A 72-year-old woman is brought to the emergency department by her daughter due to a 2-day history of persistent nausea, vomiting, and profound generalized weakness. The patient also reports seeing "yellow halos" around lights in her home. Her medical history includes heart failure with reduced ejection fraction, atrial fibrillation, and hypertension. Her daily medications are digoxin, furosemide, lisinopril, and rivaroxaban. Vital signs show a heart rate of 48/min and blood pressure of 105/65 mm Hg. Physical examination reveals a lethargic woman with dry mucous membranes.
Laboratory studies reveal:
| Test | Result |
|---|---|
| Sodium | 134 mEq/L |
| Potassium | 3.0 mEq/L |
| Chloride | 98 mEq/L |
| Bicarbonate | 26 mEq/L |
| Blood urea nitrogen | 42 mg/dL |
| Creatinine | 1.9 mg/dL (baseline 1.1 mg/dL) |
Which of the following are appropriate next steps in the evaluation and management of this patient? (Select all that apply)
- Obtain a 12-lead electrocardiogramCevap
- Measure serum digoxin concentrationCevap
- CAdminister intravenous calcium gluconate
- DOrder a non-contrast CT scan of the head
- EWithhold potassium supplementation due to the elevated serum creatinine
Cevap
The appropriate next steps are to obtain a 12-lead electrocardiogram and measure the serum digoxin concentration.
The patient's presentation of nausea, vomiting, lethargy, visual changes ('yellow halos'), and significant bradycardia is highly suspicious for digoxin toxicity. This toxicity is likely precipitated by acute kidney injury (which reduces digoxin clearance) and concurrent hypokalemia from furosemide use (which increases myocardial sensitivity to digoxin). The most critical initial steps in evaluating and monitoring this patient are to obtain a serum digoxin concentration to definitively confirm the diagnosis, and a 12-lead electrocardiogram to evaluate for potentially life-threatening arrhythmias (such as advanced atrioventricular block or ventricular tachycardia). Additionally, potassium should be carefully but promptly repleted, as hypokalemia exacerbates the toxicity.
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The initial evaluation and monitoring of digoxin toxicity involves confirming serum levels, assessing for arrhythmias with an electrocardiogram, and aggressively correcting exacerbating electrolyte abnormalities such as hypokalemia.
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