A client in the emergency room begins to experience an acute asthma attack. The nurse expects that which medication will be used as initial treatment?

A) Hydration with IV fluids:
IV hydration may be ordered to improve kidney function and help facilitate the excretion of excess digoxin from the body. Digoxin toxicity is often related to impaired renal clearance, so improving hydration can promote renal perfusion and enhance the elimination of the drug. This is a common supportive measure to help in managing digoxin toxicity.

B) Nothing as the digoxin level is within normal ranges:
This is incorrect because the patient's digoxin level is 4 ng/ml, which is significantly above the normal therapeutic range of 0.8–2.0 ng/ml. A level of 4 ng/ml is toxic, and immediate action is required. Symptoms like severe bradycardia, nausea, and vomiting are indicative of digoxin toxicity, and they necessitate prompt intervention.

C) Hold the Digoxin:
In the case of digoxin toxicity, it is crucial to hold the digoxin. Digoxin should be discontinued immediately if toxicity is suspected, as continuing the medication could worsen symptoms like bradycardia and increase the risk of potentially life-threatening arrhythmias. This step is essential to prevent further complications.

D) Digibind:
Digibind (Digoxin immune fab) is a digoxin-specific antibody used in cases of severe digoxin toxicity or overdose. It binds to the digoxin molecules and helps to neutralize its effects. Given the elevated level of digoxin (4 ng/ml) and the presence of symptoms like severe bradycardia, nausea, and vomiting, Digibind is likely to be ordered to reverse the effects of the toxicity.

E) Narcan:
Narcan (naloxone) is used to reverse opioid overdoses, not digoxin toxicity. There is no indication for the use of Narcan in this scenario, as digoxin toxicity does not involve opioid overdose. This intervention would be inappropriate and irrelevant to the management of digoxin toxicity.

Unstable Supraventricular Tachycardia: Synchronized Cardioversion

Unstable Bradycardia: Transcutaneous Pacing

Ventricular Fibrillation: Defibrillation

Ventricular Tachycardia with No Pulse: Defibrillation

Unstable Atrial Flutter: Synchronized Cardioversion

Rationales:

Unstable Supraventricular Tachycardia – Synchronized Cardioversion:

Synchronized cardioversion delivers a timed electrical shock to the heart during the R wave, avoiding the vulnerable T wave, which minimizes the risk of inducing ventricular fibrillation. This intervention is preferred for unstable SVT unresponsive to medications, as it restores normal sinus rhythm effectively.

Unstable Bradycardia – Transcutaneous Pacing:

Transcutaneous pacing provides electrical impulses to stimulate the heart when intrinsic conduction is insufficient. It is the recommended treatment for symptomatic bradycardia that does not respond to medications, ensuring adequate cardiac output while awaiting more definitive treatment.

Ventricular Fibrillation – Defibrillation:

Defibrillation delivers an unsynchronized shock to depolarize the entire myocardium, allowing the heart to reset and resume an organized rhythm. It is the first-line intervention for ventricular fibrillation, as the chaotic electrical activity makes the heart incapable of pumping blood.

Ventricular Tachycardia with No Pulse – Defibrillation:

Pulseless ventricular tachycardia requires defibrillation, as the rhythm is life-threatening and the absence of a pulse indicates the heart is not effectively pumping. This unsynchronized shock interrupts the abnormal rhythm, allowing normal sinus rhythm to potentially resume.

Unstable Atrial Flutter – Synchronized Cardioversion:

Synchronized cardioversion is used for unstable atrial flutter to restore sinus rhythm by delivering a precisely timed electrical shock. It is effective when pharmacological measures have not worked or are inappropriate, especially in cases of hemodynamic instability.