO stat Sorbitol 30 gr in 100cc tap water PO stat Furosemide 40 mg IV stat

Surgery consult

• • • • • • • Abd/pelvic US Lab test IV fluid TR : No significant findings Mesenteric ischemia R/O(Abdominal us) Foley cateter fixed NG tube fixed

Digoxin Level

Serum Dig level > 5

ED

• • Internal consult reorder Post CCU admission

Abd US:

• • • Sludge in gallbladder Multiple kidney cysts No other findings

Echocardiography

 Digoxin is absorbed rapidly from the GI tract with a bioavailability of between 75% and 95%, depending on the formulation Elimination  is primarily through renal excretion, with a half-life of 36 to 48  hours in patients with normal renal function and 3.5 to 5 days in anuric patients.,  with a half-life of 5 to 7 days in adults and up to 12 to 37 days in individuals older than 80 years old.

 .2 Inhibition of the sodium-potassium ATPase pump leads to increased concentrations of intracellular sodium, which subsequently increases sodium-calcium exchange.

CLINICAL FEATURES

• • • • • • • Nausea and vomiting Headache, dizziness, confusion, coma Bradyarrhythmias or supraventricular tachyarrhythmias with atrioventricular block Hyperkalemia Marked elevation (if obtained within 6 h) Typically in elderly cardiac patients taking diuretics; may have renal insufficiency Nausea, vomiting, diarrhea, abdominal pai n Fatigue, weakness, confusion, delirium/ coma Almost any ventricular or supraventricular dysrhythmia can occur; ventricular dysrhythmias are common Electrolyte abnormalities Normal or decreased serum potassium, hypomagnesemia

DIAGNOSIS

• • • • • • • • The diagnosis of digoxin toxicity is a composite picture, using history, physical examination, and laboratory studies as pieces of information; no single element excludes or confirms the diagnosis. In patients with heart failure and normal renal function, daily digoxin doses are usually between 125 and 250 micrograms. Digoxin toxicity can occur with a single ingestion of 1 to 2 milligrams in an adult, and fatalities have been reported following an acute ingestion of 10 milligrams in an adult and 4 milligrams in a child.

ECG

• • • • • Four specific electrocardiographic findings have been described with therapeutic levels of digoxin and are not signs of toxicity. These findings include T -wave changes such as flattening or inversion, QT -interval shortening, a "scooped" appearance of the ST segment with ST -segment depression, and an increase in U-wave amplitude

LABORATORY EVALUATION

• • • In acute poisonings, the serum potassium and digoxin levels can provide useful diagnostic information The serum potassium level may be a better indicator of end-organ toxicity and a better prognostic indicatthe acutelyor than the serum digoxin level in oned patientpois.

. Accepted therapeutic digoxin levels are 0.5 to 2.0 nanograms

TREATMENT

• • General supportive care Treatment of specific complications of toxicity, prevention of further drug absorption, enhancement of drug elimination, antidote administraI • Treatment of Digitalis Glycoside Poisoning Asymptomatic patients: • • Obtain accurate history Continuous cardiac monitoring • IV access • • Gl decontamination: activated charcoal, 1 gram/kg PO Frequent reevaluation • Calculate digoxin-specific Fab antibody fragments dose in anticipation of potential need: may bring to drug bedside, depending on ready availability • • Symptomatic patient: Obtain accurate history IV access

• • Continuous cardiac monitoring Gl decontamination : activated charcoal, 1 gram/kg PO, then 0.5 gram/kg every • 4-6 h • • • Bradyarrhythmias: Atropine: 0.5-2.0 mg/ IV Pacemaker: external or transvenous Digoxin-specific Fab a ntibody fragments: IV infusion • • • • • Ventricular dysrhythmias: Digoxin-specific Fab a ntibody fragments: IV infusion or bolus Magnesium sulfate: 2-4 grams IV Lidocaine: 1 mg/kg Fosphenytoin: 15 mg/kg, infuse at 150 mg/minute Electroca rdioversion: 10-25 J (last resort)

• • Cardiac arrest: CPR with current ACLS protocols Digoxin-specific Fab a ntibody fragments: IV bolus (5- 10 vials if amount ingested is unknown) • • Hyperkalemia: Avoid calcium chloride or calcium gluconate* Glucose-insulin

• • Sodium bicarbonate Digoxin-specific Fab a ntibody fragments: IV i nfusion or bolus • • Potassium resin binder Hemodialysis • • Hypomagnesemia: Evaluate renal status prior to replacement Magnesium sulfate: 2-4 grams IV

Gl DECONTAMINATION AND ENHANCED ELIMINATION

• • Administrating activated charcoal may have utility in early acute ingestion of digoxin Gastric lavage is not recommended, as asystole has been reported • in a digoxin-toxic patient, presumably from vagal stimulation during lavage Cathartics, forced diuresis, hemodialysis, or hemoperfusion have no role in enhancing elimination of digitalis glycosides

DIGOXIN-SPECIFIC Fab ANTIBODY FRAGMENTS

Patients developing cardiac arrest before digoxin-specific Fab antibody fragment administration had a 50% survival, which is significantly better than historical survival by treatment with conventional therapies

• • • • . Indications for digoxin-specific Fab Ventricular dysrhythmias Bradyarrhythmias unresponsive to standard therapy Hyperkalemia in excess of 5.5 mEq/L associated with a toxic digoxin level Based on serum digoxin concentration: total body load = [serum digoxin level (nanograms/ml) x 5.6 L/kg x patient's weight (kg)]/1000

• Number of vials = [serum digoxin level (nanograms/ml) x patient's weight • • • (kg)]/100 Fab antibody fragment administration is adverse .

has been reported in patients dependent Cardiogenic shock • • on digoxin for inotropic support., ventricular response to Hypokalemia atrial fibrillation may be increased. serum sickness or anaphylaxis have been observed, even in

DISPOSITION AND FOLLOW-UP

• • Because toxicity may not develop for several hours, extended observation up to 12 hours is recommended for anyone with a confirmed ingestion Patients with signs of toxicity or a history of a large ingested dose • should be admitted to a monitored unit.

Consultation with a medical toxicologist or the regional poison control center can facilitate difficultmanagement and treatment decisions

• • • • Any patient receiving digoxin-specific Fab antibody fragments requires intensive care unit observation for at least 6 to 12 hours. suicidal patients should have a behavioral health or psychiatric evaluation before discharge. Accidental exposures with no signs of toxicity after 1 2 hours can be discharged home.