M.D., a 40-year-old male patient, presented to the Emergency Department (ED) of Dubti General Hospital, the Afar regional state in Ethiopia, with a complaint of shortness of breath, palpitation, extreme fatigue, and chest pain of a day's duration. He had a dry, intermittent cough, a low-grade intermittent fever, and fatigue for a week before his current symptoms. He had no past medical or surgical history except that he was treated for pulmonary tuberculosis (PTB) six years ago. He denied alcohol intake, smoking, or any drug intake.
On arrival, his blood pressure (BP) was 80/50 mmHg, his radial pulse rate was weak and fast, and his apical heart rate (HR) was also fast, making them difficult to count. His respiratory rate (RR) was 28/min, the temperature was 37.2 C, and his oxygen saturation was 98% with room air. He had cold extremities. Otherwise, he was fully conscious, and no other pertinent physical findings were noted. Immediately after arrival, he was transferred to the intensive care unit (ICU), and on a monitor, his HR was 208. A bedside ECG was done, which showed paroxysmal supraventricular tachycardia (PSVT) (Figure 1).
Considering his clinical presentations and ECG findings, unstable PSVT and pneumonia were entertained, and at this time, carotid sinus massage and modified Valsalva maneuvers were attempted, which proved ineffective. The patient and his family members were informed about the case scenario so that they could give written informed consent for synchronized electrical cardioversion. But the family members and the patient himself refused to sign informed consent due to fear and a bad perception of the outcome from the patient himself and due to religious influence from the family members.
Even though he was not a candidate for pharmacotherapy because of instability, unfortunately, the commonly used drugs to manage PSVT (adenosine, beta-blockers, and calcium channel blockers) were not available in the hospital. This was because of the ongoing civil war in Ethiopia, which resulted in a shortage of foreign currencies to import essential drugs from developed countries and transportation problems from pharmaceutical supply agencies to hospitals. The only available drug was digoxin. Even though it is not a common practice to use digoxin to manage PSVT, taking into consideration its negative chronotropic effect and its action to suppress the AV nodal conduction velocity, digoxin 0.25 mg IV was given after informed consent was obtained from the patient and family members. After 10 minutes of digoxin administration, the HR dropped to 105 beats per minute, which were regular and full in volume. His BP came up to 95/65 mmHg, and his chest discomfort was relieved. At this time, a repeat ECG was done, which showed normal sinus rhythm (Figure 2).
He was investigated with a complete blood count (CBC), renal function test, liver function test, serum electrolyte test, and thyroid function test, but they were all normal. A chest X-ray and echocardiography were also done, and they turned out to be normal. He stayed in the ICU for 24 hours and was in stable condition. On the next day, metoprolol (12.5 mg PO BID) and amoxicillin/clavulanate (625 mg PO TID) were started, and he was transferred to the medical ward for observation. He stayed for 72 hours in the ward, and on his 4th day of admission, he was referred to a better setup to have regular follow-ups with a cardiologist.