Bradycardia – Digoxin Toxicity

Published 11/11/2022

Bradycardia – Digoxin Toxicity

Set-up:

 

Lines/access:

2 x peripheral 20G cannulas  

Infusions:

1L crystalloid at 100ml/hr 

Airway:

Own, 4L NC 

Ventilator:

Not present  

Other:

ECG with high grade AV block 

Empty bottle by bedside. 

ABG – K 5.9 

Clinical Setting

I:       You are the HDU registrar called by the ED FY2 about a patient in resus. 

S:      SHO reports patient is bradycardic, hypotensive and she is worried about a possible                 drug overdose. 

B:      64 year old male. BG of Atrial fibrillation, heart failure and depression. Recent                             bereavement. 

A:      Vomiting and HR of 30, wide complexes, BP 74/51, responsive to voice (E3V4M5).  

R:      Called for urgent assistance 

Potential Clinical Course

  • Initially A own B SpO2 92% on 4L, chest crackles bi-basally, RR 28 C HR30 bpm high grade AV block, BP 74/51, D Responsive to voice  

  • ED FY2 is alone with an ED nurse. More help on the way - if called for. Empty bottle of digoxin by bedside 

  • Blood gas K 5.9, IV fluid ongoing 

  • Atropine has minimal effect. Becomes more drowsy – only responsive to pain 

  • Asks for transcutaneous pacing 

  • Whilst setting up pacing patient becomes unresponsive – progresses to Pulseless VT 

  • After 1 shock – ROSC – Idioventricular rhythm on monitor 

  • Cardiology Consultant arrives – takes handover and asks opinion about treatment from here 

Info Sheet For Faculty

  • Initial settings (visible once monitor attached):                    
    • SpO2 92% on 4L (98% on 15L via NRM)
    • RR 28/min
    • HR 30bpm – wide complexes, high grade AV block on monitor
    • BP 74/51
    • GCS E3V4M5

 

  • Progress to:  SpO2 98% on 15L via NRM
    • RR 28/min
    • Increase HR to 36bpm on administration of atropine
    • BP 81/54
    • GCS E2V3M4

 

  • Progress to: SpO2 88% on 15L via NRM
    • RR 12/min
    • HR 27bpm
    • BP 68/43
    • GCS E1V2M1

 

  • Progress rapidly to:
    • SpO2 unrecordable
    • RR absent
    • HR 184bpm VT (no palpable pulse)
    • BP unrecordable
    • GCS E1V1M1

                   

  • Post ROSC: SpO2 94% on either BVM/NRM
    • RR 22/min
    • HR 110bpm narrow complex tachycardia
    • BP 94/62
    • GCS E3V3M3

Faculty Roles

Emergency Medicine FY2:

  • First day in resus – keen to help but not sure where anything is, how it is connected, and also unclear on doses of drugs
  • Clarifies every instruction
  • Enthusiastic and able to do CPR/BVM during cardiac arrest as just done ILS
  • Unable to operate defibrillator

 

ED Nurse:

  • Band 7 nurse – follows instructions well when paying attention, able to connect all monitoring and take blood samples and competent member of ALS team
  • If asked: Digoxin-specific antibody fragments will have to come from pharmacy and isoprenaline will have to be retrieved from coronary care

 

Cardiology Consultant:

  • You were in ED seeing another patient but heard someone was in resus with a severe bradycardia
  • Listens attentively to handover then asks participant what they think should occur next in terms of treatment, interventions, and location
Bradycardia – Digoxin Toxicity
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