Monday, May 24, 2010


A patient is brought in from a skilled nursing facility. Four hours ago, she was given somebody else's pills but the nurse has run away! No one knows what she was given, except that it's probably a common nursing home medication. She was brought in because of a witnessed seizure about three hours ago. She has recovered from the seizure but has altered mental status with delirium. Her vitals show a heart rate of 40 and a blood pressure of 90/50. There are no focal neurologic deficits. Her labs show a glucose of 40 and potassium of 5.5; otherwise electrolytes, BUN, and creatinine are normal. Acetaminophen and salicylate levels are undetectable. Chest X-ray is clear. EKG is shown above.

You secure airway, breathing, and circulation. You give dextrose. You start atropine but the heart rate and blood pressure are minimally responsive.

Challenge: What's the antidote to this ingestion?

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Suheil said...

Digoxin causing A-V Block with junctional escape and extra-systoles on EKG.

Craig Chen said...

dig is a great possibility - definitely on the differential. was looking for beta blockade but nothing in the case is specific for it. if it were dig, antidote would be digibind (dig Fab).


The EKG shows AV dissociation from beta-blocker overdose. The differential diagnosis includes calcium channel blockers (less likely to cause mental status changes, hyperglycemia rather than hypoglycemia), digoxin (see more nausea/vomiting, EKG should show scooped ST segments), clonidine (resembles opioid overdose with hypotension and bradycardia), or a cholinergic agent (see salivation, lacrimation, urination, GI upset, muscle excitability). The antidote is glucagon.

Sources: UpToDate;

v8grrl said...

I would say the actions done are extreme. Give glucagon and monitor. BP of 90/40s are not that bad and HR. OF 40. Ahhhhh that's nothing. ... It said no nuero deficits. Witnessed sz 3 hours ago. Put her on the tele floor and monitor.