For Examiner Only
Case Digoxin Toxicity
Author Emily Goren, MD
Reviewer Francis DeRoos, MD
Approved: 12/28/05
ORAL CASE SUMMARY
CONTENT AREA
Toxicology
SYNOPSIS OF CASE
Chronic digoxin toxicity with hypotension and bradycardia requiring treatment with digoxin specific
FAB fragments (Digibind).
SYNOPSIS OF HISTORY
80 year-old female complaining of progressive nausea and vomiting for 3 days. She complains of
generalized abdominal cramping and generalized weakness.
SYNOPSIS OF PHYSICAL
Elderly female weak and vomiting with bradycardia.
CRITICAL ACTIONS
1. Recognizes and immediately addresses unstable vitals, ordering IV access, Oxygen, and
Monitoring.
2. Addresses hypotensive bradycardia ordering IVF. (PM)
3. Takes complete history including medications (digoxin). (DA)
4. Correctly interprets EKG: recognizes complete av block, junctional bradycardia, ST changes.
(PS)
5. Administers Digibind. (PS) (PM)
6. Discusses diagnosis and treatment plan with patient. (IR)
7.
SCORING GUIDELINES
(Critical Action No.)
Score down if the candidate fials to initiate resuscitation and order an ECG. Penalize if
medication history and digoxin use isn’t noted. Score down if candiate fails to appreciate digoxin
toxicity on the ECG and needs to be prompted
FOR EXAMINER ONLY
For Examiner Only
PLAY OF CASE GUIDELINES
(Critical Action No.)
•
Case diagnosis is chronic digoxin toxicity.
•
Patient is hypotensive and bradycardic.
•
Candidate orders IV, monitor, and oxygen.
•
Candidate takes history including medications (digoxin).
•
Candidate performs focused physical exam.
• Candidate orders appropriate labs, and EKG which demonstrates complete av block with
junctional escape and characteristic ST changes. Digoxin level should be ordered after EKG, if
not done initially.
•
Candidate orders IV fluid – no success.
• Repeat vitals reveal worsening bradycardia and hypotension. Candidate orders atropine – no
success.
• Candidate may order pressors, attempt transcutaneous pacing or transvenous pacing – no
success.
•
Digoxin level is 4.
• Candidate treats digoxin toxicity with Digibind. Calculated dose for chronic toxicity is level x
weight in Kg / 100. Here patient is 50kg x 4 / 100 = 2 vials.
•
Candidate contacts patient’s primary doctor and admits to ICU.
• Patient’s heart rate and blood pressure improve. Repeat EKG shows sinus rhythm with first
degree av block.
•
Candidate discusses diagnosis and treatment plan with patient..
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1. Recognizes and immediately addresses unstable
vitals, ordering IV access, Oxygen, and Monitoring.
This critical action is met by recognizing and immediately addressing unstable vitals, ordering IV,
Oxygen, and Monitoring. (PS)
Cueing Guideline: Nurse asks if there are any orders.
2. Addresses hypotensive bradycardia ordering IVF.
(PM)
This critical action is met by addressing hypotensive bradycardia ordering IVF. (PM).
Cueing Guideline: Patient complains of feeling dizzy. Vital signs worsen.
3. Takes complete history including medications
(digoxin). (DA)
This critical action is met by taking complete history including medications (digoxin). (DA)
Cueing Guideline: Nurse is going through patient’s belongings and asks if you want to see
patient’s pill bottles.
4. Correctly interprets EKG: recognizes complete av
block, junctional bradycardia, ST changes. (PS)
This critical action is met by correctly interpreting EKG: recognizes complete av block, junctional
bradycardia, ST changes. (PS)
Cueing Guideline: Nurse asks what the EKG shows.
5.
Administers Digibind. (PS) (PM)
This critical action is met by administering Digibind. (PS) (PM)
Cueing Guideline: Nurse asks if you have any medication orders. Patient does not respond to any
other intervention e.g. atropine, pressors, pacing.
6. Discusses diagnosis and treatment plan with
patient. (IR)
This critical action is met by discussing diagnosis and treatment plan with patient. (IR)
Cueing Guideline: Patient starts crying – she wants to know what is going to happen to her.
For Examiner Only
Case Digoxin Toxicity
History Data Panel
Age: 80
Sex: Female
Name: Velma Vixen
Method of Transportation: Daughter
Person giving information: Patient
Presenting complaint: Vomiting for 3 days
Onset and Description of Complaint:
Patient complains of progressive nausea and vomiting for 3 days. She complains of generalized
abdominal cramping and generalized weakness. (-) fever. (+) chills. (-) diarrhea, melena or
hematochezia. She denies chest pain and shortness of breath.
Past Medical History
Allergies: PCN
Medical: CHF, HTN, NIDDM, gastritis, hypothyroidism, glaucoma
Medications: Altace (ramipril) 5 mg BID
Lasix (furosemide) 40 mg QD
Glucotrol 5 mg QD
Lanoxin (digoxin) 0.25 mg QD
Tagamet (cimetidine) 300 mg QHS
Levoxyl (levothyroxine) 100 mcg QD
Alphagan drops 0.2% OU BID
Surgical: Hysterectomy
Last Meal: Few crackers yesterday
Habits
Smoking: None.
Drugs: Denies.
Alcohol: Denies.
Family Medical History
Father: NC
Mother: NC
Siblings: NC
Social History
Married: Widowed
Children: 2
Employed: Retired school teacher
Education: College
PMD: Sally Bright, MD
For Examiner Only
Case Digoxin Toxicity
Physical Data Panel
General Appearance: Pale, elderly female who appears weak, vomiting in bed.
Vital Signs:
BP
:
P
:
R
:
T
:
O2Sat
:
Glucose :
85/40
46
20
96.9
96% on RA
250
Repeat: 70/30
28
24
After Digibind: 135/80
70
20
Neurological: CN II-XII intact. No focal motor or sensory deficits.
Mental Status: Alert and Oriented x 3.
Head: NCAT.
Eyes: PERRL, EOMI.
Ears: Normal.
Mouth: Mucous membranes dry and pale, OP clear.
Neck: Supple, no LAD, no JVD.
Skin: Dry and pale.
Chest: Slight tachypnea. Lungs clear to auscultation and equal bilaterally.
Heart: Normal S1 / S2. Bradycardia. No murmurs, rubs or gallops.
Abdomen: NABS. Soft, non-distended. Mild diffuse tenderness greatest in lower quadrants
bilaterally. No masses.
Extremities: No clubbing, cyanosis, or edema.
Rectal: Brown stool, Guiac negative.
Pelvic: Patient refuses.
Back: Kyphoscoliosis. No CVA tenderness.
Other exam findings:
For Examiner Only
Case Digoxin Toxicity
Lab Data Panel
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
14.7/mm3
9.1 g/dL
%
358 /mm3
86%
12%
2%
1%
Stimulus #5 – Liver Enzymes and Lipase
Normal
Stimulus #6 – Digoxin Level
4.0 ng/mL (0.5 - 1.5 ng/mL)
Stimulus #7 – EKG: Complete av block with
junctional escape, characteristic ST
depressions
Stimulus #8 – Portable CXR: Negative
Stimulus #3 – Chemistry
Na+
133 mEq/L
K+
3.8 mEq/L
HCO322 mEq/L
Cl99 mEq/L
Glucose
227 mg/dL
BUN
38 mg/dL
Creatinine
1.4 mg/dL
Stimulus #4 – Coagulation Panel
PT
12
PTT
24
Stimulus #9 – EKG after treatment:
Sinus with 1st degree av block
VERBAL REPORTS
Rhythym strip
Accucheck
AV block in 40's
250
For Examiner Only
Case Digoxin Toxicity
Stimulus Inventory
Stimulus #1 – Emergency Admitting Form
Stimulus #2 – CBC
Stimulus #3 – Chemistry
Stimulus #4 – Coagulation Panel
Stimulus #5 – Liver Enzymes and Lipase
Stimulus #6 – Digoxin Level 4.0 ng/mL (0.5 - 1.5 ng/mL)
Stimulus #7 – EKG: Complete av block with junctional escape, characteristic ST
depressions
Stimulus #8 – Portable CXR Negative
Stimulus #9 – EKG after treatment: Sinus with 1st degree av block
FOR EXAMINER ONLY
Mock Oral Feedback Form – ABEM model
Case Digoxin Toxicity Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
1. Recognizes and immediately addresses unstable
vitals, ordering IV access, Oxygen, and Monitoring.
2. Addresses hypotensive bradycardia ordering IVF. (PM)
 and omissions

fials to initiate resuscitation and
3. Takes complete history including medications
(digoxin). (DA)
4. Correctly interprets EKG: recognizes complete av
block, junctional bradycardia, ST changes. (PS)
5. Administers Digibind. (PS) (PM)

order an ECG. Penalize if
6. Discusses diagnosis and treatment plan with patient.
(IR)
FOR EXAMINER ONLY

Score down if the candidate
medication history and digoxin


use isn’t noted. Score down if
candiate fails to appreciate
digoxin toxicity on the ECG and
needs to be prompted
Mock Oral Feedback Form – Core Competencies
Case Digoxin Toxicity Date:
Examiner:
Does not meet
expectations
Examinee:
Meets
Expectations
Exceeds
Expectations
1. Patient care
2. Medical
knowledge
3. Interpersonal
skills and
communication
4. Professionalism
5. Practice-based
learning and
improvement
6. Systems-based
practice
Critical Actions
Dangerous actions
1. Recognizes and immediately addresses unstable
vitals, ordering IV access, Oxygen, and Monitoring.
2. Addresses hypotensive bradycardia ordering IVF. (PM)
 and omissions

fials to initiate resuscitation and
3. Takes complete history including medications
(digoxin). (DA)
4. Correctly interprets EKG: recognizes complete av
block, junctional bradycardia, ST changes. (PS)
5. Administers Digibind. (PS) (PM)

order an ECG. Penalize if
6. Discusses diagnosis and treatment plan with patient.
(IR)
FOR EXAMINER ONLY

Score down if the candidate
medication history and digoxin


use isn’t noted. Score down if
candiate fails to appreciate
digoxin toxicity on the ECG and
needs to be prompted
Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
: Velma Vixen
Age
: 80
Sex
: Female
Method of Transportation : Daughter
Person giving information : Patient
Presenting complaint
: Vomiting for 3 days
Background:
Velma Vixen, an 80 yo female presents to ED complaining of vomiting for 3 days.
Vital Signs
Vital Signs:
T 96.9
P 46
RR 20
BP 85/40
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
14.7/mm3
9.1 g/dL
%
358 /mm3
86%
12%
2%
1%
Stimulus #3 – Chemistry
Na+
133 mEq/L
K+
3.8 mEq/L
HCO322 mEq/L
Cl99 mEq/L
Glucose
227 mg/dL
BUN
38 mg/dL
Creatinine
1.4 mg/dL
Stimulus #4 – Coagulation Panel
PT
12
PTT
24
Stimulus #5 – Liver Enzymes and Lipase
Normal
Stimulus #6 – Digoxin Level
4.0 ng/ml (0.5-1.5 ng/ml)
Stimulus #7 – EKG
Stimulus #8 – CXR
Stimulus #9 – EKG after Treatment