Drtweetie
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A 79 yo woman presents to MD w/ nausea, dizziness, lightheadedness, and fatigue. She began feeling these sxx approx 5 days ago. She denies any emesis, diarrhea, constipation, or fevers. Her past med hx is notable for HTN, CHF, CAD, and emphysema. Her meds include atorvastatin, digoxin, lisinopril, carvedilol, and aspirin. She used to smoke one pack per day, but quit 10 yrs ago. A week prior to her presentation, she was diagnosed with NSTEMI and received a coronary angiogram within 2 days of her initial admission with no intervention taken. On PE, her BP 105/59, and HR 47. She's afebrile. She appears pale and uncomfortable. Head and neck exam normal. LUng exam reveals a prolonged expiratory phase, with mild crackels at bases. Her cardiac exam demonstrates bradycardia, and S3. Abd exam is benign. She has 1+ lower extremity pitting edema. CXR shows enlarged cardiac silhouette and flattened diaphragms. EKG shows third degree heart block with a junctional rhythm at rate of 45 bpm.
Lab:
WBC 6300
Hct 45%
Plt 225,000
Na 137, K 5.1, Cl 103, HCO3: 21: BUN 30, Cr 2.2; AST 33; ALT 21; ALKP 101
What is the next step in management of this patient?
a. iv furosemide
b. high dose steroids and bronchodilation
c. iv atropine
d. trans-venous pacing
e. digoxin level
f. nasal oxygen
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| cirus
Forum Guru
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D
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| doyoudig
Forum Guru
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My 1st choice - Nasal O2 if she is Hypoxemic
Next --> Iv Atropine
--> IV Atropine
Pt is Hypotensive and Bradycardic, Your Initial Rx will be IV Atropine, which may just alleviate the block if not and Pt is unresp then implement Transcutaneous Pacing in the ER until a Permananet Pacemaker an be doen in the OR Setting
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| cirus
Forum Guru
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Atropine is not used for 3rd degree Hrt block, its either salmeterol or epenephrine if the ventricular rate is slow..
So ttt is Pacing
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| Justice
Just signed contract
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To me, this Pt looks having digoxin toxicity. I would go with
e. digoxin level
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| cirus
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Justice wrote:
To me, this Pt looks having digoxin toxicity. I would go with
e. digoxin level
I thought about that first, but look on the K level, already she is hyperkalemic, & by K antagonises digoxin effect on heart.
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| doyoudig
Forum Guru
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cirus, that's not how I remember it from UW or Kaplan questions that were posted a while back
Pt's going into cardiac arrest - Epin
can u site ur source or direct me?
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| kochs
Forum Senior
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after reading the below link, the answer should be transvenous pacing.
http://www.emedicine.com/emerg/topic235.htm
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| doyoudig
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answers to ur question pls???
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| doyoudig
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thx kochs, wrong post earlier
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| Drtweetie
Forum Elite
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The pt described has the classic symptoms of digoxin toxicty. Her EKG shows findings consistent with this diagnosis. Her renal function has worsened secondary to contrast nephropathy followign her previous catherization, her dig clearance has likely diminished. Therefore, checking digoxin level would be the best answer.
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| usmle-china
Forum Newbie
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bradycardia, AV block, hopertension and lung problem indicate that this old lady overdosed beta-blocker ( carvedilol). Digixin toxicity never cause hypotension, and relatively high K+ can role out this.
The treatment of beta-blocker overdose is managed with atropine and IV fluid, followed by glucagon to increase cAMP.
The answer is : C
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