digoxin is a drug that is mainly used to treat signs and symptoms of atrial fibrillation and mild - to - moderate reduced ejection fraction heart failure . digoxin works by inhibiting the sodium / potassium atpase and suppressing the atrioventricular ( av ) conduction . most common significant adverse reactions involve the cardiovascular system , and include accelerated junctional rhythm , atrial tachycardia with or without block , st segment depression , pr prolongation , and first , second , or third degree av block . however , we report a rare case of right bundle branch block ( rbbb ) with serious digoxin toxicity . a 76-year - old female with medical history significant for systolic congestive heart was brought in after she was found to be lethargic and had abdominal pain with diarrhea for 3 weeks . history was limited as patient was somnolent and on venturi mask . in the emergency department , the patient was given four boluses of isotonic saline , but her systolic blood pressure was still ranging in 6070 mmhg . hence , central line was placed and norepinephrine was started . her vitals were remarkable for heart rate of 69 beats / min , respiratory rate of 17 breaths / min , oxygen saturation of 98% on venturi mask , and blood pressure of 79/42 mmhg on norepinephrine . physical examination was significant for lethargic appearing female . the right upper chest had inspiratory crackles , and lower extremities had mottled appearance . laborataries were remarkable for potassium of 8.5 mmol / l , lactic acid of 7.4 mmol / l , bicarbonate of 10 mmol / l , with creatinine of 3.6 mg / dl . arterial blood gas showed ph of 7.039 , co2 of 44 mmhg , hco3 of 12 meq / l , and po2 of 60 mmhg . digoxin level was 29 ng / ml . electrocardiogram ( ekg ) showed rbbb and nonspecific st- and t - segment depression [ figure 1 ] . she was given digibind for her severe digoxin toxicity and received insulin with dextrose , albuterol , 2 amps ( 50 meq ) of bicarbonate , and calcium gluconate for potassium toxicity . repeat ekg showed resolved rbbb and improved st- and t - segment depressions [ figure 2 ] . nonetheless , the patient went into bradycardia and then asystole , and expired despite resuscitative efforts . electrocardiogram during admission in the emergency department , demonstrating the right bundle branch block and nonspecific st - and t - segment changes repeat electrocardiogram after administration of digibind resolved right bundle branch block rbbb is extremely rare , aravanis and michaelides reported a case of rbbb with atrial flutter . signs of toxicity can occur at doses > 2 ng / ml , and our patient had digoxin level of 29 ng / ml , which decreased to 20 ng / ml after digibind was administered . our case demonstrates that the appearance of a new rbbb can be a manifestation of digoxin toxicity . hence , digoxin toxicity can produce many arrhythmias and rbbb needs to be added on to the list . emergency room physicians should be vigilant for diagnosing digoxin toxicity in patients that present with classic overdose symptoms , and have new rbbb on ekg reading .
a 76-year - old female , with medical history significant for systolic congestive heart failure , who presented to the emergency department with lethargy and abdominal pain with diarrhea for the past 3 weeks . due to hypotension , 
 the patient received multiple boluses of isotonic saline and was started on norepinephrine . 
 laboratories were significant for severe digoxin toxicity ( 29 ng / ml ) , in setting of acute kidney injury . 
 electrocardiogram ( ekg ) revealed a new right bundle branch block ( rbbb ) . 
 she was given digibind and her repeat digoxin level was 20 ng / ml . repeat ekg showed resolved rbbb . 
 this case identifies that patients with digoxin toxicity are at risk for rbbb . 
 this is a rare finding and is not commonly recognized . 
 emergency medicine physicians are often the first to encounter patients with digoxin toxicity and need to be aware of such ekg findings .