FL_Medic Posted March 8, 2009 Share Posted March 8, 2009 I've heard that Glucagon is a safe treatment for Dig toxicity as well as beta-blocker OD Link to comment Share on other sites More sharing options...
itku2er Posted March 8, 2009 Share Posted March 8, 2009 Then let's up the stakes. Same patient, same presentation, different vitals. Alert, disoriented. Multifocal Atrial tachycardia with superimposed 3rd degree block (pathognomonic for dig toxicity) Ventricular rate (and pulse) 30 BP 70/40 What do you want to do? You get one choice. Pace, or drug. Don't just guess; justify your answer as to why one is better than the other. 'zilla Pace and atrophine. Need the combination to keep the heart going. Since the transport time is 45 min you need to be aggressive and keep them alive till they get into the ER doors. * Activated charcoal can be used so I have read. Never seen it done. But digibond seems to be on the top of the list at the hospitals to use it the levels are over 10,* Link to comment Share on other sites More sharing options...
AnthonyM83 Posted March 9, 2009 Author Share Posted March 9, 2009 I'd have to go with pacing. Digibind might fail, but pacing probably won't. At least we can have the symptoms corrected.... Link to comment Share on other sites More sharing options...
Camulos Posted March 9, 2009 Share Posted March 9, 2009 Then let's up the stakes. Same patient, same presentation, different vitals. Alert, disoriented. Multifocal Atrial tachycardia with superimposed 3rd degree block (pathognomonic for dig toxicity) Ventricular rate (and pulse) 30 BP 70/40 What do you want to do? You get one choice. Pace, or drug. Don't just guess; justify your answer as to why one is better than the other. 'zilla Although this a bit unrealistic, as I would normally have both, I am happy to play the game. If I only had one to choose from I would choose pacing over medication therapy for this revised scenario. My justification for this is; • I believe the chance that atropine may have little effect is too high due to the fact that the rhythm is not primarily vagally mediated. • I have had some success with glucagon in the past however the benefits of this are only transient. Given that we are 45 minutes away from the hospital, I believe the benefit of glucagon would not sustain the patient for this time given its short half life. Please note here that I have no option for continuous infusion in this case due to the amount normally carried. • This level of hemodynamic instability requires drastic action and as such I believe that cardiac pacing would provide the best chance at a positive outcome given the length of time away from the hospital. In pacing this pt though I am cognisant of the risk of decreasing the fibrillatory threshold. I have also had difficulty pacing some of these pt’s in the past due to the inability to capture despite the use of high voltage settings. Good scenario though. I believe in these cases it always comes down to a risk v benefit analysis (for me anyway). In this particular scenario I simply believe that the risk of medication only therapy MAY either not be effective or not buy me enough time to get to the hospital. Whilst pacing alone is not ideal I believe it is the best option if forced to choose only one. Of course though this is my prehospital treatment as my decision in hospital would be different. Keen to hear others views on this. Stay safe; Curse Link to comment Share on other sites More sharing options...
Doczilla Posted March 9, 2009 Share Posted March 9, 2009 I've heard that Glucagon is a safe treatment for Dig toxicity as well as beta-blocker OD For Beta blocker OD, yes. Calcium channel blocker OD, possibly. For dig toxicity, no. Glucagon is not indicated here. Sounds like the classic dementia where patients do normal tasks repeatly to act like they are ok. Dementia is a slow, progressive, irreversible decline in mental function. Acute changes in behavior or fluctuating symptoms suggest delirium, which is usually secondary to an acute and often reversible cause. Atropine can be used to prevent heart block. Atropine can be used to TREAT heart block, but is not usually used to prevent it except under limited circumstances, like intubation in pediatrics. Don't throw atropine at someone unless you have a good reason. I believe the chance that atropine may have little effect is too high due to the fact that the rhythm is not primarily vagally mediated. Actually, in the setting of dig toxicity, heart block IS parasympathetically mediated, through 3 mechanisms: 1) direct vagal stimulation 2) increased parasympathetic transmission at the AV node 3) increased sensitivity of baroreceptors in the aortic arch (which in turn leads to vagal stimulation) Atropine is therefore DOC in heart block caused by dig toxicity. Don't let some ACLS instructor tell you never to bother with atropine in heart block. In this situation, it will help. Pacing has to be done with caution in the setting of dig toxicity. It will lower fibrillatory threshold and should be avoided if at all possible. Pharmacological treatment is preferred. I don't know of any prehospital system that carries digibind. It takes 45 minutes to get it from the pharmacy at my hospital. The cost/benefit ratio would be extremely high, particularly when dig toxicity is difficult to diagnose without a dig level. Digibind would be the DOC if you had all of the info and the ability to give it. 'zilla Link to comment Share on other sites More sharing options...
chbare Posted March 9, 2009 Share Posted March 9, 2009 Great scenario! Why do you have visual changes with digoxin overdose? It is nice to have the docs involved as well. It is nice to take a break from they typical us versus the world mentality of other places and have good interaction with the docs. Take care, chbare. Link to comment Share on other sites More sharing options...
Camulos Posted March 9, 2009 Share Posted March 9, 2009 Atropine is therefore DOC in heart block caused by dig toxicity. Don't let some ACLS instructor tell you never to bother with atropine in heart block. In this situation, it will help. Can you really be so sure it WILL help? After a quick check there are quite a few reports of atropine being ineffective in the setting of digoxin overdose. I am happy to be proven wrong but it was this unknown quantity that provided my main justification for advocating cardiac pacing if I had to only choose ONE treatment - as per your question. I would be keen hear your answer and justification to your question Doczilla on which ONE you would choose in the scenario - drugs or pacing? Stay safe, Curse Link to comment Share on other sites More sharing options...
FL_Medic Posted March 9, 2009 Share Posted March 9, 2009 I've read that with dig toxicity patient's are more likely to have a negative reaction from electrical therapy, ie ventricular fibrillation may result. TCP is the least likely to cause this due to low energy levels, but it's still a thought to consider. Link to comment Share on other sites More sharing options...
Camulos Posted March 9, 2009 Share Posted March 9, 2009 I've read that with dig toxicity patient's are more likely to have a negative reaction from electrical therapy, ie ventricular fibrillation may result. My understanding is that this is more prevalent in the setting of cardioversion. As was said earlier TCP definitely lowers the fibrillatory threshold though so can cause the same problems. TCP is normally only used after medications have been ineffective. And from what I have read medications are quite frequently ineffective in this setting. Hence my reason to choose TCP over drugs if only given ONE choice. Of course in real life I would have both and would try the atropine first and then progress to TCP if it was ineffective. However Doc's question didn't allow for this and asked us to choose one only. Stay safe, Curse Link to comment Share on other sites More sharing options...
AnthonyM83 Posted March 10, 2009 Author Share Posted March 10, 2009 Great scenario! Why do you have visual changes with digoxin overdose? THAT I'd like to know. Haven't had time to research it...gotta go study. Someone should research and post. Link to comment Share on other sites More sharing options...
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