Rare Manifestation of Digoxin Toxicity: Right Bundle Branch Block

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.