Podcast explores cases of slow and low poisonings caused by beta blockers, calcium channel blockers, and digoxin. It covers management strategies, including decontamination, high-dose insulin therapy, and the controversy surrounding glucagon as a treatment. The importance of waiting six hours for accurate interpretation of digoxin levels is emphasized, along with the use of lipid emulsion therapy and its complications.
Read more
AI Summary
AI Chapters
Episode notes
auto_awesome
Podcast summary created with Snipd AI
Quick takeaways
Recognize the potential for intentional and unintentional overdoses of cardiovascular drugs like B-blockers, calcium channel blockers (CCB), and digoxin in the emergency department.
Be vigilant in recognizing the vague presentation of digoxin toxicity in elderly patients, as they may not initially exhibit classic cardiac symptoms but instead present with weakness, dizziness, nausea, and diarrhea.
Consider contributing factors to digoxin toxicity in elderly patients, such as hypokalemia from Furosemide use, drug-drug interactions, and possible volume depletion from conditions like pneumonia.
In dijoxin toxicity, the ECG findings may include a scooping ST segment, big QRS complexes, high voltage, and signs of myocardial irritability such as atrial fibrillation with a slow rate or ventricular tachycardia.
Deep dives
Ditch Toxicity in an Elderly Patient
An 86-year-old man with a history of CHF and hypertension on dijoxyn, Ramapril, and Furosemide presents with weakness, dizziness, nausea, and diarrhea. His ECG shows a junctional rhythm and his blood pressure is 105/60. The potential factors contributing to dijoxyn toxicity in this patient are hypokalemia from Furosemide use, volume depletion from pneumonia and possible AKI, and a drug-drug interaction with Clarithromycin. It is important to recognize the vague presentation of dijoxyn toxicity in elderly patients, as they may not exhibit the classic cardiac symptoms initially.
Dealing with Dijoxyn Toxicity
Dijoxyn toxicity can present with various symptoms, including visual disturbances, gastrointestinal issues (nausea, diarrhea, anorexia), and cardiac manifestations (arrhythmias, bradycardia). It is often seen in elderly patients on dijoxyn therapy, especially when additional risk factors such as hypokalemia and drug interactions are present. In this case, the patient's use of Furosemide, recent Clarithromycin prescription, and possible pneumonia-induced volume depletion contribute to the dijoxyn toxicity. Prompt recognition and management are crucial, and the patient may require potassium repletion, supportive care, and discontinuation of contributing medications.
Recognizing Dijoxyn Toxicity in the Elderly
Elderly patients taking dijoxyn are at risk for dijoxyn toxicity, which can present with non-specific symptoms such as weakness, dizziness, nausea, and diarrhea. Contributing factors to the toxicity in this case include hypokalemia from Furosemide use, drug-drug interaction with Clarithromycin, and possible volume depletion from pneumonia. Dijoxyn toxicity may exhibit cardiac manifestations such as arrhythmias and bradycardia. Given the broad range of symptoms, it is important to be vigilant in recognizing dijoxyn toxicity, especially in elderly patients, and consider potential contributing factors.
Elderly Patient with Gastrointestinal Symptoms: Dijoxyn Toxicity
An 86-year-old patient on dijoxyn presents with weakness, dizziness, nausea, and diarrhea. These symptoms combined with a junctional rhythm on ECG and a history of pneumonia and Furosemide use raise suspicions of dijoxyn toxicity. Elderly patients are more vulnerable to dijoxyn toxicity, especially when additional factors such as drug interactions and hypokalemia are present. Prompt recognition and management, including potassium repletion, discontinuation of contributing medications, and supportive care, are crucial in these cases.
Identification and Symptoms of Dijoxin Toxicity
Dijoxin toxicity can present with symptoms such as weakness, dizziness, shortness of breath, chest pain, and confusion. These symptoms are commonly observed in elderly patients who are on dijoxin medication. Clinicians need to differentiate between acute dijoxin overdose and chronic dijoxin toxicity, as the presentation and management can differ. Acute overdose patients may exhibit more severe cardiac complications and gastrointestinal symptoms, while chronic toxicity patients present with more subtle and vague symptoms that require closer examination.
ECG Findings in Dijoxin Toxicity
The ECG findings in dijoxin toxicity can vary depending on the effects of dijoxin on the myocardium. The classic dig effect on an ECG is a scooping ST segment, often seen in atrial fibrillation patients with controlled rate. Other ECG manifestations include big QRS complexes and high voltage due to underlying cardiac issues. In dijoxin toxicity, the ECG may show signs of myocardial irritability, such as atrial fibrillation with a slow rate or ventricular tachycardia. AV dissociation, junctional tachycardia, and heart block may also occur. Importantly, dijoxin toxicity does not typically result in rapid atrial fibrillation.
Diagnosis and Treatment of Dijoxin Toxicity
Diagnosing and treating dijoxin toxicity involves several considerations. Diagnosing it based solely on dijoxin levels can be misleading, as levels should only be measured at least six hours after the last dose or overdose to avoid artificially elevated levels. Specific indications for administering dijoxin immune fab (dig fab) include acute or chronic toxicity associated with severe dysrhythmias, hyperkalemia (potassium of 5 or greater), high serum digoxin levels, or cases where digoxin toxicity is suspected in patients who would otherwise be discharged. Treatment for chronic dijoxin toxicity consists of dig fab therapy, while acute dijoxin overdose may also require atropine, pacing (as a temporary measure before dig fab), and calcium for cardioprotection. It's important to note that treatment protocols and dosing for dig fab may vary and should be individualized based on the patient's clinical status.
One of the things we need to think about whenever we see a patient who’s going low and slow with hypotension and bradycardia is an overdose. B-blockers, calcium channel blockers (CCB) and digoxin are some of the most frequently prescribed cardiovascular drugs. And inevitably we’re gonna be faced with both intentional and unintentional overdoses from these drugs in the ED. If we can recognize these overdoses early and manage them appropriately, well - we’ll save some lives...
Get the Snipd podcast app
Unlock the knowledge in podcasts with the podcast player of the future.
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode
Save any moment
Hear something you like? Tap your headphones to save it with AI-generated key takeaways
Share & Export
Send highlights to Twitter, WhatsApp or export them to Notion, Readwise & more
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode
