The Foxglove’s bite

Author: Eleanor Burke / Editor: Mark Winstanley / Reviewer: Kathryn Blackmore / Codes: Published: 23/09/2021

A 77-year-old gentleman presented to the Emergency Department (ED) with general lethargy and poor oral intake over the last 48 hours. He had known dementia and was struggling to swallow. No falls, no chest pain, no vomiting, no abdominal pain, bowels opened as normal. Slight reduced frequency of urination and no dysuria.

On examination he was bradycardic at 45 BPM, BP stable at 130/80, RR 18, O2 sats 97% on air, apyrexial. Chest had fine bibasal creps, heart sounds no murmur but irregularly irregular (known AF), abdomen soft non tender and neurologically he had some reduced power in the left arm and leg due to a previous CVA.

Extensive PMH including AF, Previous CVA, T2DM, LVH, HTN.

This was his ECG.

An urgent blood gas revealed a K+ 7.1. He was therefore treated with insulin/dextrose and a salbutamol nebuliser.

eGFR 11 (baseline >90), creatinine 412 (baseline 80),urea 36.

An urgent renal review took place and slow fluids with serial K+ levels and further insulin/dextrose infusions were provided.

Digoxin level was 3.62 initially (normal range 0.6-1.3 to 2.6 ng/mL)(4). Calcium gluconate and digoxin immune fab were considered.

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