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Bradycardia in a Patient With Heart Failure


Case Study

A rapid response event was initiated by the bedside nurse for a patient with a heart rate of 44 beats per min (bpm) on the telemonitor. On prompt arrival of the rapid response team, it was noted that the patient was a 64-year-old male with comorbidities of chronic systolic heart failure, atrial fibrillation, and osteoarthritis, who was admitted three days ago for severe gastroenteritis and dehydration. The patient was receiving IV fluids since admission but was unable to get any fluids this day since he refused to be hooked up to continuous infusion. He had also refused any blood draws this morning. The patient was receiving metoprolol, apixaban, aspirin, lisinopril, and digoxin. Pacer pads were attached to the patient in preparation for any need for cardiac pacing.

Vital Signs

  • Temperature: 98.6 °F

  • Blood Pressure: 90/60 mmHg

  • Heart Rate: 45 beats per min – with junctional bradycardia and narrow QRS complexes on telemonitor ( Fig. 11.1 )

    Fig. 11.1, Telemetry strip showing junctional bradycardia with inverted P and T waves with a narrow QRS complex.

  • Respiratory Rate: 14 breaths per min

  • Pulse Oximetry: 94% oxygen saturation on room air

Focused Physical Examination

The patient was a middle-aged man sitting up in bed, leaning forward in obvious distress. The room was filled with an unmistakable smell of fecal matter. Before examining the patient, it was ensured that everyone had proper protective gowns, surgical gloves, and surgical masks on. The patient’s heart auscultation revealed bradycardia, no prominent murmurs. Chest auscultation was clear. His abdominal exam showed diffuse tenderness. When asked, the patient reported that this started a few hours ago, and he did not report this to the nurse as he thought this might be from his continued diarrhea. He denied pain anywhere else in the body.

Interventions

A stat electrocardiogram (EKG) was ordered, along with a troponin level and electrolytes. The patient was given 1000 cc Plasma-Lyte bolus. EKG obtained showed sinus bradycardia, with occasional breaks of junctional rhythm, depressed T waves, and ST depression in the lateral leads. His last laboratory tests showed that he was hypokalemic with a potassium of 2.8. Patient’s potassium was being corrected intravenously till one day ago; however, he had refused medications and fluids today. With this history in mind, it was decided that this patient might be suffering from hypokalemia induced digitalis toxicity. He was given one dose of atropine (0.5 mg IV) and started on intravenous potassium supplementation. His heart rate and blood pressure improved to 55 bpm and 100/60 mmHg, respectively. Further labs were sent, including a lactate level, digoxin level, and magnesium level. It was decided to transfer him to the cardiac care unit for closer monitoring and possible need of digoxin-specific Fab fragments.

Final Diagnosis:Hypokalemia Induced Digoxin Toxicity Resulting in Sinus Dysfunction

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