Digitalis poisoning and its treatment

Rare Manifestation of Digoxin Toxicity: Right Bundle Branch Block

A 76-year-old female, with medical history significant for systolic congestive heart failure, who presented to the emergency department with lethargy and abdominal pain with diarrhea for the past 3 weeks. Due to hypotension, the patient received multiple boluses of isotonic saline and was started on norepinephrine. Laboratories were significant for severe digoxin toxicity (29 ng/mL), in setting of acute kidney injury. Electrocardiogram (EKG) revealed a new right bundle branch block (RBBB). She was given Digibind and her repeat digoxin level was 20 ng/mL. Repeat EKG showed resolved RBBB. This case identifies that patients with digoxin toxicity are at risk for RBBB. This is a rare finding and is not commonly recognized. Emergency medicine physicians are often the first to encounter patients with digoxin toxicity and need to be aware of such EKG findings.

CALCIUM IN RELATION TO THE ACTIONS OF OUABAIN AND ADRENALINE ON THE HEART

Isolated pairs of rabbit auricles have been observed in media containing 6, 24 or 75 mM-potassium, with corresponding reductions in sodium concentration. In 24 mM-potassium, adrenaline restored beating and excitability, as did calcium chloride, but ouabain had no effect. In 75 mM-potassium, adrenaline had no effect; calcium chloride caused a contracture; ouabain had no direct effect, but auricles which had been beating in the presence of ouabain contracted promptly on transfer to 75 mM-potassium. Left auricles, which do not beat spontaneously, were less sensitive to calcium and to ouabain. The results showed a membrane stabilizing action of calcium and an action on muscular contraction, and suggested that cardiac glycosides acted by causing accumulation of calcium at the activator site in the tissue.

Electrophysiological observations on the digitalis-potassium interaction in canine Purkinje fibers

We studied the effects of elevating potassium concentration on the membrane potential of Purkinje cells exposed to toxic concentrations of acetylstrophanthidin or ouabain. Conventional intracellular microelectrode techniques were employed. Rapid elevation of [K+]o from 2.7 to 5.4 mEq/liter resulted in an initial increase (more negative) in membrane potential of cells demonstrating ouabain-induced phase 4 depolarization. The increase in maximal diastolic potential occurred initially without suppression of phase 4 depolarization. In cells rendered inexcitable by ouabain or acetylstrophanthidin, elevation of [K+]o consistently increased membrane potential and restored excitability. In four experiments automaticity was initiated within 2 minutes after the increase in [K]o. Although automaticity reappeared, as maximal diastolic potential increased, the automatic rate slowed and then pacemaker activity was suppressed. Studies with 3H-ouabain showed that the increase in membrane potential paralleled K+-induced release of 3H-ouabain from Purkinje cells. These studies suggest that elevation of [K+]o reverses digitalis toxic manifestations in canine Purkinje fibers by causing release of cardiac glycosides bound to the membrane. The observed increase in membrane potential of ouabain-treated Purkinje fibers that occurred after [K+]o elevation was considered to be mediated in part by restoration of the Na pump and by electrogenic pumping.

Atrial Flutter as a Manifestation of Digitalis Toxicity

Although digitalis overdosage is known to produce a variety of atrial, junctional, and ventricular arrhythmias, atrial flutter due to digitalis intoxication has been rarely reported. The present paper reviews the literature and reports what appears to be the sixteenth case. The available information on the accepted cases of atrial flutter due to digitalis toxicity has been analyzed for clues as to when digitalis can be considered the cause of the flutter.