Digoxin Toxicity: Myths, Truths and Management

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Author: Andrew V. Bokarius, MD
Emergency Medicine Resident
University of Chicago
AAEM/RSA Publication Committee Member

The Case:
A 68-year-old male with a history of heart failure presents with weakness, confusion, and visual disturbances including yellow/green halos and scotomas. Digoxin is on the list of current medications. Vitals are notable for bradycardia with a HR of 55. The patient is awake but confused.

The Clinical Decision-Making:
While your differential diagnosis may include calcium channel toxicity, beta blocker toxicity, sick sinus syndrome, clonidine toxicity, organophosphate poisoning, and other potential diagnoses, digoxin toxicity should be at the top of the list.

You quickly recall how digoxin works: it inhibits the Na/K ATPase, causing intracellular sodium levels to rise. Sodium is then exchanged for calcium via a Na/Ca transporter. The intracellular calcium concentration is thus increased, thereby increasing contractility. Furthermore, digoxin also may increase vagal tone and can lead to bradyarrhythmias.

Wilderness Medicine: Special Considerations for Submersion Injuries

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Author: Mike Wilk, MS4
Loyola University Chicago Stritch School of Medicine
Originally Published: Modern Resident February/March 2016

Drowning still remains a leading cause of accidental death in the United States, particularly for young children.[1] In the past, many terms were developed in reference to subtypes of drowning such as near drowning, dry and wet drowning and shallow water blackout. However, recent guidelines have been simplified and now only categorize a drowning as fatal or non-fatal.[2] Drowning occurs after an initial period of panic and breath holding, which eventually leads to reflex inspiration as water enters the respiratory tract causing widespread hypoxia.

Based on previous animal model studies, it was once thought that there were physiological differences in saltwater versus freshwater submersion injuries that could thus require differing treatments. For example, it was thought that since freshwater submersion aspiration contents are hypotonic, it would result in intravascular fluid overload leading to hypotonic serum levels. Contrasting saltwater submersions, aspiration was thought to be hypertonic in nature, thus leading to massive pulmonary edema and hypertonic serum levels. In reality, nearly all survivors simply do not aspirate enough fluid that lead to clinically relevant changes.[3]

Age-Adjusted D-Dimer in the Evaluation of Venous Thromboembolic Disease

Common Sense - AAEM Member Magazine

Authors: Lee Grodin, MD; Raymond Beyda, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD
Edited By: Jay Khadpe, MD FAAEM and Michael C. Bond, MD FAAEM
Originally Published: November/December 2016 Common Sense

The D-dimer test is an important and widespread tool to assess for venous thromboembolic disease (VTE) in low risk patients. The test has a high sensitivity and negative predictive value; however it is also prone to false positives. Additionally, as D-dimer levels naturally rise with age, the test may lead to more frequent false positives in the elderly than the general population. Recently several investigations examined age related refinements to the interpretation of D-dimer results to rule out VTE. For this month’s resident journal review, we review two retrospective studies and one prospective study that evaluate using age-adjusted D-dimer levels to increase its specificity while retaining its sensitivity. Verification of the results of studies could reduce the use of expensive imaging studies, reduce patient exposure to radiation and contrast, and prevent unnecessary hospital admissions and anticoagulation. These issues are particularly pertinent for the elderly population.

When SCUBA diving goes wrong – Decompression Illness

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Jonathan Morgan, MSIV

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Medical Student

Lake Erie College of Osteopathic Medicine-Bradenton

A 54 year-old male presents to your emergency department complaining of dizziness that started shortly after completing a dive. He is a biologist who was studying the nearby river. He reports that about 10 minutes after surfacing he became profoundly dizzy. He also reports nausea that has since resolved. He thinks his hearing is normal. He can walk, but stumbles sideways.

His companions administered oxygen immediately and called 911. He is currently alert, oriented, complaining of only dizziness. His vitals are: BP 130/70, Pulse 76, RR 14, Temp. 37.0 C, SpO2 98% on room air.

What do you need to know about his dive?

Basic information includes maximum depth of the dive, time at maximal depth, decompression or safety stops used, previous dives within 12 hours, and type of gas and equipment used. [1]

Physician Advocacy: Disability Coverage for the EP

Photo Credit: Flickr - Zeevveez

Author: Linda Sanders, MD
Temple University Hospital
Originally Published: Modern Resident February-March 2016

As a new generation of residents prepares to enter private and academic practice as attending emergency physicians, most intend to practice emergency medicine for the next 30 years, maybe more. But in an environment that demands that we have fine motor skills, quick decision making abilities, fast communication and the ability to practice at least eight hours a day, a physical or mental ailment can make one incapable of EM practice. The incidence of disability among practicing physicians is around 2-10%.[2]