Severe suicidal digoxin and propranolol toxicity with insulin overdose
A 32-year-old male doctor, known case of type I diabetes mellitus for last 4 years, on glargine insulin 30 units once daily and regular insulin 15 units thrice daily, presented to our casualty with an alleged history of ingestion of 100 tablets of 0.25 mg digoxin (total dose 25 mg) and 50 tablets of 40 mg propranolol (total dose 2 g) along with subcutaneous injection of 1,600 units of regular insulin about 2 h prior to presentation. He was conscious with the following vital parameters: Heart rate 74/min, blood pressure 106/70 mmHg, respiratory rate 26/min, random blood sugar level 58 mg/dl, and was maintaining normal oxygen saturation on room air. Systemic examination was unremarkable. His initial electrocardiograph showed normal sinus rhythm. Arterial blood gas analysis revealed: pH 7.391, pCO2 32.8 mmHg, pO2 102.4 mmHg, HCO3 19.5 mEq/l, Na 136 mEq/l, and K 3.73 mEq/l. He complained of nausea and had one episode of vomiting in the casualty. Gastric lavage was immediately done with 100 g activated charcoal and he was given 50 ml of intravenous (IV) 25% dextrose injection along with other relevant supportive management. Routine laboratory investigations were sent for along with serum digoxin levels, serum insulin, and C-peptide levels and urine toxicology screen. He was shifted to the intensive care unit (ICU) for further medical management.\nIn the ICU, the patient had bradycardia (maximum heart rate of 58/min and a minimum heart rate of 39/min). Injection atropine 0.6 mg IV was administered on two occasions. In view of recurrent hypoglycemia, IV bolus of 50 ml of 25% dextrose, followed by infusion of 20% dextrose at the rate of 100 ml/h was started. Initial investigations revealed serum digoxin levels of 7.5 ng/ml (normal range 0.7-2 ng/ml), serum insulin 500 μIU/ml, and serum C-peptide 0.43 ng/ml (normal range 0.48-3.3 ng/ml). Blood counts, liver, and renal function tests along with serum electrolytes and serial blood gas analysis were normal. Electrocardiograph showed sinus bradycardia.\nImmediate cardiology opinion was taken because of high serum digoxin levels and propranolol toxicity. To manage propranolol overdose, injection glucagon 5 mg slow IV bolus followed by an infusion at 5 mg/h was started. As digoxin specific antibody fragments (Fab) were unavailable, we tried to find other alternative approaches. As per the opinion of the nephrologist hemoperfusion with charcoal-based cartridge (Gambro Adsorba 300C and 150C) with a blood flow of 150 ml/h was done for 15 h after a written informed consent from the attendants. Close observation and regular monitoring of serum electrolytes with digoxin levels were done during this entire period.\nBy the end of day 1 of ICU stay, patient showed significant improvement and serum digoxin levels showed a decreasing trend []. On day 2, his heart rate varied between 58-66/min. Dextrose (20%) infusion was continued at a rate of 100 ml/h for 30 h and then reduced to a rate of 80 ml/h for the next 20 h. His random blood sugar levels hovered around 200 mg/dl. On day 3 he was started on oral diet and his maintenance Dextrose infusion was tapered down and finally stopped (total dose of IV glucose 1,115 g) [].\nGlucagon infusion was given at a rate of 5 mg/h for the 19 h and then tapered to 2 mg/h which was continued for next 21 h targeting a heart rate above 50/min and adequate perfusion (total dose of IV glucagon 142 mg) [].\nOn day 4, with a good hemodynamic profile and a serum digoxin level of 1.4 ng/ml, he was shifted to the step down unit. He continued to remain asymptomatic there and was discharged on the 6th day after consultation with a psychiatrist.