Severe suicidal digoxin toxicity managed with resin hemoperfusion: A case report
A 30 year old female presented to casualty with an alleged history of ingestion of 70 tablets of 0.25 mg digoxin (total dose 17.5 mg) one hour prior to presentation. She had developed nausea and recurrent vomiting 20 minutes after ingestion. Immediate gastric lavage was done and activated charcoal 100 gm was given through nasogastric tube. One gram magnesium sulphate was also given intravenously. On examination, she was conscious, oriented, afebrile, and had a heart rate of 102/ minute, BP of 106/70 mmHg, respiratory rate of 20/ minute, and was maintaining oxygen saturation of 99% on room air. Systemic examination was unremarkable and her initial electrocardiograph showed normal sinus rhythm. All routine laboratory tests were sent along with serum digoxin levels and urine toxicology screen. She was immediately shifted to ICU.\nInitial investigations revealed serum digoxin levels of 12.63 ng/ml (normal range 0.8- 2.0 ng/ml), serum calcium 8.3 mg/dl, potassium 4.6 mmol/L, sodium 137 mmol/L, magnesium 3.13 mg/dl, and a normal hemogram, liver and renal function tests. She had persistent vomiting and also developed diplopia, blurring and yellowing of vision within two hours of admission along with intermittent episodes of bradycardia along with hypotension (systolic BP up to 70 mmHg). Electrocardiographs initially showed variable and prolonged PR [] with atrial ectopics, which subsequently converted into complete heart block. Prophylactically transcutaneous pacing was applied to gain time for temporary pacemaker insertion as the patient continued to have episodes of symptomatic bradycardia (heart rate going down up to 30/minute). Immediate cardiology opinion was taken and temporary pacemaker was inserted []. In view of high serum digoxin levels, presence of bradyarrhythmias with hypotension and nonavailability of Fab fragments, hemoperfusion with resin-based cartridge (HA280 resin hemoperfusion cartridge, Jafron Biomedical Co. Ltd., China) was done over 4 hours after taking nephrology opinion and written informed consent from the attendants. Lack of adequate literature about safety and efficacy of the procedure were carefully explained to the attendants. Patient was closely observed and platelets, coagulation profile, serum electrolytes and digoxin levels [] were monitored regularly. Patient tolerated the procedure well and there were no associated side effects, fall in platelet levels or procedure-related complications.\nPatient showed gradual symptomatic improvement with clearing of vision and resolution of nausea and vomiting within 4 hours of resin hemoperfusion. Her heart rate also improved and her atrioventricular block also got corrected over the next 24 hours. Serum digoxin levels dropped to 3.06 ng/ml after 24 hours and to 2.56 ng/ml after 36 hours of resin hemoperfusion. Temporary pacemaker was kept in situ, on demand mode, for 24 hours after complete resolution of symptoms and serum digoxin levels coming in nontoxic range. She continued to remain asymptomatic and was discharged after 4 days of hospitalization.